Migraine and headache

Question 1

Differentiate between tension-type, migraine and secondary headaches

Answer 1

• tension-type and migraines both primary headaches
• symptoms between the two overlap due to similar pathogenesis
  
  • channelopathies
  • vascular phenomena
  • genetic predisposition
  • triggers: stress, foods (cheese, chocolaate, caffiene), late nights, early rises, menstruation or COPC
• tension-type:
  
  • ​symmetrical headache
  • gradual onset
  • ‘tightness, band or pressure’
  • no associated symptoms
• migraine (without aura)
  
  • ​90% migraine
  • last 1-72 h
  • commonly bilateral, may be unilateral
  • ‘pulsatile’
  • over termporal or frontal area
  • • GI disturbances (N/V, abdo pain), photophobia, phonophobia
  • aggrevated by exercise
• migraine (with aura)
  
  • ​10% migraine
  • preceded by AURA: visual, sensory, motor
    
    • negative phenomena: hemianopia, scotoma
    • positive phenomena: zigzag lines
  • last a few hours
  • lie down, dark room- sleep tends to relieve the bout
  • absense of problems between episodes
  • premonitory symptoms: tiredness, difficulty concentrating, autonomic features)
• secondary headaches
  
  • ​headaches due to tumour are worse on lying and waking (may cause night time waking)
  • mood, personality or educational performance changes
  • visual field defects​
  • CN palsy
  • abnormal gait
  • torticollis
  • growth failure
  • papilloedema
  • cranial bruits

Question 2

What are the features of raised intracrainial pressure?

Answer 2

• Cushing’s triad:
  
  • Hypertension
  • Bradycradia
  • Irregular respiratory rate
• Loss of conscious level
• Irritability
• Poor feeding
• High pitched cry
• Nausea/ vomiting
• Seizures
• Focal neurological deficits
• Coma
• Change in pupil reaction, impaired upward gaze- sunsetting sign
• Bulging fontanelles
• Rapidly increasing head circumference

Question 3

Treatment of raised intracranial pressure

Answer 3

• head positioned midline
• head end of bed tilted by 20-30”
• isotonic fluids at 60%
• intubation and ventilation if GCS <9
• mannitol or 3% saline as osmotic diuretics
• normothermia and high (normal) blood pressure
• neurosurgical intervention if intracranial mass