Headaches Flashcards
Differentials to headache
Tension headaches
Migraines
Cluster headaches
Secondary headaches
Sinusitis
Giant cell arteritis
Glaucoma
Intracranial haemorrhage
Subarachnoid haemorrhage
Analgesic headache
Hormonal headache
Cervical spondylosis
Trigeminal neuralgia
Raised intracranial pressure (brain tumours)
Meningitis
Encephalitis
Red flags with a headache
Fever, photophobia or neck stiffness (meningitis or encephalitis)
New neurological symptoms (haemorrhage, malignancy or stroke)
Dizziness (stroke)
Visual disturbance (temporal arteritis or glaucoma)
Sudden onset occipital headache (subarachnoid haemorrhage)
Worse on coughing or straining (raised intracranial pressure)
Postural, worse on standing, lying or bending over (raised intracranial pressure)
Severe enough to wake the patient from sleep
Vomiting (raised intracranial pressure or carbon monoxide poisoning)
History of trauma (intracranial haemorrhage)
Pregnancy (pre-eclampsia)
What is a tension headache?
Tension headaches are very common. Classically they produce a mild ache across the forehead and in a band-like pattern around the head. This may be due to muscle ache in the frontalis, temporalis and occipitalis muscles. Tension headaches comes on and resolve gradually and don’t produce visual changes.
Associations with tension headache?
Stress
Depression
Alcohol
Skipping meals
Dehydration
Treatment with tension headache?
Reassurance
Basic analgesia
Relaxation techniques
Hot towels to local area
Secondary headaches?
Secondary headaches give a similar presentation to a tension headache but with a clear cause. They produce a non-specific headache secondary to:
Underlying medical conditions such as infection, obstructive sleep apnoea or pre-eclampsia
Alcohol
Head injury
Carbon monoxide poisoning
What is sinusitis?
Sinusitis causes a headache associated with inflammation in the ethmoidal, maxillary, frontal or sphenoidal sinuses. This usually produces facial pain behind the nose, forehead and eyes. There is often tenderness over the affected sinus, which helps to establish the diagnosis.
Sinusitis usually resolves within 2-3 weeks. Most sinusitis is viral. Nasal irrigation with saline can be helpful. Prolonged symptoms can be treated with steroid nasal spray. Antibiotics are occasionally required.
What is an analgesic headache?
An analgesic headache is a headache caused by long term analgesia use. It gives similar non-specific features to a tension headache. They are secondary to continuous or excessive use of analgesia. Withdrawal of analgesia important in treating the headache, although this can be challenging in patients with long term pain and those that believe the analgesia is necessary to treat the headache.
What is a hormonal headache?
Hormonal headaches are related to oestrogen. The produce a generic, non-specific, tension-like headache. They tend to be related to low oestrogen:
Two days before and first three days of the menstrual period
Around the menopause
Pregnancy. It is worse in the first few weeks and improves in the last 6 months. Headaches in the second half of pregnancy should prompt investigation for pre-eclampsia.
The oral contraceptive pill can improve hormonal headaches.
What is cervical spondylosis?
Cervical spondylosis is a common condition caused by degenerative changes in the cervical spine. It causes neck pain, usually made worse by movement. However, if often presents with headache.
It is important to exclude other causes of neck pain such as inflammation, malignancy and infection. It is also important to exclude spinal cord or nerve root lesions.
What is trigeminal neuralgia and how is it treated ?
The trigeminal nerve is made up of three branches:
Ophthalmic (V1)
Maxillary (V2)
Mandibular (V3)
Trigeminal neuralgia can affect any combination of the branches. The cause is unclear but it is thought to be caused by compression of the nerve. 90% of cases are unilateral, 10% are bilateral. Around 5-10% of people with multiple sclerosis have trigeminal neuralgia.
It presents with intense facial pain that comes on spontaneously and last anywhere between a few seconds to hours. It is often described as an electricity-like shooting pain. Attacks often worsen over time.
There are a number of possible triggers for the pain in patients with trigeminal neuralgia. These include things like cold weather, spicy food, caffeine and citrus fruits.
Treatment
NICE recommend carbamazepine as first-line for trigeminal neuralgia. Surgery to decompress or intentionally damage the trigeminal nerve is an option.
Describe a cluster headache and a typical patient?
Cluster headaches cause severe and unbearable unilateral headaches, usually around the eye.
They are called cluster headaches as they come in clusters of attacks and then disappear for a while. For example, a patient may suffer 3 – 4 attacks a day for weeks or months followed by a pain-free period lasting 1-2 years. Attacks last between 15 minutes and 3 hours.
A typical patient with cluster headaches in your exams is a 30 – 50 year-old male smoker. Attacks can be triggered by things like alcohol, strong smells and exercise.
Symptoms of a cluster headache
Cluster headaches are often described as one of the most severe and intolerable pains in the world. They are sometimes referred to as “suicide headaches” due to the severity of the pain.
Symptoms are typically all unilateral:
Red, swollen and watering eye
Pupil constriction (miosis)
Eyelid drooping (ptosis)
Nasal discharge
Facial sweating
Treatment and prophylaxis?
Acute management:
Triptans (e.g. sumatriptan 6mg injected subcutaneously)
High flow 100% oxygen for 15-20 minutes (can be given at home)
Prophylaxis options:
Verapamil
Lithium
Prednisolone (a short course for 2-3 weeks to break the cycle during clusters)
