🧠Neurology🧠 - Headache

Question 1

How common are headaches?

Answer 1

One-year prevalence of headache disorders is 50%
20% of what neurologists see and care for
100,000 people absent from work or school every day

Question 2

How can headaches be broadly subdivided?

Answer 2

Primary and secondary headaches?

Question 3

What is the difference between a primary and secondary headaches?

Answer 3

Primary headache have no underlying cause, while secondary headaches are a result of other conditions (can be serious but serious causes are rare e.g. subdural haemorrhage)

Question 4

What are the two subtypes of primary headache?

Answer 4

Long lasting (>4 hrs) and short lasting (<4 hours)

Question 5

What headaches fall under the category of long-lasting headaches?

Answer 5

Migraines
Tension type headaches
(some medication overuse headaches, such as paracetamol)

Question 6

What headaches fall under the category of short-lasting headaches?

Answer 6

Trigeminal autonomic cephalalgia (e.g. cluster headaches as the most common form)

Question 7

What are the red flags for the clinical approach to headaches?

Answer 7

Secondary headache
Preliminary diagnosis of primary headache, however meets one of the SNOOP criteria - suggesting secondary headache

Question 8

What is the SNOOP criteria?

Answer 8

Systemic
Neurologic
Onset (sudden)
Onset (age)
Pattern change
Papilledema
Pregnancy
Phenotype of rare headache

Question 9

Elaborate on “systemic” as part of the SNOOP criteria

Answer 9

History of malignancy, immunosuppression, HIV, complaints of fever, chills, night sweats, myalgias, weight loss etc…
Abnormal systemic examination, incl. blood pressure and temperature

Question 10

Elaborate on “neurologic” as part of the SNOOP criteria

Answer 10

Focal or global neurologic symptoms, such as changes in personality/behaviour, visual abnormalities, motor weakness, sensory loss etc…
Abnormal neurologic examination

Question 11

Elaborate on “onset” as part of the SNOOP criteria

Answer 11

Onset, sudden - headache reaches peak intensity extremely quickly (<1 minute) - thunderclap headache
Onset, age - new-onset headache before age 5 or over age 65

Question 12

Elaborate on “pattern change” as part of the SNOOP criteria

Answer 12

Progressive headache (changes in frequency to daily) or change in headache characteristics
Precipitated by the Valsalva manoeuvre
Postural aggravation

Question 13

Elaborate on “papilledema” as part of the SNOOP criteria

Answer 13

The swelling of both optic discs in your eyes due to increased intracranial pressure (intracranial hypertension)

Question 14

Elaborate on “pregnancy” as part of the SNOOP criteria

Answer 14

New-onset headache during pregnancy
Change in headache during pregnancy

Question 15

Elaborate on “phenotype of rare headache” as part of the SNOOP criteria

Answer 15

Patient presents with symptoms consistent with that of trigeminal autonomic cephalalgia, hypnic, exercise-,cough-,or sex-induced

Question 17

What are the characteristic features of a migraine?

Answer 17

Unilateral location
Pulsating quality
Moderate to severe pain intensity
Aggravation by routine physical activity
Last hours (or even days)
Usually features one or more of: nausea/vomiting, photophobia/phonophobia
Can be with or without aura

Question 18

What is the pathophysiology of migraines?

(will not be examined, serves just for context)

Answer 18

Pathophysiology of Migraines
Triggering Factors:

Migraines can be triggered by various factors, including hormonal changes, stress, certain foods, and environmental changes. These triggers can lead to the activation of pain pathways in the brain.
Cortical Spreading Depression (CSD):

CSD is a phenomenon characterized by a wave of depolarization followed by a wave of hyperpolarization across the cortex.
This wave results in a transient disruption of neuronal activity, spreading over the surface of the brain.
CSD is believed to be responsible for the aura phase of migraines, causing visual disturbances or other sensory symptoms.
It also triggers the release of inflammatory mediators and neuropeptides, which contribute to the headache phase.
Activation of the Trigeminal System:

The trigeminal nerve (Cranial Nerve V) is involved in facial sensation and pain. During a migraine, it becomes activated, leading to the release of pro-inflammatory neuropeptides, including CGRP.
Trigeminal Ganglia: The cell bodies of trigeminal neurons reside in the trigeminal ganglia. During a migraine, these neurons become sensitized and facilitate the transmission of pain signals to the brain.
Sensitized trigeminal afferents lead to the release of inflammatory mediators, which promote vasodilation and further sensitization of pain pathways.
Role of Calcitonin Gene-Related Peptide (CGRP):

CGRP is a potent vasodilator and plays a key role in the pathophysiology of migraines. It is released from trigeminal neurons during a migraine attack.
Elevated levels of CGRP lead to increased vascular permeability and neurogenic inflammation, contributing to headache pain and associated symptoms.
CGRP antagonists (e.g., monoclonal antibodies targeting CGRP) have been developed as a treatment option for migraine prevention due to their ability to inhibit these pain pathways.
Neurogenic Inflammation:

The activation of the trigeminal system and the release of CGRP and other neuropeptides lead to neurogenic inflammation, characterized by vasodilation and increased vascular permeability in the meningeal tissues.
This inflammation contributes to the throbbing pain characteristic of migraines.

Question 19

What is meant by “aura”?

Answer 19

Sensory disturbances “often visual” often preceding or accompanying a headache

Question 20

What is a visual aura?

Answer 20

Complex array of symptoms reflecting focal cortical or brainstem dysfunction
Gradual evolution: 5-20 minutes (<60minutes)
Usually before headache

Question 21

What are the phases of a migraine?

Answer 21

Premonitory
Aura
Headache
Recovery

Question 22

What timeframe is typical of the premonitory phase and what can be observed?

Answer 22

Up to 48 hours before a migraine
Yawning, polyuria, mood change, irritable, light sensitive, neck pain, concentration difficulty

Question 23

What timeframe is typical of the aura phase and what can be observed?

Answer 23

5-20 minutes before a migraine
Visual/sensory disturbances, weakness, speech arrest

Question 24

What timeframe is typical of the headache phase and what can be observed?

Answer 24

4-72 hours
Head and body pain, nausea, photo/phono phobia

Question 25

What timeframe is typical of the recovery phase and what can be observed?

Answer 25

Up to 48 hours post migraine
Mood disturbed, food intolerance, feeling “hungover”

Question 26

What are the management options for a migraine?

Answer 26

Lifestyle
Pharmacological therapy:
Acute/abortive
Long term preventative

Question 27

What pharmacological management for migraines should be avoided and why?

Answer 27

Opiate-based and mixed analgesics should be avoided
Risk of medication overdose headache
Less effective for migraines (don’t address the underlying mechanisms of migraine, which involve neurovascular changes and inflammation)
Increased Sensitivity to Pain
Dependency and addiction

Question 28

What are the lifestyle changes that help manage migraines?

Answer 28

Avoid triggers
Diet
Sleep
Exercise
Practice mindfulness

Question 29

What are the acute/abortive pharmacological therapy options for migraines?

Answer 29

Basic painkillers like paracetamol
NSAIDs (high dose and soluble)
Prokinetics
Triptans

Question 30

What are the long term preventative pharmacological therapy options for migraines?

Answer 30

> = 5 days/month
“low and slow” dosage and increase gradually until optimal dose reached

Question 31

What are some migraine preventatives?

(to be aware)

Answer 31

Question 32

What is the most common type of headache?

Answer 32

Tension headache

Question 33

How do patients typically describe a tension headache?

Answer 33

Tight muscles around head and neck, as though head is in a vice

Question 34

What are the characteristics of a tension headache?

Answer 34

Lasts 30mins (but can be hours long):
Bilateral
Mild or moderate
Not aggravated by movement
No added features typically:
-No nausea or vomiting
-No photophobia or phonophobia

Question 35

What is the treatment for tension headaches?

Answer 35

Reassurance will suffice for the majority of patients
Individual attacks can be treated with simple analgesics, such as aspirin or paracetamol
Preventative medications rarely required

Question 36

What are the characteristics of a cluster headache?

Answer 36

Severe unilateral pain
Last 15-180 minutes if untreated.
At least one of the following, ipsilaterally:
-Conjunctival redness and/or lacrimation
-Nasal congestion and/or rhinorrhoea
-Eyelid oedema

Question 37

What other features may accompany a cluster headache?

Answer 37

Forehead and facial sweating
Miosis and/or ptosis
A sense of restlessness or agitation
Not associated with a brain lesion on MRI

Question 38

What are the acute treatments for cluster headaches?

Answer 38

Triptan - nasal or subcutaneous
High flow oxygen - oxygen inhibits neuronal activation in the trigeminocervical complex

Question 39

What are the prevention treatments for cluster headaches?

Answer 39

Verapamil - get an ECG first as effects electrical conduction in the heart, particularly at the AV node
Greater occipital nerve block

Question 40

Outline the areas of the head felt by each headache type discussed in this deck

Answer 40

Question 41

Summarise all three headache types

Answer 41