Lecture 2- Headache (cephalalgia)

Question 1

Difference between primary and secondary headaches

Answer 1

Primary:
- no underlying pathology (idiopathic)
- recurrent and non-progressive
- Neurologic exam is unremarkable 
- look for the absence of red flags
Secondary:
- underlying pathology
- sudden onset, constant, progressive
- red flags

Question 2

RED FLAGS OF HEADACHES: SNOOP

Answer 2

• systemic symptoms or secondary risk factors
• neurologic symptoms
• older
• onset
• previous headache history

Question 3

COMMON HEADACHE PRESENTATION

Answer 3

Primary headaches

• migraine
• tension-type
• cluster

Question 4

COMMON MIGRAINE ( no aura)

Answer 4

• lasts 4-72 hours
• unilateral, pulsation, moderate to severe in intensity
• may be made worse by mild physical activity (walking)
• may experience nausea, vomiting, photo or photophobia

Question 5

CLASSIC MIGRAINE: (aura)

Answer 5

• prodromal phase up to several hours before headache, causing unusual symptoms such as mood changes, food cravings and excessive thirst
• aura: one or more of the following symptoms which are all fully reversible
• visual symptoms: flickering lights, spots or lines
• sensory symptoms: pins and needles and/or numbness
• speech disturbance
  NOTE: symptoms last 5-60 mins, headache occurs during aura or within 60 mins, postdromal phase of fatigue

Question 6

TENSION TYPE HEADACHE

Answer 6

• most common
• can occur once a month or 15 times a month
• can last 30 mins- 7 days
• bilateral locations, pressing/tightening, non-pulsation, “band” quality, mild to moderate intensity
• not aggravated by routine physical activity e.g. Walking
• NO nausea, vomiting
• POSSIBLE photophobia or photophobia

Question 7

CERVICOGENIC HEADACHE: primary or secondary???

Answer 7

• diagnosis usually through demonstration of clinical signs that implicate a source of pain from the cervical spine.. E.g. Disc lesion or myofascial referral
• SCM and TRAPEZIUS most common for myofascial
• symptoms made worse by neck movement or awkward head positions
• restricted ROM
• moderate, non-throbbing, usually posterior head, commonly unilateral
• mild dizziness, nausea or “aura” are UNCOMMON but may be present

Question 8

Importance of the history and physical examination in a patient with headache

Answer 8

• S: so important as assists in diagnosis
• O: may indicate red flags, acute or chronic
• C: assist in diagnosis, may indicate neurogenic cause
• R:
• A: assists in diagnosis, may indicate red flags/ systemic cause
• T: provides an outcome measure for Rx
• E: may indicate red flags, produce clues for treatment, discuss how medication may be helping
• S: may indicate red flags, assist in diagnosis

Question 9

MAKING THE DIAGNOSIS: PATIENT HISTORY

-location

Answer 9

location of headache:

• unilateral: migraine if anterior, cervicogenic usually posterior
• ocular or retro orbital: opthalamic cause or migraine
• para nasal: sinusitis (with local tenderness)
• “band-like” tensions
• occipital: TTH or meningeal, vascular or cervicogenic

Question 10

MAKING THE DIAGNOSIS: THE PATIENT HISTORY

onset

Answer 10

• acute, subacute or chronic

Question 11

MAKING THE DIAGNOSIS: THE PATIENT HISTORY

Character of the pain

Answer 11

• pulsation or throbbing is most common ( often migraine or TTH)
• SOLS can cause any type of headache (pattern is constant and progressive)

Question 12

Causes of a headache

Answer 12

• subarachnoid haemorrhage
• meningitis
• opthalmic disorders
• sinusitis
• dental
• cervical