L13 - Headache

Question 1

Primary headache

Answer 1

Normally recurrent
Due to headache condition
Non life threatening

Question 2

Secondary headaches

Answer 2

Due to another condition
Acute
Severe pain
More likely to be life or sight threatening

Question 3

Primary headache disorders

Answer 3

Tension headache
Migraine
Cluster headache

Question 4

Secondary headache conditions

Answer 4

Stroke
Space occupying lesion:
- tumour 
- cerebral abscess 
Intracranial haemorrhage 
Acute sinusitis 
Otitis media intracranial spread of infection 
Temporal arteritis 
Closed angle glaucoma 
Medication over use 
Hypertension 
Pre-eclampsia

Question 5

SNOOP - red flag signs of headaches

Answer 5

Systemic:

• meningitis - fever, neck stiffness, photophobia
• cancer
• HIV
• pregnancy - pre-eclampsia

Neurological symptoms:

• SOL
• intracranial haemorrhage
• closed angle glaucoma

Onset new/ changed in under 50 yr olds
- malignancy

Onset in thunderclap headache
- subarachnoid haemorrhage

Papilloedema - increased ICP

• pulsatile tinnitus
• positional provocation
• precipitated by exercise

Question 6

Who does tension type headaches affect?

Answer 6

More common in females and young adults

Normally have first onset before 50 yrs old

Question 7

Tension type headache

Answer 7

Sight: generalised frontal and occipital
Quality: tight band like pain +/- radiating into the neck
Intensity: mild or moderate
Time: worst at the end of the day, lasting for about 1 hour and recurrent
Aggravating factors: stress, poor posture, lack of sleep
Relief: analgesics
Secondary symptoms: slight nausea

Clinical exam: normal

Question 8

Who gets migraines

Answer 8

More common in females
Presents in early to mid life
Most have first attack by 30

Question 9

Possible pathophysiology

Answer 9

Vasodilation of meningeal blood vessels

Question 10

Migraine

Answer 10

Sight: unilateral frontal or temporal
Quality: throbbing or pulsating
Intensity: moderate- severe, go to bed or avoid light
Time: prolonged headache
Aggravating factors: stress, certain food, lack of sleep, menstrual cycle, FHx
Relief: analgesics and triptans
Secondary symptoms: nausea and vomiting, aura, sensory deficit, neurological symptoms

Clinical exam: normal

Question 11

Medication over use headache

Answer 11

Affects females more
Headache occurs for more than 15 days per month
Occurs in patients with pre- existing headache disorders due to overuse of regular analgesics for at least 10 days per month
Headache does not respond to medication or another type of headache
occurs
Co-exists with depression and sleep disturbances

Question 12

Advice for medication over use headache

Answer 12

Shouldn’t take analgesics for more than 2 days per week
Discontinue medication if headaches become worse - headache will worsen before improves but normally resolved completely by 2 months

Question 13

Common drug that causes medication over use headaches

Answer 13

Cocodamol

Question 14

Who gets cluster headaches?

Answer 14

More common in males
1 in 1000
Usually begins in 30-40s

Question 15

Signs of cluster headache

Answer 15

Red conjunctiva
Nasal congestion
Ptosis
Tearing

On the same side as the headache

Question 16

Cluster headache pain

Answer 16

Sight: unilateral around or behind the eye
Quality: sharp, stabbing and penetrative pain
Intensity: severe suicidal
Time: 15 mins - 3 hours, occurs in clusters with periods of remission
Aggregating factors: alcohol, smoking, warm temperature, volatile smells, lack of sleep
Relief: oxygen and triptans
Secondary symptoms: ipsilateral autonomic symptoms e.g. tears, red conjunctiva, ptosis, nasal congestion

Clinical exam: autonomic features

Question 17

Space occupying lesion pain

Answer 17

Sight: dependent on SOL
Quality: dull and variable, gradual and progressive
Intensity: mild
Time: worse in the morning when waking
Aggregating factors: cough, poor posture I.e. leaning forward, valsava manoeuvre (raised ICP)
Relief: analgesics
Secondary symptoms: Nausea, vomiting, neurological symptoms, visual symptoms e.g behaviour change, seizures (dependent on site of SOL)

Clinical exam: unilateral neurological signs, papilloedema

Question 18

Trigeminal neuralgia

Answer 18

More common in females

50- 60 year olds

Question 19

Pathophysiology of trigeminal neuralgia

Answer 19

Compression of the trigeminal nerve due to a looped blood vessel
5% due to tumours/ skull base abnormalities or AV malformations

Question 20

Trigeminal neuralgia pain

Answer 20

Sight: unilateral felt in 1+ divisions of CNV Commonly Va causes headaches
Quality: sharp, shooting pain like stabbing electric shock
Intensity: severe
Time: 2 secs - 2mins sudden onset
Aggregating factors: light touch to face/ scalp, eating, cold wind, combing hair
Relief: difficult to treat
Secondary symptoms: preceding symptoms = numbness or tingling

Clinical exam: normal

Question 21

Temporal arteritis

Answer 21

Vasculitis involving small or medium sized arteries of the head most commonly the superficial temporal artery

Most affects females over the age of 50

Risk of irreversible loss of vision due to ischemia of CN II therefore treat with prednisone and confirm with a biopsy

Question 22

When to consider temporal arteritis

Answer 22

Sudden onset headache in over 50s with jaw claudication and visual disturbance