Headaches

Question 1

What is a primary headache?

Answer 1

Migraine
Tension-type headache
Trigeminal autonomic cephalalgias
———-Cluster headache

Question 2

What is a secondary headache?

Answer 2

Headache is spercipitated by another condition / disorder - local os systemic. Serious causes of secondary headache are uncommon.

Question 3

What are long lasting primary headache disorders?

Answer 3

Migraine
Tension type headache

Question 4

What are short lasting headaches?

Answer 4

Trigeminal autonomic cephalalgias
———-Cluster headache

Question 5

What is medication overuse headache?

Answer 5

When they have long lasting headaches, and take codeine based medications, and can then get a headache from medication overuse

Question 6

What are 4 key red flags that suggest secondary headaches?

Answer 6

Age - New onset or different headaches in a person >50yrs
Onset - Sudden, abrupt onset of a severe headache (thunderclap headache)
Systemic symptoms- Fever, neck stiffness, rash, weight loss
Neurological signs - Confusion, impaired consciousness, focal neurology, swollen optic discs

Question 7

What are characteristics of episodic headaches?

Answer 7

Unilateral location
Pulsating quality
Moderate or severe pain intensity
Aggravation by routine physical activity
Last hours and sometimes days!

Question 8

What other symptoms are there for episodic migraines?

Answer 8

Nausea and/ vomiting
Photophobia (lights) and/ phonophobia (sounds)
+/- Auras

Question 9

What are auras?

Answer 9

Complex array of symptoms reflecting focal cortical or brainstem dysfunction

Gradual evolution: 5-30minutes (<60minutes)
Usually before headache

Question 10

What is the migraine phase before headache?

Answer 10

Premonitory symptoms - yawning, polyuria, mood change, irritable, light sensitive, neck pain, concentration difficulty

Question 11

What does the migraine phase aura involve?

Answer 11

Visual, sensory (numbness/paraesthesia), weakness, speech arrest

Question 12

What does the headache phase involve?

Answer 12

Head and body pain, nausea, photophobia

Question 13

What are the phases after the headache?

Answer 13

Resolution: rest and sleep
Recovery: mood disturbed, food intolerance, feeling hungover
Can take up to 48 hours

Question 14

What is the first way to manage migraines?

Answer 14

Lifestyle: avoid triggers
Diet
Sleep
Exercise
Mindfulness

Question 15

What is the second step to manage migraines?

Answer 15

Pharmacological therapy

Question 16

What are the 2 types of pharmacological therapies?

Answer 16

Acute/abortive
Long term preventative

Question 17

What is acute/abortive management?

Answer 17

Hard and fast!
Paracetamol
NSAIDs (high dose & soluble)
Prokinetics
Triptans (5-HT1B/1D/1F receptor agonists)

Question 18

What is long term preventative management?

Answer 18

> 5 days/month
“low and slow” with doses until at optimal dose

Question 19

What are the new medications on the block for preventing migraine?

Answer 19

CGRP Anitbodies

Question 20

What is a tension type headache described as?

Answer 20

Patients usually say its feels like:

Tight muscles around head and neck, as though head is in a vice.

Question 21

What are features of tension type headaches?

Answer 21

Lasts 30mins (but can be hours long):
—-Bilateral
—–Mild or moderate
—–Not aggravated by movement
No added features typically
—–No nausea or vomiting
—–No photophobia or phonophobia

Question 22

What is the treatment for tension type headaches?

Answer 22

Reassurance may suffice in the majority of patients.
Individual attacks can be treated with simple analgesics such as Aspirin or Paracetamol.
Preventative medications rarely required

Question 23

What are the features of a cluster headache?

Answer 23

Severe unilateral pain
Last 15-180 minutes if untreated.
At least one of the following, ipsilaterally:
——-Conjunctival redness and/or lacrimation
———Nasal congestion and/or rhinorrhoea
——–Eyelid oedema
Forehead and facial sweating
Miosis and/or ptosis
A sense of restlessness or agitation
Not associated with a brain lesion on MRI

Question 24

What is the acute treatment for cluster headaches?

Answer 24

Triptan: Nasal or subcutaneous route

High flow oxygen: Oxygen inhibits neuronal activation in the trigeminocervical complex

Question 25

What prevention treatment can be offered for a cluster headache?

Answer 25

Verapamil (Calcium channel inhibitor)
—-Get an ECG first in case they have a heart condition/ heart block as this can make it worse
Greater occipital nerve block

Question 26

Compare migraines, tension type headaches and cluster headaches?

Unilateral/bilateral
Pulsating or not
Severity
Aggravated by?
Other symptoms
Length
Frequency