Headaches

Question 1

Tension headache - definition

Answer 1

Either episodic or chronic, rarely disabling. The attacks are generalised throughout the head with a predilection for involving the frontal and occipital regions. The pain is typically expressed as being a ‘tight band’ around the head.

Question 2

Tension headache - risk factors

Answer 2

• mental tension
• stress
• missing meals
• fatigue.

Question 3

Tension headache - clinical features

Answer 3

• generalised head pain
• frontal or occipital head pain (often bilateral pressure-like and non-throbbing pain).
• non-pulsatile head pain (often described as dull pain)
• constricting pain (tight band around head)
• not aggravated by activity
• normal neurological examination

Question 4

Tension headaches - investigations

Answer 4

Clinical Dx

no N + V
photo or phonophobia absent or only 1 present

Question 5

Tension headaches - Management

Answer 5

• acute attack: simple analgesics (aspirin or paracetamol or ibuprofen or naproxen)
• chronic (>7 to 9 headaches days/month): antidepressants (amitriptyiline or doxepin or mirtazapine)

Question 6

Migraine - definition

Answer 6

Migraine is a chronic, genetically determined, episodic neurological disorder that usually presents in early-to-mid life. Key features are nausea, photophobia, and disability, along with headache.

Question 7

Migraine - risk factors

Answer 7

family history of migraine
high caffeine intake
exposure to change in altitude pressure
female sex
obesity
habitual snoring (OSA)
stressful life events
lack of sleep

Question 8

Migraine - clinical features

Answer 8

usually unilateral, throbbing pain
prolonged headache (4 to 72 hours if untreated)
nausea
decreased ability to function
headache worse with activity
sensitivity to light (photophobia)
sensitivity to noise (phonophobia)
aura

Question 9

What is an aura?

Answer 9

Symptoms preceding attacks. Commonly seen with migraine; rarely seen with occipital seizures. Patients have both positive phenomena (visual sparkles, flashing lights) and negative phenomena (visual loss or scotoma). Sensory aura (numbness, tingling), and aura with aphasia/dysphagia may occur.

Question 10

Migraine - investigations

Answer 10

Clinical Dx

at least 5 attacks, unilateral, pulsating, N or V, aggravated by routine physical activity eg walking or stairs

Question 11

Migraine - Management

Answer 11

• oral sumatriptan, OR NSAIDs OR paracetamol (monotherapy or combination triptan + 1 other)
• pregnant: paracetamol
• N + V: add enti-emetic (metoclopramide, prochlorperazine)
• prophylaxis: propanolol
• oxygen via non-rebreather mask my improve

Question 12

Cluster headaches - definition

Answer 12

Severely painful, unilateral headache attacks lasting 15 to 180 minutes, associated with autonomic symptoms secondary to parasympathetic hyperactivity and sympathetic hypo-activity. Recurrent or some patients will develop chronic cluster headache and experience daily attacks without periods of remission.

Question 13

Cluster headaches - risk factors

Answer 13

male sex
family history
head injury
cigarette smoking
heavy drinking

Question 14

Cluster headaches - clinical features

Answer 14

repeated attacks of unilateral pain (Rapid onset of orbital, retro-orbital, or temporal pain, or maxillary region, 15 to 180 minutes. The average number of attacks is 4 per day, maximum of 8), awaken from sleep
excruciating pain
lacrimation, rhinorrhoea, and partial Horner's 
syndrome (ptosis and myosis), 
agitation
nausea, vomiting
photophobia, phonophobia
migrainous aura

Question 15

Cluster headaches - investigations

Answer 15

brain CT scan or MRI
ESR
pituitary function tests (eg TFTs, LH, FHS, IGF-1)

Abnormalities indicate secondary cause eg tumour, cavernous sinus pathology, pituitary adenoma, giant cell arteritis

Question 16

Cluster headaches - management

Answer 16

• acute: subcutaneous sumatriptan and oxygen (non-rebreather mask)
• prophylaxis: verapamil 1st choice, prednisolone 2nd

Question 17

Headaches - red flags

Answer 17

• headache, fever, stiff neck = MENINGITIS
• Hx of blunt head trauma at temporoparietal aspect of skull = EPIDURAL HEMATOMA (immediate CT)
• ‘thunderclap’ (sudden onset of severe headache) usually in women 40-60 yrs, reaches max intensity within minutes = SAH (immediate CT)
• first severe headache, >50 y/o, high ESR = GIANT CELL ARTERITIS?
• > 50 y/o, decreased visual acuity, nausea/vomiting, eye pain, mid-dilated fixed pupil = ACUTE ANGLE-CLOSURE GLAUCOMA
• New onset or change in pattern of headaches, N+V, vision or sensation problems = BRAIN TUMOUR?
• headache + focal neurological signs = STROKE?

Question 18

What is a “chronic daily headache”?

Answer 18

Descriptive term
- Headaches on > 15 days per month for 3 months
- Includes:
Chronic migraine
Chronic TTHA
Medication overuse headache
NDPH (New daily persistent headache)

Question 19

Medication Overuse Headache (MOH)

Answer 19

Headache on 15 or more days per month for 3 or more months with either:

• Triptans, opioids or combination on 10 or more days per month
• Simple analgesics on 15 or more days per month

Question 20

MOH - clinical features

Answer 20

• typically migraines in teens > long term analgesics > Daily migraine-like headache in middle age
• Resembles primary headache
• Painkillers don’t work or ‘take edge off’
• Reluctant to give drug history

Question 21

New daily persistent headache

Answer 21

• Most recall onset
• Often antecedent event
• Mimics chronic migraine or TTHA
• Can be self-limiting but usually persistent

Question 22

Chronic migraine - lifestyle measures

Answer 22

• Painkillers for severe attacks only
• Stay off caffeine
• Keep hydrated
• Exercise
• Eat regularly