Headaches Flashcards
Several life-threatening conditions can present with an acute-onset headache.
It is important that these are differentiated from an acute presentation of a benign primary headache such as a migraine.
What are the acute-onset headaches need to be aware of [9+]
Subarachnoid haemorrhage:
- a bleed into the subarachnoid space. Commonly due to a ruptured aneurysm. Classically causes a ‘thunderclap headache’ with maximal intensity within a few seconds to under one minute.
- Often described as being ‘hit on the back of the head’.
- May be associated with loss of consciousness, neck pain, nausea, vomiting and/or photophobia.
Intracerebral haemorrhage:
- this is a type of stroke due to a bleed into the brain parenchyma.
- Typically causes a sudden onset headache and there may be a history of anticoagulation use.
- Can cause focal neurological deficits (e.g. hemiplegia) depending on the location of the bleed. Associated with other global neurological features such as reduced consciousness, seizures, nausea and/or vomiting.
Migraine
- a primary headache that typically causes a unilateral, throbbing headache associated with phonophobia, photophobia and nausea/vomiting. May be associated with an aura (i.e. fully-reversible visual, sensory or other central nervous system symptoms). Typically last 4-72 hours.
Trauma
- (and associated injuries): a head injury can lead to a localised on generalised headache and may present weeks after the trauma due to a secondary complication (e.g. subdural haematoma). Can cause coma or decline in mental status due to associated bleed (e.g. extradural, subdural or subarachnoid haemorrhage).
Arterial dissection
- this refers to a tear within the arterial wall lining (i.e. intima). A headache with neck pain or pain that radiates into the neck may be suggestive of carotid or vertebral dissection. Usually a history of trauma (even if minor). Depending on the extent of the dissection stroke/TIA symptoms may occur whereas others have an isolated headache/neck pain. An isolated, painful Horner’s syndrome (miosis, ptosis) is classic for carotid artery dissection due to the location of the sympathetic fibres around the carotid artery.
Cerebral venous thrombosis:
- occurs due to a thrombus within one of the major veins of the head. The presentation is highly variable, but classically seen in those with thrombosis risk (e.g. inherited thrombophilia, pregnancy). Features depend on the location but can include seizures, focal neurological deficits and papilloedema.
Meningitis:
- refers to an infection of the meninges. Can be life-threatening if bacterial. Acute meningitis should always be suspected in a patient with a global acute headache, neck stiffness, fever and photophobia. The combination of headache, neck stiffness and photophobia is known as meningism.
Spontaneous intracranial hypotension:
- this refers to a sudden onset headache on sitting or standing. May be associated with other neurological features and thought to occur due to a cerebrospinal fluid leak in the spine. Typically resolves with lying flat.
Acute angle-closure glaucoma:
- this is an ophthalmic emergency that develops due to blockage of the drainage of the aqueous humour within the anterior chamber of the eye. Causes a rise in intra-ocular pressure, severe eye pain, and headache. Visual disturbance is commonly seen.
What are subacute causes of headache need to consider? [4+]
Giant cell arteritis:
- this is a type of large-vessel vasculitis with preferential involvement of the carotid artery and its branches. Classically causes a unilateral temporal headache in older patients with scalp pain, jaw claudication and visual changes. Without urgent steroids can lead to permanent visual loss.
Brain abscess:
- this refers to a localised area of infection within the brain parenchyma. May be features of recent bacteraemia, infective endocarditis or head/neck infection (e.g. otitis media). Focal neurological deficits may be present that depend on location and fever may be noticed but often absent.
Space occupying lesions:
- a progressive headache with other features of raised intracerebral pressure (ICP) that include worse on lying down, bending over, straining or in the early morning. May be a primary brain tumour or metastatic spread from another cancer (e.g. lung cancer). Papilloedema (swollen optic discs) is usually present and may have focal neurological deficits related to the location of the lesion. With a severe rise in ICP, may have features of abnormal consciousness, nausea and vomiting.
Idiopathic intracranial hypertension (IIH):
- a disorder caused by chronically elevated ICP, which leads to the characteristic clinical features of global headache, papilloedema, and visual loss. It is a high-pressure headache worse on lying down and bending over and usually seen in overweight individuals.
Red flags
There are several red flags that are essential to determine in the history that may indicate a serious underlying cause of headache that requires further investigation. These can be remembered by the mnemonic ‘HEADACHE PAINS’:
What does this stand for? [+]
H - Head injury (any history of trauma?)
E - Eye pain +/- autonomic features
A - Abrupt onset (i.e. thunderclap headache)
D - Drugs (analgesia overuse or since new drug started)
A - Atypical presentation or progressive headache
C - Change in the pattern or recent-onset new headache
H - High fever and systemic symptoms
E - Exacerbating factors (worse on lying/standing, sneezing, coughing, exercise)
P - Pregnancy or puerperium
A - Age (onset > 50 years)
I - Immunosuppressed (e.g. systemic therapy, HIV)
N - Neoplasia (current or past history of cancer)
S - Swollen optic discs (papilloedema)
When taking a headache history, what are the key parts need to ask about?
Onset and timing
* What was the patient doing at the time? (e.g. spontaneous or trauma)
* How quickly did the headache reach maximum intensity? (e.g. within a few seconds or several days)
* Has the headache been persistent since onset or come and go?
Location
Unilateral:
- classic causes of a unilateral headache include giant cell arteritis, migraine, or cluster headaches
Bilateral:
- this may be generalised or specific to a region such as a bilateral frontal headache in tension-type
- Pain radiating from, or too, the neck and upper back may indicate meningeal irritation seen in subarachnoid haemorrhage or meningitis. It may also be seen in cervical spondylosis.
Associated features
* Nausea and/or vomiting: commonly found in patients with migraine and form part of the diagnostic criteria. Also seen in patients with raised ICP (e.g. IIH, space-occupying lesion) and systemic illness (e.g. meningitis).
* Neck stiffness: a cardinal feature of meningeal irritation and may indicate meningitis or subarachnoid haemorrhage. Neck pain may also occur in arterial dissection or cervical spondylosis.
* Photophobia: this refers to a dislike for bright lights. A common feature of migraines and patients with meningeal irritation
* Phonophobia: this refers to a dislike for loud sounds. Another common feature of migraines
* Visual changes: changes can occur as part of an aura in migraine. Visual loss may occur in giant cell arteritis, acute angle-closure glaucoma or raised intracranial pressure. Cerebrovascular events or space-occupying lesions may affect the visual pathway leading to visual field defects.
* Focal neurological deficits: this refers to neurological signs and symptoms that localised to a specific area such as left-sided weakness or a cranial nerve defect. The findings depend on the location of the abnormality.
* Global neurology deficits: this refers to features consistent with global dysfunction of the brain. This is often due to raised intracranial pressure or severe infection. Features typically include altered mental status, seizures, and/or coma.
Past medical history
- Understanding a patients’ co-morbidities are vital to determine the possible cause of headache. A really key question is whether the patient has previously experienced headaches and how the current headache differs from those previous experiences. Headache is always concerning in a patient with no previous history, especially in the elderly.
Other parts of the medical history to think about include:
- Current or previous history of cancer: may suggest metastatic spread
- Any trauma: may indicate a bleed or fracture
- Any recent head and neck surgery: could suggest a tracking infection or abscess
- Any thrombosis risk: increased risk of cerebral venous thrombosis
- Drug history: is there an element of medication overuse headache?
- Family history: particularly around history of bleeding, subarachnoid haemorrhage or aneurysms
TOM TIP: Asking specifically about red flags demonstrates that you are thinking about serious causes. This will score extra points in OSCEs and help you document well when seeing patients.
What are examples of red flags? and what would they indicate? [+]
Fever, photophobia or neck stiffness
- (meningitis, encephalitis or brain abscess)
New neurological symptoms
- (haemorrhage or tumours)
Visual disturbance
- (giant cell arteritis, glaucoma or tumours)
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)
Vomiting
- (raised intracranial pressure or carbon monoxide poisoning)
History of trauma
- (intracranial haemorrhage)
History of cancer
- (brain metastasis)
Pregnancy
- (pre-eclampsia)
What are the three main types of primary headache? [3]
Migraine
Cluster
Tension-type
Describe how each of the following are in a migraine [+]
- Location
- Character
- Duration
- Other features
Migraine:
- Location = unilateral (although can be B/L in children)
- Character: pulsating, prefer dark quiet room
- Duration: 4-72hrs
- Other: N&V; photophobia; aura
Describe how each of the following are in a cluster headache [+]
- Location
- Character
- Duration
- Other features
Location:
- bilateral; frontal
- stabbing pain around one eye (recurrent attacks ‘always’ affect same side)
Character:
- pressure or band-like
- comes and goes
Duration
- 30mins - 7days
- Clusters typically last 4-12 weeks
Other features
- Often accompanied by redness, nasal stuffiness, lacrimation, lid swelling
Describe how each of the following are in a tension type headache [+]
- Location
- Character
- Duration
- Other features
Location:
- unilateral; around the eye
Character:
- deep, continous pain
- reaches intensity in minutes
Duration
- 15mins - 3hrs
Other feature:
- Ipsilaterla autonomic features (e.g. lacrimation)
Describe the presentation of a tension type headache [5]
bilateral
non-pulsatile
mild-to-moderate pain with a pressing or tightening quality.
often described as a ‘tight band’ around the head or a pressure sensation.
may be related to stress
not associated with aura, nausea/vomiting or aggravated by routine physical activity
NB: Symptoms tend to be bilateral, where as migraine is typically unilateral
Chronic tension-type headache is defined as a tension headache occur on [] or more days per month.
Chronic tension-type headache is defined as a tension headache occur on 15 or more days per month.
NICE produced guidelines on the management of tension-type headache in 2012:
acute treatment [3]
prophylaxis [2]
acute treatment:
- aspirin, paracetamol or an NSAID are first-line
prophylaxis:
- NICE recommend ‘up to 10 sessions of acupuncture over 5-8 weeks’
- low-dose amitriptyline is widely used in the UK for prophylaxis against tension-type headache.
Tension headaches may be associated with [5]
Stress
Depression
Alcohol
Skipping meals
Dehydration
How would you investigate for a cluster headache? [1]
MRI with gadolinium contrast is the investigation of choice
How do you dx a cluster headache?
A. At least five attacks fulfilling criteria B-D:
B. Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15-180 minutes (when untreated)
C. Either or both of the following:
One. at least one of the following symptoms or signs, ipsilateral to the headache:
* conjunctival injection and/or lacrimation
* nasal congestion and/or rhinorrhoea
* eyelid oedema
* forehead and facial sweating
* miosis and/or ptosis
Two: a sense of restlessness or agitation
D. Occurring with a frequency between one every other day and 8 per day
E. Not better accounted for by another ICHD-3 diagnosis.
Describe the acute [2] and prophylactic [2] tx of a cluster headache
Acute:
* 100% oxygen (80% response rate within 15 minutes)
* subcutaneous triptan (75% response rate within 15 minutes)
Prophylaxis:
* Verapamil is the drug of choice
* There is also some evidence to support a tapering dose of prednisolone
Hormonal headaches are related to low [].
How do they present? [+]
Hormonal headaches are related to low oestrogen.
They have similar features to migraines, with a unilateral, pulsatile headache associated with nausea. They are sometimes called menstrual migraines.
Hormonal headaches are related to low oestrogen. They have similar features to migraines, with a unilateral, pulsatile headache associated with nausea. They are sometimes called menstrual migraines. They may occur: [3]
- Two days before and the first three days of the menstrual period
- In the perimenopausal period
- Early pregnancy (headaches in the second half of pregnancy should prompt investigations for pre-eclampsia)
What are the key differentials for a unilateral headache? [3]
Common
Migraine
Infrequent
Cluster headache
Rare
Paroxysmal hemicrania
SDH
Tension
Headache
Headache
sinusitis
temporal arteritis
cluster headache
A man presents with a severe occipital headache and vomiting. It came on suddenly and reached maximum intensity within a minute. On examination there is neck stiffness is a stereotypical history of [1]
Subarachnoid haemorrhage
acute narrow-angle glaucoma
Extradural (epidural) haematoma
Herpes simplex encephalitis
Acupuncture
Raised ICP
Describe the usual type of cluster headache patient [1]
A typical patient is a 30-50 year old male smoker. They may have triggers, such as alcohol, strong smells or exercise.
Describe what is meant by Paroxysmal hemicrania (PH) [1]
Describe the presentation [3]
attacks of severe, unilateral headache, usually in the orbital, supraorbital or temporal region
- These attacks are often associated with autonomic features, usually last less than 30 minutes and can occur multiple times a day. (Occurring with frequency >5 times daily)
Either or both of the following:
At least one of the following symptoms ipsilateral to the headache:
- conjunctival injection
- lacrimation
- nasal congestion
- rhinorrhoea
- eyelid oedema
- forehead or facial sweating
- miosis
- ptosis. &
Restlessness or agitation
How do you treat PH? [1]
PH is completely responsive to treatment with indomethacin.
* 150mg of oral indomethacin daily
* This can be increased to 225mg daily if required
How do you ddx PH from cluster headache? [4]
- PH more frequent but lesser duration
- PH treated with indomethacin
- PH does not follow circadian rhythm (time fo day) or circaannual rhythm (time of year)
-PH not associated to ptosis or miosis
How would you Ix for PH? [1]
In any case of severe, unilateral headache, a diagnostic trial of indomethacin can be considered, sometimes referred to as an ‘indotest’
- a 50mg IM injection of indomethacin would be expected to give almost immediate protection from any further attacks for around 12 hours
