Migraines and Headaches

Question 1

Give some examples of primary headaches

Answer 1

• Migraine
• Cluster Headache
• Tension Headache SOL

Question 2

Give some examples of secondary headaches?

Answer 2

• Vascular e.g. Subarachnoid haemorrhage
• Infective
• Neoplasia
• Drugs e.g. analgesic overuse headache
• Inflammation e.g. Temporal Arteritis
• RICP
• Trauma
• Metabolic
• Toxins

Question 3

How does the headache from an arachnoid haemorrhage present?

Answer 3

Rapid onset headache, also described as worst ever, usually occipital plus stiff neck, focal signs and reduced consciousness.

Question 4

If a headache comes on very gradually over a number of days what might this suggest?

Answer 4

Gradual onset – venous sinus thrombosis (subacute and papilloedema)

Question 5

If the pain from a headache is worst on bending over what pathology does this suggest?

Answer 5

Sinusitis – pain worst on bending over

Question 6

How does a headache caused by raised ICP present?

Answer 6

Characteristics of a RICP headache – present on waking, worse if lying, bending forward or coughing and exacerbated by Valsalva/bending/coughing

Check for papilledema, vomiting, seizures, and odd behaviour.

Question 7

What might be causing a headache with eye pain and reduced vision?

Answer 7

Headache with eye pain and reduced vision think glaucoma. Starts around one eye, radiates to the forehead.

Question 8

If a headache presents with jaw claudication and visual disturbance what should you immediately be worried about?

Answer 8

Headache with jaw claudication and visual disturbance think GCA must be ruled out in new onset headaches in anyone over 50.

Question 9

Describe the accompanying red flag signs for a meningeal headache

Answer 9

Headache with signs of infection and neck stiffness/focal neurology, nausea/vomiting – red flag sign.

Question 10

Are migraines more common in men or women?

Answer 10

15% of people suffer migraines, and it is 3x more common in women.

Question 11

Describe the clinical features of a migraine

Answer 11

1/3 have auras – bright flashing lights and zig zagging lines (sometimes without a headache)
Moderate to severe headache felt as a throbbing/pulsatile pain and unilateral
Nausea and vomiting
Increased sensitivity to light and sound – photophobia/phonophobia
Hemiplegia
Speech disturbances
Patient constrict themselves to a dark room

Question 12

List some common triggers for a migraine

Answer 12

Stress
Premenstrual or pregnancy (need specialist help)
Tiredness
CHOCOLATE – chocolate, hangovers, orgasms, cheese/caffeine, oral contraceptives, lie-ins, alcohol, travel or exercise

Question 13

What are the diagnostic criteria for migraine

Answer 13

Migraine Criteria – at least 5 attacks fulfilling these 4 criteria

1. Headache lasting 4-72 hours
2. Two of the following features: unilateral location, pulsating quality, moderate or severe pain intensity, aggravation by or causing avoidance of routine physical activity
3. During headache – nausea and/or vomiting or photophobia and phonophobia
4. Not attributable to another disorder

Question 14

What long term advice should be given to migrainers

Answer 14

Avoid identified triggers and ensure analgesic rebound headache does not complicate

Question 15

What is the acute management for a migraine

Answer 15

Oral triptan (or nasal if 12-17) e.g. sumatriptan or rizatriptan, combined with basic analgesia. CI in IHD, uncontrolled BP, recent lithium, ergot or SSRI use
Anti-emetics even in the absence of N and V
Warm or cold packs to the head

Question 16

What prophylactic medication can be offered for migraines and when should it be offered?

Answer 16

1st line – propranolol or topiramate (teratogenic and can interfere with COCP)
Amitriptyline

Offered when there are more 2 or more episodes per month.

Question 17

Describe tension headaches

Answer 17

The common headache that most people have usually due to dehydration. Bilateral, tight band, non-pulsatile and scalp muscle tenderness. Treat with simple analgesia, never opioids and if chronic low dose amitriptyline.

Question 18

What are cluster headaches?

Answer 18

Extremely disabling repetitive headaches. Much more common in men and smokers but can occur at any age.

Question 19

What are the clinical features of a cluster headache?

Answer 19

Sudden attacks of severe, strictly one-sided, stabbing pain usually starting around the eye
Lasting 15-180 minutes
Eye becomes watery and blood shot with lid swelling, facial flushing and rhinorrhoea
Miosis and ptosis in 20% of attacks
Occurs once or twice a day and is often nocturnal
Clusters last 4-12 weeks, once a year and always same side

Question 20

How are cluster headaches managed?

Answer 20

Acute – give 100% oxygen for 15 mins via non-rebreathe mask and sumatriptan at onset
Preventative – avoid triggers e.g. alcohol and consider corticosteroids (short term), verapamil or lithium.

Question 21

How do medication overuse headaches occur?

Answer 21

Due to chronic painkiller use for longer than 14 days. Most common culprits are paracetamol with codeine/opiates, ergotamine and triptans.

Question 22

Describe trigeminal neuralgia including symptoms and triggers

Answer 22

Constant aching, burning may occur before spasm-like pain. Pain is felt in the areas supplied by the trigeminal nerve e.g. cheek, jaw, teeth, gums, lips and less often the eye and forehead. The pain is unilateral and usually gets worse when you eat but there is no crepitus. Can also get autonomic effects such as teary, sweaty and sniffly etc.

Question 23

What are the red flag signs in trigeminal neuralgia suggesting serious underlying disease?

Answer 23

• Sensory changes
• Deafness or other ear problems
• History of skin or oral lesions that could spread perineurally
• Pain only in the ophthalmic division of the trigeminal nerve (eye socket, forehead, and nose), or bilaterally
• Optic neuritis
• A family history of multiple sclerosis
• Age of onset before 40 years

Question 24

What commonly causes trigeminal neuralgia?

Answer 24

Usually idiopathic but can be neurovascular conflict, MS, tumour, trauma, and stroke.

Question 25

What are the management options for trigeminal neuralgia?

Answer 25

Carbamazepine
Analgesic medication
If failure to respond or atypical features e.g. <50years refer to neurology