Headaches

Question 1

Types of Headaches

Answer 1

• Subarachnoid Haemorrhage
  
  • Meningitis
  • Tumour
  • Migraine
  • Tension-type
  • Giant Cell Arteritis
  • Cluster
  • Medication overuse
  • Trigeminal Neuralgia
  • Head injury
  • Sinusitis
  • Raised ICP

Question 2

Define Migraine and its Clinical Presentation

Answer 2

Not well understood; either initiation of activity in brainstem or reticular formation or cortical depression

• Unilateral pulsating headache, nausea & vomiting, constitutional upset (fatigue, carb craving, diuresis) lasting > 48 hours
• +/- prodrome of gradually evolving symptoms including;
  * visual phenomena
  * altered sensation of face or limbs
  * double vision
  * vertigo (aura)

Question 3

Define Tension-type and its Clinical Presentation

Answer 3

May be a variation of migraine and some patients can have both types or tension after cluster type

Bilateral non-pulsating headache lasting 30minutes up to weeks without vomiting or neck stiffness

Question 4

Define Giant Cell Arteritis

Answer 4

Aka temporal arteritis is a connective tissue disorder

Question 5

Define Cluster and its Clinical Presentation

Answer 5

Re-occuring headaches that may be due to hyper-reactivitiy of the superficial temporal artery smooth muscle with a high (9) male:female ratio

• Severe unilateral headache which may involve pain around one eye
• Has lacrimation and rhinorrhoea.
• Duration is 12 minutes - 3 hours
• Frequency is 1-2 times per day
• Lasts for 4-12 weeks with pain-free periods

Question 6

Define Medication overuse and its Clinical Presentation

Answer 6

Medications likely to cause this are
- triptans
- opioids
- NSAIDs
- sergotamine.
These drugs down-regulate receptor and enzymes (i.e. COX 1,2) responsible for nociception creating lowered threshold for pain perception.

• Usually 30-60 female that has a history of a decade of migraine or tension-type headache there may be a family history of headache complicated by emotional distress

Question 7

Define Trigeminal Neuralgia

Answer 7

Unilateral, facial pain in the distribution of the maxillary or mandibular branches

Question 8

Common Headache Risk factors

Answer 8

• Female (migraine)
  
  • Male (cluster)
  • Family Hx
  • Trigger
    
    • Alcohol
    • Caffeine
    • Anxiety
    • Exercise
    • OCP
    • Travel

Question 9

Headache Investigations

Answer 9

No routine investigations of routine primary headaches are necessary

• CT
  
  • Exclude haemorrhagic stroke (thunderclap, quick onset) or lesions reducing CSF volume
• LP
  
  • If neck stiffness is present to exclude meningitis
• ESR
  
  • To rule out temporal arteritis (or polymyalgia rheumatic)

Question 10

Migraine Management

Answer 10

• Acute (one of)
  * 1st Line
  * NSAID
  * 2nd Line
  * Triptan/Ergotamine
  
  • PLUS Antiemetic
    
    • Domperidone
    • Metoclopramide
    • Prochlorperazine
  • Prevention
    
    • Amitriptyline
    • Pizotifen
    • Propranolol

Question 11

NSAIDs Used for Common Headaches

Answer 11

• Aspirin
  
  • Diclofenac
  • Ibuprofen
  • Naproxen
  • (Paracetamol)

Question 12

Triptans Used for Migraines

Answer 12

• Non-selective 5HT receptor agonist leading to inhibition of trigeminal neurotransmission
  
  • Eletriptan
  • Naratriptan
  • Ritatriptan

Question 13

Tension-Type Headache Management

Answer 13

• Short lived attacks
  * NSAIDs
  * TCAs
  * Amitriptyline