Primary Headaches

Question 1

Name three primary headaches

Answer 1

• Tension
• Cluster
• Migranes

Question 2

What is a tension headache?

Answer 2

• Most common type of headache, more common in teenagers, adults, women
• It can be chronic, lasting days, hours or 30mins, episodic.
• It is thought to be due to muscle-tension although it is not understood

Question 3

Aetiology of tension headaches (8)

Answer 3

• Stress and anxiety
• Squinting
• Poor posture
• Dehydration
• Tiredness
• Missing meals
• Lack of physical activity
• Screen + Bright lights

Question 4

Clinical features of tension headaches (5)

Answer 4

(1. ) Bilateral ‘tight band’ tenderness
- frontal and occipital regions
- dull-ache

(2. ) Can be episodic or persistent
- Usually lasts from 30mins to several hours

(3. ) Associated Sx
- Not associated with N+V or photophobia
- Not aggravated by physical activity
- Tightness of neck muscles

(4. ) Look at Hx
- May indicate recent stress, depression, insomnia, missed meals or analgesic overuse, as well as history of similar episodes

Question 5

Treatment and Management of tension headache (3)

Answer 5

(1. ) Identify precipitants and reassure pt
(2. ) Simple Analgesics
- Paracetamol or ibuprofen
- Beware of medication overuse
(3. ) Lifestyle changes
- Relaxation techniques often help if the headaches are stress based
- Changes to sleep patterns
- Diet and water intake
- Physiotherapy (muscle relaxation, stress management)
- Acupuncture courses

Question 6

What are Cluster Headaches? 5 RF? Triggers?

Answer 6

(1. ) Rare but severe primary headache disorder. Cause is not fully understood - interaction between genetic and environmental factors
(2. ) RF: Male, 20-50y, Smokers, Alcohol, Fx
(3. ) Triggers (although isn’t always associated with it): alcohol, histamine, physical exertion, sleep, smelling volatile substance

Question 7

Clinical features of Cluster Headaches (5)

Answer 7

(1. ) Sudden onset
(2. ) Severe unilateral pain around the eye or temporal region

(3. ) Ipsilateral autonomic Sx:
- lacrimation
- Eyelid oedema
- Conjunctival injection (enlargement of vessels)
- nasal congestion
- rhinorrhoea (nasal mucus discharge)
- forehead and facial sweating or flushing
- ptosis

(4. ) Headaches have a periodic pattern
- Occur at same time for weeks, can last 30-90mins
- Cycles of headaches followed by headache-free periods

(5.) Pts are agitated during the headache

Question 8

Mx of Cluster Headaches including what to avoid and prophylaxis (4)

Answer 8

(1. ) SC or nasal triptan
(2. ) Offer short burst oxygen
(3. ) AVOID paracetamol, NSAIDs, opioids, ergots and oral triptans

(4. ) Prophylaxis
- Verapamil (CCB)
- Sodium valproate (AED)
- Short course of oral steriods
- Lithium therapy: May be considered in severe debilitating clusters

Question 9

What is a Migraine? RF?

Answer 9

• Migraine cause is not well understood but involves multiple neural networks and anatomical regions in the brain.
• It is characterized by episodic severe headaches with associated symptoms such as photophobia, phonophobia, N+V
• The most common are migraine with aura or without aura
• RF = Female, obesity, depression, medication overuse

Question 10

List 4 auras experienced before a migraine

Answer 10

(1. ) Aura = refers to sensation a person experiences before they get a migraine. Sensation may occur from 10-30mins before attack
(2. ) Auras can include:
- Feeling less mentally alert or having trouble thinking
- Seeing flashing lights or unusual lines, zig zag lines, missing parts of vision
- Feeling tingling or numbness in face or hands
- Having an unusual sense of smell, taste or touch

Question 11

What is the prodrome phase of migraines?

Answer 11

- Prodrome phase = Some migraine sufferers may experience Sx a day or two before the actual migraine occurs
o	Constipation 
o	Depression
o	Frequent yawning
o	Irritability 
o	Neck stiffness
o	Unusual food cravings

Question 12

Clinical features of Migraines

Answer 12

5 attacks that lasts 4-72h plus:

(1. ) Severe + unilateral (can be bilateral)
(2. ) Throbbing sensation
(3. ) Worsen with physical activity
(4. ) Associated Sx [aura]
- N+V
- Pain behind eye or ear or in temples
- Seeing spots or flashing lights
- Sensitivity to light (photophobia) and/or sound (phonophobia)
- Temporary vision loss

(5.) Not attributed to another disorder

Question 13

Management of Migraines

Answer 13

Conservative

• Headache diary
• Identify tiggers and lifestyle changes: COMBINED PILL IS CI, stress, hydration, exercise, meals etc
• Treat co-morbidities: Sleep apnoea, anxiety etc
• dark room may help

Medical
(1.) Simple analgesia: Ibuprofen, Aspirin, Paracetamol [1st line for mild, moderate]

(2. ) Oral triptan +/- analgesia [1st line for moderate-severe]
- Beware of medical overuse headache

(3. ) Antiemetics - metoclopramide, prochlorperazine
- For nausea

(4. ) Prophylaxis: reduce the frequency of migraine attacks
- beta blockers: propranolol
- Amitriptyline
- Antiepileptics - topiramate
- Consider acupuncture, relaxation techniques

Question 14

What is 1st, 2nd line and prophylaxis for migraines?

Answer 14

• 1st = simple analgesias
• 2nd = Triptans/5HT-agonists
• Prophylaxis = bblocker, antiepileptic, antidepressant (if failure consider botulism toxin)

Question 15

Triggers for migranes

Answer 15

Cheese, OCP, Caffeine, Alcohol, anxiety/stress, travel, exercise, sleep (too much or too little)