Headaches: Tension, Cluster, Migraine, IHH, Temporal arteritis, Medication Overuse, Cavernous Sinus Thrombosis

Question 1

IHH
-presentation

Answer 1

Persistant frontal, retroorbital
Bilateral, dull

Worsened by coughing, physical activity, pressing

Papilloedema => Ongoing progressive visual loss - different to migraine
Enlarged blind spot
If CNVI involved => diplopia

N+photophobia

Question 2

IHH
-pathophysiology
-risk factors

Answer 2

High ICP

Most common - obese females in 20-30s
Pregnancy
Drugs
-COCP, CS, tetracycline, VitA, Li

Question 3

IHH
-investigations, diagnosis
-management

Answer 3

Find any underlying causes
CT, MRI
ICP monitoring

IIH diagnosis of exclusion

Lifestyle - weight loss

Medication - acetazolamide, antiepileptic (topiramate)

Surgical
-repeated lumbar puncture
-optic nerve sheath decompression and fenestration

Question 4

Migraine
-epidemiology, pathophysiology

Answer 4

Young females

Result of abnormal brain activity affecting nerve signals, chemicals, blood vessels => pain

Question 5

Migraine
-diagnosis

Answer 5

Min 5 attacks lasting 4-72hrs

Min 2 of

unilateral
pulsation
moderate/severe
worse with activity
Min 1 of

N+V
photophobia/phonophobia

Question 6

Clinical course of migraine

Answer 6

Prodrome - 48hrs due to hypothalamic involvement
-fatigue
-cravings

Aura - 20min per symptom, last for 1hr - hypothalamic activity spreads to other brain areas
-marching progression through visual => sensory => motor, aphasia
-LOSS OF FUNCTION

Headache - 72hrs
-photophobia, phonophobia
-N+V

Resolution
-fatigue

Question 7

Migraine management
-acute
-preventative

Answer 7

Acute treatment
1st line - paracetamol, ibuprofen at first signs of headache
2nd line - triptan (before its at its worse+ antiemetics (metoclopramide or domperidone)

Preventative
-topiramate OD (antiepileptic)
others - propanolol/amitriptyline

Identify and avoid triggers - migraine diary
-date, time, duration
-warning signs
-symptoms
-medication

Question 8

Common migraine triggers

Answer 8

Tired/stress
Alcohol
COCP, periods
Hungry, thirsty
Bright light
Cheese, chocolate, red wine, citrus

Question 9

Medication overuse headache
-prevalence
-pathophysiology

Answer 9

More common in women
Pathophysiology a mystery :(

Question 10

Medication overuse headache criteria

Answer 10

Preexisting headache disorder
15+ headache days/month
Regular overuse of 3 months+ of acute/symptomatic headache treatment

Question 11

Medication overuse headache management

Answer 11

Definitive - withdrawal of overused drug
-IMMEDIATELY - simple + triptans
-GRADUAL - opioids

warn that symptoms may initially worsen but should improve over weeks
Keep headache diary

Reassess underlying cause

Question 12

Cluster headache
-diagnostic criteria

Answer 12

Min 5 attacks with the same presentation

15mins-3hrs
Severe unilateral eye pain, same side everytime

Restlessness/agitation
Ipsilateral to pain
-Tears, runny nose. sweating
-Eyelid edema
-miosis, ptosis
Frequency ranging from 1 every other day - 8 a day
-attacks will cluster

Question 13

Cluster headache management
-acute
-preventative

Answer 13

Acute - high flow O2
-2nd line - triptan (SC, IN) - can only use it 2x a day due to increased risk of side effects with prolonged use

Confirmation needed with neuroimaging
-often there is an underlying brain lesion

Preventative - verapamil whilst they have episodic clusters

taper off when clusters end
alts - topiramate, lithium

Question 14

Primary vs secondary headache

Answer 14

Primary more likely if

headache type known for years
gradual onset
no neuro deficit
Secondary more likely if

new unknown headache
sudden onset (as if something fell on your head = ASSUME VASCULAR UNLESS PROVEN OTHERWISE WITH CT, LP
electric shock-like - trigeminal?
neuro deficit, altered consciousness
50+
positional changes, precipitated by something
systemically unwell

Question 15

Thunderclap headache
-possible causes

Answer 15

SAH
ICH
Cerebeal venous thrombosis
Arterial dissection - intracranial/extracranial

Question 16

Headache due to CSF pressure change
-differentiating between high and low pressure headaches

Answer 16

Raised pressure - SOL, bleed, abscess, IIH

worse in morning
better upright
worse with Valsalva
Low pressure - dural tear (idiopathic/trauma)

worse as day progresses
better recumbent

Question 17

Differentiating between primary headaches
-duration
-localisation
-accompanying symptoms
-intensity

Answer 17

Duration

constant - tension?
seconds - trigeminal?
mins to hours - cluster?
Localisation

same unilateral attacks - trigeminal?, cluster?
bilateral - tension?
unilateral - migraine
Accompanying symptoms
-nausea, photophobia, lacrimation, aura?

Intensity, changes with physical activity?

worsens on mv - migraine?
improves on mv - tension? cluster?

Question 18

Trigeminal neuralgia
-presentation
-pathophysiology
-management

Answer 18

Severe unilateral pain limited to divisions of CNV
-electric shock like
Evoked by light touch (washing, shaving, talking, brushing teeth)

Most idiopathic
Compression by tumour/vascular (common: superior cerebellar artery)

Carbemazepine
Failure to respond => neuro referral

Question 19

Tension
-epidemiology
-pathophysiology
-presentation
-management

Answer 19

Common in both sexes, 40-50
Pathophysiology unclear but related to increased central sensitization

Tight band-like pressure, bilateral
Lower intensity
No aura, N/V
Not worsened by physical activity

Acute
-aspirin/paracetamol/NSAID
Prophylaxis
-address triggers - stress, poor sleep, anxiety, depression
-up to 10 sessions of acupuncture over 5-8wks

Question 20

Temporal arteritis/GCA
-epidemiology and associations
-pathophysiology

Answer 20

70, white females
Associated with PMR

Genetic, environmental (seasonal, geographic clustering?), immune dysregulation => vascular inflammation and damage

Question 21

Temporal arteritis/GCA
-presentation

Answer 21

Rapid onset headache
Jaw claudication
Tender palpable temporal artery

VISION TESTING VITAL
-temporary visual loss
-sudden permanent visual loss - most feared complication

Consitutional - tired, depression, low-grade fever, anorexia, night sweats
PMR - aching, morning stiffness in proximal limbs, no weakness

Question 22

Cavernous sinus thrombosis
-what is it
-presentation
-key investigations
-management

Answer 22

Clot in cavernous sinuses
-venous plexus surrounding ICA, CN3, 4, 5v1, 5v2

Can be caused by facial or skull infection
-sinusitis

Sharp severe headache around eye
Swelling, bulging eye
Double vision
FEVER

FBC, cultures
Contrast CT and MRI

ABx + IV CS