Neuro16 - Headache

Question 1

Overview of causes of headaches

Primary Headache Disorders x3

Secondary Causes of Headaches (life-threatening x3 sight-threatening x2, systemic x2, medication x2)

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
   - some life-threatening and many are acute
   - life-threatening: SOL, intracranial haemorrhage or infections (meningitis, abscess, encephalitis)
   - sight-threatening: temporal arteritis, acute glaucoma
   - systemic: hypertension, pre-eclampsia
   - medication: overuse or side effects

Question 2

SNOTP mnemonic to catch potentially life-threatening headaches

S
N
O
T
P x4

Answer 2

1. ) Systemic signs and disorders
   - intracranial infections, cancer, pregnancy
2. ) Neurological symptoms
   - space occupying lesion, intracranial haemorrhage, glaucoma (visual symptoms)
3. ) Onset new or changed/patient Over 50 years old
   - malignancy, closed angle glaucoma
4. ) Thunderclap presentation
   - subarachnoid haemorrhage
5. ) Papilledema, Pulsatile tinnitus, Positional provocation, Precipitated by exercise
   - all caused by raised intracranial pressure

Question 3

8 features of a tension-type headache

Pathophysiology
Demographic
Site
Quality
Intensity/Timing
Aggravating Factors x4
Relieving Factors
Secondary Symptoms

Answer 3

1. ) Pathophysiology - tension in head and neck muscles
2. ) Demographic - F>M, 20-39 yrs
3. ) Site - generalised (mainly frontal and occipital)
   - may radiate into the neck

4.) Quality - tight/band-like, constricting

5. ) Intensity/Timing - mild-moderate
   - recurrent, lasting 30mins to 1 hour
6. ) Aggravating Factors
   - stress, poor posture, lack of sleep
   - worse at the end of the day

7.) Relieving Factors - responds to simple analgesics

8. ) Secondary Symptoms - few
   - may have slight nausea

Question 4

8 features of a migraine

Pathophysiology
Demographic
Site
Quality
Intensity/Timing
Aggravating Factors x6
Relieving Factors
Secondary Symptoms x4

Answer 4

1.) Pathophysiology - unclear

2. ) Demographic - F>M, first onset usually by 30
   - often have family history of migraines
3. ) Site - unilateral (temporal or frontal)
4. ) Quality - throbbing, pulsating
5. ) Intensity/Timing - moderate-severe (often disabling)
   - prolonged (between 4-72 hours)
6. ) Aggravating Factors - triggers for different people:
   - light, sound, stress, lack of sleep, menstrual cycle, certain foods
7. ) Relieving Factors - can respond to simple analgesics
   - may need triptans
8. ) Secondary Symptoms
   - N/V, aura, photophobia, phonophobia

Question 5

8 features of a cluster headaches

Pathophysiology
Demographic
Site
Quality
Intensity/Timing
Aggravating Factors x5
Relieving Factors
Secondary Symptoms x4

Answer 5

1. ) Pathophysiology - unknown
2. ) Demographic - M>F, first onset at 30-40 yrs
3. ) Site - unilateral, around or behind the eye
4. ) Quality - sharp, stabbing, penetrating
5. ) Intensity/Timing - severe, often disabling, agitating
   - lasts 15 mins to 3 hours
   - occurs in clusters w/ periods of remission, (3m-3yrs)
6. ) Aggravating Factors
   - lack of sleep, warm temp, volatile smells, alcohol, cigarettes
7. ) Relieving Factors - simple analgesics ineffective
   - triptans and high flow oxygen needed
8. ) Secondary Symptoms - ipsilateral autonomic:
   - red/watery eye, blocked/runny nose, ptosis

Question 6

4 features of medication overuse headaches

Pathophysiology
Demographic
Criteria
Treatment

Answer 6

1.) Pathophysiology - use of regular analgesics (esp
co-codamol) at least 10 days a month

2.) Demographic - F>M, patients with a pre-existing headache disorder

3.) Criteria - constant headache present on at least
15 days/month not responding to the analgesics

4. ) Treatment - stop taking the medication
   - headache worsens before it improves
   - usually resolved by 2 months

Question 7

7 features of headaches caused by a space occupying lesion (SOL)

Site
Quality
Intensity/Timing
Aggravating Factors x4
Relieving Factors
Secondary Symptoms x3
Clinical Examination x2

Answer 7

1. ) Site - depends on location of the lesion
2. ) Quality - dull (often variably described)
3. ) Intensity/Timing - may be mild
   - gradual and progressive
4. ) Aggravating Factors
   - worse upon waking up
   - posture (leaning forward), cough, valsalva manoeuvre

5.) Relieving Factors - simple analgesics may be effective in the early stages

6. ) Secondary Symptoms
   - N/V, focal neurological or visual symptoms
   - change in behaviour or personality
7. ) Clinical Examination
   - unilateral neurological signs, papilloedema

Question 8

8 features of headaches caused by trigeminal neuralgia

Pathophysiology
Demographic
Site
Quality
Intensity/Timing
Aggravating Factors x4
Relieving Factors
Secondary Symptoms x2

Answer 8

1. ) Pathophysiology - compression of CN V due to loop of a blood vessel
2. ) Demographic - F>M, 50-60 yrs
3. ) Site - unilateral in one or more division of CN V
   - CNVa often described as a headache
4. ) Quality - sharp, stabbing, burning
5. ) Intensity/Timing - severe, sudden onset
6. ) Aggravating Factors
   - light touch, eating, cold wind, combing hair
7. ) Relieving Factors - simple analgesics not effective
8. ) Secondary Symptoms - tingling, numbness

Question 9

5 features of headaches caused by temporal arteritis

Pathophysiology
Demographic 
Symptoms x4
Complication 
Treatment

Answer 9

1. ) Pathophysiology - vasculitis involving small and medium sized arteries of the head
   - commonly the superficial temporal artery

2.) Demographic - F>M, >50 yrs (mostly >75)

3. ) Symptoms
   - jaw claudication, scalp tenderness, vision loss
   - systemic inflammation: fever, night sweat, weight loss
4. ) Complication - risk of irreversible loss of vision due to ischemia of CNII
5. ) Treatment - using steroids

Question 10

Migraines

Risk Factors
Clinical Features
Management
Referral

Answer 10

1. ) Risk Factors
   - young (onset <30), female, family history
   - triggers: light, sound, stress, lack of sleep, menstrual cycle, certain foods
2. ) Clinical Features
   - unilateral headache, pulsating/throbbing in nature
   - can be moderate to severe, lasting 4-72hrs
   - associated sx: photophobia, phonophobia, N+V
   - aura: transient focal neuro sx before or with the headache visual (zigzag lines, scotoma), paraesthesia
3. ) Management
   - avoid triggers, lifestyle changes
   - simple analgesia +/- triptan, anti-emetic if needed
   - preventative treatment if frequent or prolonged and not pregnant or breastfeeding (propranolol, topiramate)
   - headache diary: identify triggers, monitor treatment
4. ) Referral
   - serious cause of headache e.g. SOL,
   - migraine lasting for more than 72 hours
   - atypical sx, optimum treatment has failed