Headaches

Question 1

What can cause primary headache?

Answer 1

Migraine
Cluster
Tension

Question 2

What can cause secondary headache?

Answer 2

Meningitis, SAH, GCA, idiopathic intracranial hypertension, medication overuse.

Question 3

What are the risk factors for migraines?

Answer 3

Female (20%)

Question 4

What are the partial triggers for migraines?

Answer 4

Chocolate
Hangovers
Orgasms
Cheese
Oral contraceptive pill
Lie-ins
Alcohol
Tumult
Exercise

Question 5

Describe the epidemiology of headaches

Answer 5

Very common. Episodic tension headache most common.

Question 6

Give the symptoms of migraine without aura.

Answer 6

4-72 hours
Nausea/ vomiting
Photo- and phonophobia
Throbbing pulsatile pain
Unilateral and localised pain in the frontotemporal/ ocular area.

Question 7

What are the types of migraine?

Answer 7

Migraine with aura
Migraine without aura
Migraine variants
(PTS)

Question 8

What investigations would you do if someone presents with headache?

Answer 8

Bloods - microbiological cultures - meningitis, encephalitis?
Scans - CT scan - haemorrhage/ stroke?
Eye investigation - acute glaucoma?

Question 9

What are the diagnostic criteria for migraine with aura?

Answer 9

FeatureFULL compared to tension headache.
1. One of 4 fully reversible aura symptoms:
Visual - dots, melting/jumbling of lines
Sensory - tingling, numbness
Speech/ language - aphasia
Motor - rule out stroke and TIA!
2. Two of 4 characteristics:
- 1+ aura symptom spreading gradually over >5min
- each individual aura symptom lasts 5-60 min.
- at least 1 aura symptom is unilateral
- accompanied or followed 60 minutes later with headache
(PTS)

Question 10

What are the symptoms of tension headache?

Answer 10

‘featureless’ compared to migraine; ‘normal’ and common
Photo OR phonophobia.
Moderate

Question 11

What are the diagnostic criteria for migraine with aura?

Answer 11

At least 5 attacks:

1. lasting 4-72 hours
2. 2+ of: Unilateral, pulsating, moderate/severe pain, aggravation by physical activity (lying still)
3. 1+ of: Nausea/vomiting, photophonia and phonophobia.

Question 12

Describe the management of migraine.

Answer 12

Lifestyle: avoid triggers, change or stop OC pill
Medical: Oral triptan eg synatriptan and NSAID/ paracetamol; consider adding anti-emetic
Prophylaxis: propanolol; if ineffective - acupuncture; amitriptyline (antidepressant)
Riboflavin daily may help (NICE, lecture 23.3.18, PTS)

Question 13

What are the diagnostic criteria for cluster headache?

Answer 13

Severe, unilateral, orbital/supraorbital/temporal pain
15-180 mins
<8 per day
sense of agitation - opposite to people with migraines who don’t want to move.
Ipsilateral cranial autonomic features: eye lacrimation (tears), redness, rinhorrhea (runny nose), miosis, ptosis.

Question 14

What are the diagnostic criteria for classical trigeminal neuralgia?

Answer 14

1. 3+ attacks of unilateral pain ….
2. … in the trigeminal region only….
3. …occuring in paroxysmal attacks lasting up to 2 minutes/ severe/ stabbing/sharp/ Triggered by stimulation eg brushing teeth….
   4…with no neurological deficit.
   (PTS, lecture)

Question 15

Define infrequent episodic tension headache

Answer 15

<1 day per month, lasting 30m-7 days

Bilateral, pulsating, mild/moderate, photo OR phonophobia, NOT aggravated by physical activity, NO nausea or vomiting.

Question 16

Define frequent episodic tension headache

Answer 16

1-14 days per month on average for >3 months

Question 17

Define chronic tension headache

Answer 17

> 14 days per month on average for > 3 months

Question 18

Define probable tension headache

Answer 18

Doesn’t fit any other criteria, one feature short of fulfilling tension headache criteria.

Question 19

Describe the management of tension headache.

Answer 19

Analgesics eg aspirin, NSAIDs (ibuprofen, diclofenac)
TCAs eg amitriptyline.
(PTS)

Question 20

Define episodic cluster headache.

Answer 20

2+ cluster periods lasting 7 days to 1 year, separated by pain-free periods lasting at least a month.

Question 21

Define chronic cluster headache

Answer 21

Occurs for >1 year without remission, or remission lasting <1 month.

Question 22

Describe the management of an acute attack of cluster headache.

Answer 22

1. Sumatriptan sc/ zolmitriptan nasal spray
2. 100% oxygen therapy
3. Prevention: verapamil, lithium, corticosteroids.
   (PTS)

Question 23

Describe the management of trigeminal neuralgia.

Answer 23

1. Anti-convulsant eg carbamazepine
2. Phenytoin, gabapentin
3. Surgery: microvascular decompression; sterotactic radiotherapy.

Question 24

Give a risk factor for cluster headaches

Answer 24

Being male