Headaches

Question 1

What are some key differentials for headaches?

Answer 1

• tension headache
• cluster headaches
• migrane
• trigeminal neuralgia
• raised intracranial pressure (due to tumours, haemorrhage, IIH etc).
• infections - e.g. meningitis, encephalitis otitis media, sinusitis
• exposure to substances - e.g. alcohol, medication overuse headaches
• trauma
• giant cell arteritis
• opthalm conditions - e.g. glaucoma
  + many others

Question 2

Describe a tension headache

Answer 2

• bilateral
• tight band / pressure around the head sensation
• may be related to stress
• not associated with aura, nausea/vomiting, photophobia

Question 3

How are tension headaches managed?

Answer 3

Analgesia per the WHO pain ladder
- Paracetamol or NSAID
Aim to reduce stress.

Question 4

What are cluster headaches?

Answer 4

Headaches that occur in clusters lasting several weeks.

Question 5

Who are most likely to suffer from cluster headaches?

Answer 5

• male
• smokers
• can be triggered by alcohol

Question 6

Describe the symptoms of cluster headaches?

Answer 6

Recurrent attacks of
- headache that lasts between 15 mins and 3 hrs
- there occur once or twice a day for 4-12 weeks before a pain free period before the next cluster
- sudden onset unilateral stabbing periorbital pain with a watery, bloodshot eye
- rhinnorhea
- miosis, ptosis and lid swelling

Question 7

How are cluster headaches managed?

Answer 7

• avoid triggers
• prophylaxis with verapamil (CCB)
• manage acute attacks with 100% oO2 or nasal (or subcut) triptan

Question 8

What are the symptoms of giant cell arteritis?

Answer 8

• Unilateral headache
• Jaw claudication
• tender, palpable temporal artery
• visual changes

Question 9

What investigations are done to diagnose giant cell arteritis?

Answer 9

• bloods - inflammatory markers - CRP and ESR
• Temporal artery biopsy

Question 10

What is giant cell arteritis?

Answer 10

A medium and large vessel vasculitis that can lead to permanent visual loss.

Question 11

What other condition is associated with giant cell arteritis?

Answer 11

Polymyalgia rheumatica

Question 12

How is giant cell arteritis managed?

Answer 12

• urgent high dose steroids
• urgent opthalm review

Question 13

What are the features of a medication overuse headache?

Answer 13

• headache is present for >15days per month
• developed or worsened whilst taking regular symptomatic (analgesic) medication
• patients on opioids or triptans are most at risk

Question 14

Who is affected by migraines?

Answer 14

Female > Male
(1 in every 5 females)
Common (15 in every 100)
Presents early to mid-life
Most have first attack by 30

Question 15

Describe the presentation of migraines?

Answer 15

• unilateral, throbbing headache
• may be preceded by an aura
• headache lasts 4-72 hours
• associated photophobia / phonophobia
• may have identifiable triggers

Question 16

What can trigger migraines?

Answer 16

Certain foods - e.g. chocolate
Menstrual cycle
Stress
Lack of sleep
Medications - e.g. COCP

Question 17

How are migraines managed?

Answer 17

• avoid triggers
• prophylaxis with propranolol (B blocker) or Topiramate
• manage acute attack with oral triptans alongside Paracetamol / NSAIDs
• ensure not taking COCP

Question 18

Why should the COCP be avoided in people who have migraine with aura?

Answer 18

As it increased their risk of an ischaemic stroke.

Question 19

What are the red flags of headache presentation?

Answer 19

Systemic signs
Neurological symptoms
Onset new or changed in patient > 50 years old
Onset thunderclap presentation
Papilloedema, positional provocation, precipitated by exercise