Headaches

Question 1

What are the signs and symptoms of a tension headache?

Answer 1

1) Chronic daily headache
2) Bilateral, non-pulsatile, tight-band like
3) mild to moderate +/- scalp tenderness
4) No vomitting, no sensitivity to head movement or aura

Question 2

How to diagnose a tension headache?

Answer 2

1) Clinical Diagnosis
2) Headache diary?
3) NO IMAGING!!!

Question 3

Management of tension headache?

Answer 3

1) Reassurance + lifestyle advice - regular exercise, avoid triggers, physiotherapy, relaxation therapy
2) Acute symptomatic treatment - appropriate for episodes occurring >2 days a week - aspirin, paracetamol, NSAIDS (NOT OPIOIDS)
3) Course of acupuncture - only prophylactic treatment recommended

Question 4

Risk factors for migraine?

Answer 4

1) Cheese
2) Caffeine or withdrawal
3) Alcohol
4) Oral contraceptive
5) Menstruation
6) Anxiety
7) 90% in <40 years old

Question 5

How does a migraine present?

Answer 5

1) +/- aura lasting 5-60 mins with headache following within an hour - visual (hemianopia, flashing, jagged lines), sensory, motor, vestibular.
2) Moderate to severe (4-72 hours)
3) Unilateral, pulsatile, throbbing, worse on movement.
4) Photophobia/phonophobia
5) Nausea +/- vomitting

Question 6

What investigations are carried out for a migraine?

Answer 6

1) Clinical Diagnosis
2) Exclusion - CRP + ESR
3) Neuroimaging and LP if red flags.

Question 7

What are some red flags for a headache?

Answer 7

1) Worst/severe headache
2) Rapid onset/progressive
3) Change in pattern
4) Onset >50 years
5) Epilepsy
6) Posteriorly located headaches
7) Abnormal neuro examination

Question 8

Management of migraine?

Answer 8

1) Reduce triggers (dietary changes)
2) Acute: Combination of triptan (Sumatriptan) and NSAID/Paracetamol +/- anti-emitic if required
3) Nasal triptan if 12-17yo
4) Prophylactic - If 2+ attacks a month or acute treatment is needed more than twice a week: Topiramate (teratogenic) or teratogenic

Question 9

How does a cluster headache present?

Answer 9

1) Rapid onset excruciating pain around one eye (unilateral)
2) Rising to crescendo over minutes and lasting 15-160mins, once or twice a day
3) Can last up to 5-12 weeks followed by pain free periods months to years
4) Nocturnal/early mornings waking patient up
5) Watery + bloodshot eye - lacrimation, rhinorrea, facial flushing, miosis +/- ptosis
6) Vomiting
(Spring/Autumn months)

Question 10

How do you diagnose cluster headaches?

Answer 10

Clinical

Question 11

How do you treat cluster headaches?

Answer 11

Abortive:
1) 100% 15L Oxygen for 10-20 minutes via non-rebreathable mask.
2) Sumatriptan (6mg subcut at onset) or Zolmitriptan (5mg nasal spray)
Preventative:
1) Verapamil (80mg TDS/QDS) is first line.
2) Prednisolone (short course during cluster)
3) Avoid alcohol

Question 12

Cause of trigeminal neuralgia?

Answer 12

Compression of trigeminal nerve mainly due to arterial/vasculature, or aneurysms, meningeal inflammation and tumours. Hypertension risk factor. Causes excitation of trigeminal nerve. (Peak age 50 years)

Question 13

Clinical presentation of trigeminal neuralgia?

Answer 13

1) Sudden UNILATERAL paroxysms of knife-like/electric shock pain
2) Starts in the mandibular division and radiates upwards to maxillary and ophthalmic divisions
3) Last seconds to minutes, many spasms throughout the day
4) Atypical TN can be burning sensation
5) Triggers: Shaving, eating, talking, dental prosthesis, vibration and cold winds.
6) Often associated with Polymyalgia Rheumatica

Question 14

Diagnosing trigeminal neuralgia?

Answer 14

1) Exclude temporal arteritis
2) MRI to exclude secondary causes and pathologies
3) IHS criteria for TN:
a) Paroxysmal attacks of pain lasting between a second to 2 minutes, affecting 1 or more of the trigeminal divisions, and fulfilling b and c.
b) Pain has 1 of the following characteristics: 1) sharp, superficial, stabbing or intense, 2) precipitated from trigger areas or trigger factors
c) Attacks stereotyped in individual patient.
d) No neurologic focal deficit
e) Not attributed to different disorder

Question 15

How to treat TN?

Answer 15

1) Typical analgesics and opioids do not work
2) Carbamazepine 600mg-1200mg daily
3) Other options: Gabapentin, Lamotrigine (discontinue if TN spontaneously remits after 6-12 months)
4) Percutaneous Rhizotomy
5) Neurovascular decompression
6) Radiation therapy: Stereotactic radio surgery

Question 16

Cause of Giant Cell/temporal Arteritis?

Answer 16

1) Inflammatory granulomatous vasculitis of the large cerebral arteritis.
2) Must be excluded in any >50yo with new headche lasting few weeks, ELDERLY.

Question 17

Signs and symptoms of GCA?

Answer 17

1) Temporal pulsating headache
2) Jaw claudication (on eating)
3) Scalp tenderness (combing/washing hair)
4) Amaurosis faux - sudden blindness typically in one eye
5) Tender, thickened, nodular, pulseless temporal artery
6) Systemic features - myalgia, fever, breathlessness, fatigue, morning stiffness

Question 18

Diagnosis/Investigations of GCA?

Answer 18

1) Raised ESR (50-120mm/h) and CRP
2) Normochromic, normocytic anaemia
3) Temporal artery biopsy within 1 week of steroids (do not delay steroids) - will show skip lesions in multiple sites
4) Doppler USS

Question 19

Treatment of GCA?

Answer 19

1) HIGH DOSE Prednisolone (60mg OD PO) - start ASAP due to risk of permanent visual loss from from anterior ischaemic optic neuropathy from vasculitis of ciliary arteries. Reduce steroids gradually over 12-18 months.
2) IV methylprednisolone for 3 days if visual symptoms present.
3) PPI’s and bisphosphonates due to long term steroid use.
POLYMYALGIA RHEUMATIC present at 50% of cases. Monitor treatment looking at ESR/CRP.