Neuro - Primary Headache Disorders & Non-Threatening Headaches

Question 1

Headaches

Primary Headache Disorders
Secondary Causes of Headaches
Examination

Answer 1

1. ) Primary Headache Disorders - most common cause
   - all non-life-threatening and many are chronic
   - tension headache, migraine, cluster headache
   - clinical examination is normal
2. ) Secondary Causes of Headaches
   - life-threatening: intracranial haemorrhage, SOL, infections (meningitis, abscess, encephalitis)
   - sight-threatening: temporal arteritis, acute glaucoma
   - non-threatening: sinusitis, cervical spondylosis, trigeminal neuralgia, post-LP
   - systemic: hypertension, pre-eclampsia, hormonal
   - medication: overuse or side effects
3. ) Examination
   - fundoscopy: looking for papilloedema for ↑ICP

Question 2

Tension-Type Headache

Pathophysiology
Clinical Features
Management

Answer 2

1.) Pathophysiology - muscle ache in the frontalis, temporalis and occipitalis muscles
- triggers: stress, depression, lack of sleep, alcohol,
hunger, dehydration, poor posture
- age of onset 20-39, more common in women

2. ) Clinical Features - mild ache across the forehead in a band-like pattern, bilateral and non-pulsatile
   - may radiate into the neck or also have slight nausea
   - gradual onset, recurrent, lasting 30m-1hr
   - worse at the end of the day
   - responds to simple analgesics
3. ) Management
   - reassurance of nothing concerning
   - simple analgesia, heat compress
   - relaxation techniques/stress management

Question 3

Migraines

Risk Factors
Clinical Features
5 Stages
Hemiplegic Migraine

Answer 3

1. ) Risk Factors
   - young (onset <30), female, family history
   - stress, trauma, menstruation, COCP, dehydration
   - bright lights, strong smells, sound, abnormal sleep
   - certain foods: e.g. chocolate, cheese and caffeine
2. ) Clinical Features
   - unilateral headache, pulsating/throbbing in nature
   - can be moderate to severe, lasting 4-72hrs
   - associated sx: photophobia, phonophobia, N+V, aura
   - visual aura: blurring, sparks zigzag lines, scotoma etc.
   - sensory aura: paraesthesia from fingers to face
3. ) 5 Stages
   - prodromal: subtle sx such as yawning, fatigue or mood changes up to 3 days prior to migraine onset
   - aura: can last up to an hour
   - headache: lasts 4 hours to 3 days
   - resolution: headache can fade away or be relieved completely by vomiting or sleeping
   - postdrome: ‘migraine hangover’, sx: fatigue, nausea, light sensitivity, dizziness, body aches, ↓concentration
4. ) Hemiplegic Migraine - varying symptoms:
   - typical migraine sx, sudden or gradual onset
   - hemiplegia (unilateral weakness of the limbs)
   - ataxia, changes in consciousness
   - mimics a stroke, must act fast to exclude a stroke

Question 4

Management of Migraines

Non-Medical Management
Abortive Medical Management
Preventative Medical Management
Referral

Answer 4

1. ) Non-Medical Management
   - patients often develop their own patterns to help relieve their sx e.g. going to sleep in a dark room
   - prophylaxis: avoid triggers, lifestyle changes
   - headache diary: identify triggers, monitor treatment
   - reassurance: migraines tend to get better over time and people often go into remission from their sx
2. ) Abortive Medical Management
   - simple analgesics: paracetamol, ibuprofen/naproxen
   - anti-emetics: metoclopramide if vomiting
   - triptans: 5HT receptors agonists, used to abort the headache as it starts e.g. sumatriptan 50mg
3. ) Preventative Medical Management - all help to reduce the frequency and severity of attacks
   - propranolol, topiramate (teratogenic and ↓effectiveness of OCPs), amitriptyline
   - acupuncture: recommended by NICE
   - supplements: vitamin B2 (riboflavin)
   - menstruation-related: NSAIDs (e.g. mefenamic acid) or certain triptans (frovatriptan or zolmitriptan)
4. ) Referral
   - serious cause of headache e.g. SOL,
   - migraine lasting for more than 72 hours
   - atypical sx, optimum treatment has failed

Question 5

Cluster Headaches

Risk Factors
Clinical Features
Management

Answer 5

1. ) Risk Factors
   - initial onset at 30-50yrs, more common in men
   - triggers: smoking, alcohol, volatile smells, exercise, lack of sleep, warm temperatures
2. ) Clinical Features - sudden onset of extremely severe unilateral sharp/stabbing peri-orbital pain
   - occur in clusters e.g. daily attacks for 4-12wks followed by a pain-free period for 3 months to 3yrs
   - can have multiple attacks a day lasting 15m to 3hrs
   - may have aura-type symptoms like in migraines
   - other unilateral sx: red, swollen and watering eye, miosis, ptosis, nasal discharge, facial sweating
3. ) Management
   - SC/INH triptans: e.g. SC sumatriptan 6mg
   - high flow 100% oxygen for 15-20 minutes
   - prophylaxis: verapamil, lithium, prednisolone (a short course for 2-3 wks to break the cycle during clusters)

Question 6

Medication Overuse Headaches

Pathophysiology
Diagnosis
Treatment

Answer 6

1.) Pathophysiology - use of regular analgesics (esp
co-codamol) at least 10 days a month
- occurs in patients w/ pre-existing headache disorder
- more common in females

2.) Diagnosis - constant headache present on at least
15 days/month not responding to the analgesics
- medications used for >10days per month for >3mths
- similar non-specific features to a tension headache
- definitive diagnosis: symptoms must resolve within 2 months of stopping the causative medication
- other clinical features: headaches generally worst in the morning and worse after exercise

3. ) Treatment - stop taking the medication
   - headache worsens before it improves
   - stop simple analgesia and triptans abruptly
   - stop opioid analgesia gradually
   - sx should have resolved within 2 months

Question 7

Acute (Rhino-)Sinusitis

Aetiology
Pathophysiology of Bacterial Rhinosinusitis
Clinical Features/Diagnosis
Initial Management

Answer 7

1. ) Aetiology - symptomatic inflammation of the mucosal lining of the nasal cavity AND paranasal air sinuses
   - viral: rhinoviruses and coronaviruses
   - post-viral: residual mucosal inflammation following a viral infection that produces ongoing symptoms
   - risk factors: cigarette smoke, air pollution, septal deviation, polyps, anxiety/depression, asthma, diabetes
2. ) Pathophysiology of Bacterial Rhinosinusitis
   - primary viral infection leads to reduced ciliary function, oedema, increased secretions
   - impeded drainage from sinuses (mainly maxillary) and stagnant secretions becomes ideal for bacteria
   - common bacteria: S. pneumoniae, H. influenzae, Moraxella catarrhalis, S aureus
3. ) Clinical Features/Diagnosis - 2+ of the following:
   - headache: facial pain behind the nose, forehead and eyes, often tenderness over the affected sinus
   - recent URT infection, fever, altered sense of smell
   - blocked/runny nose (+/- green/yellow discharge)
   - sudden onset of symptoms, sx >10 days (but <12wks) w/o improvement and worsen after initial improvement
4. ) Initial Management - depends on days of symptoms:
   - <5d or improving: analgesia and nasal decongestants or nasal irrigation w/ saline and steam inhalation
   - >10d or worsening after 5d: topical nasal steroids and oral antibiotics are indicated
   - referral to ENT: no improvement after 7-14 days of treatment or the presence of red-flag symptoms

Question 8

Trigeminal Neuralgia

Pathophysiology
Clinical Features
Management

Answer 8

1.) Pathophysiology - compression of trigeminal nerve
- causes: MS, malignancy, AV malformation, sarcoidosis, lyme disease
- often unilateral (90%) but can also be bilateral
- age onset is 50-60, more common in females
- triggers: light touch, eating, wind blowing on face,
spicy food, caffeine, citrus fruits

2. ) Clinical Features
   - severe, sudden onset shooting/stabbing facial pain
   - often unilateral in 1+ divisions of the trigeminal nerve (if CN Va, its often described as a headache)
   - can also experience numbness or tingling sensations
   - trigger pain by lightly touching their face
   - can last anywhere between a few secs to hrs
   - attacks often worsen over time
3. ) Management
   - 1°: carbamazepine, others: phenytoin, gabapentin
   - surgical: microvascular decompression, treatment of the underlying cause