S8) Headache Flashcards
Headache is a common presenting complaint.
How can it be categorised?
– Primary (due to a headache disorder) - more common
– Secondary to another condition - less common but can be sight/life threatening
Majority of the headaches are …
Majority are benign (non-life threatening) due to primary headache disorder
Headache is most commonly caused by a primary headache disorder.
Describe the clinical features of a primary headache disorder.
– Non- ‘life or sight’ threatening
– Many chronic (i.e. recurrent)
Headache is most commonly caused by a primary headache disorder.
Describe the clinical features of a secondary due to another condition.
– Some are life or sight threatening
– Many acute
Identify examples of primary headache disorder.
– Tension headache
– Migraine
– Cluster headache
Identify examples of secondary headaches.
Life threatening:
– Intracranial lesion e.g. tumour (benign, malignant or metastases) e.g. haemorrhage (?trauma or aneurysm)
– Meningitis
Sight threatening:
– Giant cell (temporal) arteritis
– Acute glaucoma
Non- life/sight threatening causes:
– sinusitis
– medication overuse headache
– trigeminal neuralgia
– drug side effects/ medication related and medication overuse e.g. CCBs, statins
– Systemic: hypertension, pre-eclampsia
Differential diagnosis of headache (primary headache in green, secondary headache in red.
Conditions requiring immediate emergency assessment are labelled ‘A&E’).
Secondary headaches occur because of another condition.
Skim through the notes.
Diagnosing Cause: patient’s history is key and history taking
o History
→ Full HPC using SOCRATES/SQITARS
→ What might be causing/triggering the headache? → PMH of headache?
→ Drug history
• Analgesics
• Side effects causing headache (e.g. vasodilators)
→ FH
• E.g. migraine with aura has some heritability
→ SH
• Stress
- Diet (some foods can trigger migraine)
- Hydration
What are the red flags for potentially life threatening headaches?
Red flag features of headaches (i.e. those features which make us worry)
– Systemic signs and disorders (e.g. of meningitis or hypertension)
– Neurological symptoms
– Onset new or changed and patient >50 yo (can be suggestive of malignancy e.g. brain metastases
– Onset in thunderclap presentation (suggests vascular cause such as SAH)
– Papilloedema (suggests raised ICP)
Using the red flags of headaches, identify causes behind them.
Red flag features of headaches (i.e. those features which make us worry)
– Systemic signs and disorders (e.g. of meningitis or hypertension)
– Neurological symptoms
– Onset new or changed and patient >50 yo (can be suggestive of malignancy e.g. brain metastases
– Onset in thunderclap presentation (suggests vascular cause such as SAH)
– Papilloedema (suggests raised ICP)
What clinical examination would you do for someone with a headache?
- Vital signs e.g. BP, PR, temp - e.g. raised ICP can cause bradycardia / hypotension.
- Hypertension itself can cause headache*
- Neurological examination (cranial and peripheral nerve examination, Glasgow-coma scale)
- Other relevant systems, guidance by history (e.g. if associated
- feelings of faintness then examine CVS)*
- Be alert to presence of red flags
List the common headaches from most common to less common in order.
– Tension -type headache (primary headache disorder) – MOST COMMON
– Migraine (primary headache disorder)
– Medication overuse (secondary headache)
–Cluster headache (primary headache disorder)
In whom can we see tension-type headaches in?
Most common type of headache
F>M
Common Young (teenagers) and young adults [20-39 yr])
First onset >50yr unusual
What is the pathophysiology of tension-type headaches?
Pathophysiology thought due to tension in muscles of head and neck e.g. occipitofrontalis
Usually no family history
How can someone with tension type headache present?
– Generalised- predilection for frontal and occipital regions
– Tight/ band like, constricting, +/- radiating into neck
– Mild-moderate intensity
– Worse at end of the day; recurrent (30m-1hr)
– Few associated symptoms-may be slight nausea
Describe the clinical features of tension type headaches.
– Site
• Bilateral frontal • Can radiate to neck
– Quality
- Squeezing / band-like constriction
- Non-pulsatile
– Intensity
• Mild-moderate
– Timing
- Worse at end of day (as stress builds up)
- Chronic if > 15 times per month
- Episodic if <15 times per month
– Aggravating factors
- Stress
- Poor posture (e.g at a computer)
• Lack of sleep
– Relieving factors
• Simple analgesics can help
– Secondary symptoms
• Sometimes mild nausea
What would the clinical examination of tension type headache be like?
Clinical examination is normal
What are the triggers for the tension type headaches?
stress, poor posture, lack of sleep often aggravates
How can we treat tension type headache?
Often responds to simple analgesics + give reassurance
In whom can we see migraines in?
F>M (1 in every 5 F) -Twice as many females as males
Common (15 in every 100)
Presents early to mid-life
Most have first attack by 30
Severity decreases as age increases
What is the pathophysiology for migraine?
– Pathophysiology unclear
– Possible theories proposed e.g.
- neurogenic inflammation of trigeminal sensory neurons innervating large vessels and meninges
- Alters way pain processed by brain; area becomes sensitized to otherwise ignored stimuli (Areas of those nerves become more sensitised to the presence of stimuli)
– Usually family history
How does someone with migraines present?
– Unilateral, temporal or frontal
– Throbbing, pulsating
– Moderate-severe, often disabling (need to lie down)
– Prolonged headache- between 4-72 hours
– Associated symptoms? e.g. photophobia, photophonia (sensitivity to sound), nausea +/- vomiting, aura (peculiar sensory signs e.g. visual or neurological signs e.g. speech disturbance)
Describe the clinical features of migraines.
– Site
• Unilateral, often frontal
– Quality
• Onset can be sudden or gradual. Throbbing / pulsating
– Intensity
• Moderate
– Timing
• Lasts between 4 and 72 hours, possibly with cyclical character
– Aggravating factors
• Photophobia / phonophobia (dislike of loud noise)
– Relieving factors
- Sleep helps
- A number of medications are available (e.g. triptans)
– Secondary symptoms
- May have aura (characteristic feeling preceding attack)
- Nausea and vomiting
What are the triggers for migraines?
Triggers:
– certain food e.g. cheese, chocolate
– menstrual cycle
– stress
– lack of sleep
– strong familial links - usually a family history of someone else suffering from migraines
What would the clinical examination be like in a person with migraines?
Clinical examination is normal - can occur between episodes of migraines and also during the migraine attack unless there is evidence of neurological dysfunction that occur as a part of an aura.
How would you treat migraines?
Can respond to simple analgesics (may need triptans); tend to want to lie down
In whom can we see medication overuse headache?
F>M
30-40 yr
Headache present on at least 15 days/month (constant)
This is a secondary headache → occurs in patients with pre-existing headache disorder e.g. history of tension headaches or migraines who’s been taking analgesics (overusing them) + has now developed this secondary headache on top of their primary headache disorder.
How does medication over-use cause headaches? (pathophysiology)
Using regular analgesics (presents on at least 10 days/month) - when you overuse analgesia - it leads to an upregulation of pain receptors, eventually headaches no longer respond to the painkillers so pts keep taking more → makes it worse!
– Headache not responding
Related to upregulation of pain receptors in meninges
What are the clinical features of medication overuse headaches?
– Present on at least 15 days per month
– No improvement after OTC medication (e.g. paracetamol)
– Diagnostic criteria are not important for you to know, but you need to know that patients who get this headache are using analgesics on at least 10 days per month
– This headache only seems to come about in people who are taking analgesia for headache in the first place
– Can get a variety of symptoms
– Often co-exists with depression and sleep disturbance
How can medication overuse headaches present?
Variable character- can be dull, tension-type or migraine-like
Co-exists with depression and sleep disturbance
How can we treat medication over-use headache?
Discontinue medication (headache worsens before improves) - break the cycle of overuse -(following this will get worse before getting better)
– Typically resolved completely by 2 months
In whom can we see cluster headaches?
M >F
Smoking history = risk factor
1 in 1000
Usually begins 30-40 years
What is the pathophysiology of cluster headaches?
Pathophysiology unknown
→ ?hypothalamic activation with secondary trigeminal and autonomic involvement
How does a cluster headache present?
– Unilateral, around or behind eye
– Sharp, stabbing, penetrating, often at night
– Severe, intense, often disabling, agitated
– 15 mins- 3 hours; occur in clusters with periods of remission (3m-3 years) —////////—–///////—–/////–
– Ipsilateral autonomic symptoms e.g. red, watery eye, blocked runny nose, ptosis
Describe are the clinical features of cluster headaches?
– Site
• Around / behind one eye • No radiation
– Quality
• Sharp and penetrating
– Intensity
• Very severe • Constant intensity
– Timing
- Rapid onset
- Attacks last 15 min – 3hrs and occur 1-2 times per day
- Usually at night
- Clusters of attacks last 2-12 weeks
- Remissions between clusters can last 3 months – 3 years
– Aggravating factors
- Head injury
- Alcohol
- Smoking
– Relieving factors
• Simple analgesics can help
– Secondary symptoms
• Features associated with decreased sympathetic activity:
- Red, watery eye - Nasal congestion - Ptosis
What are the triggers for cluster headaches?
Triggers:
– alcohol
– cigarettes
– volatile smells
– warm temp
– lack of sleep
– Histamine (hayfever)
– GTN
– solvent inhalation
Describe what the clinical examination would be like in a person with cluster headaches?
- *Clinical examination** – evidence of autonomic features (during attack)
- examination normal during remission (i.e. period of no attack)
What is the treatment for cluster headaches?
Simple analgesics often ineffective; oxygen and triptans used
Identify examples of secondary headaches.
– Intracranial haemorrhage*- some can cause signs/symptoms of meningism e.g. subarachnoid haemorrhage (blood can irritate meninges - headache, neck stiffness, photophobia) - sudden onset
– Raised ICP due to a space occupying lesions e.g. a tumour - gradual onset due to growth of tumour size
– Trigeminal neuralgia
– Temporal (giant cell) arteritis
Space occupying lesion can also cause headaches.
How does it cause this?
Causing raised intracranial pressure
Note: Headache rarely occurs in absence of other suspicious historical or exam findings
Describe the presentation of a space-occupying lesion causing headaches.
– Gradual,progressive
– Dull, but often variably described; key is progressiveness of severity
– May be mild in severity, worse in mornings
– Early-morning, on waking (rarely: headache wakes them)
– Worsened with posture (leaning forward), cough, Valsalva manoeuvre, straining
– Nausea, vomiting, focal neurological or visual symptoms (other neurological signs could include behavior/ personality change, seizures)
What symptoms can be seen in headaches caused by space occupying lesion?
o Associated neurological features
– E.g. visual disturbance or focal signs o
o Additional features of raised ICP
– Early morning headache
– Nausea and vomiting
– Worse on coughing and bending
Describe the clinical examination of space-occupying lesion causing headache.
Clinical examination – focal (unilateral) neurological signs, papilloedema
What is the treatment for space-occupying lesion?
Simple analgesics may be effective in early stages
In whom can we see trigeminal neuralgia?
F>M
25/100,000
UK popn. 50-60 years
What is trigeminal neuralgia caused by?
– Most caused by compression of CN V due to loop of a blood vessel (by a vascular malformation)
– 5% due to tumors/skull base abnormalities, MS or AV malformations
Describe the presentation of trigeminal neuralgia.
– Unilateral, pain felt in ≥1 divisions of CN V: if involves CNVa often described as headache
– Sharp, stabbing, ‘electric’ shock (sometimes burning) - often fearful of next episode due to how it manifests
– Severe, lasts few seconds- 2 mins
– Sudden onset
– Maybe preceding symptoms: tingling, numbness; pain can radiate to areas within CNV distribution
Describe the clinical features seen in trigeminal neuralgia.
– Site
- Unilateral, often over one eye
- Radiates to eyes, lips, nose and scalp (think distribution of CN V)
– Quality
- Sharp and stabbing
- ‘Electric shock’ feeling
– Intensity
• Severe
– Timing
- Sudden onset
- Lasts a few seconds to 2 minutes
– Aggravating factors
- Light touch to face
- Eating
- Cold wind
• Vibrations
– Relieving factors
• Can be difficult to alleviate
– Secondary symptoms
• Can have numbness and tingling preceding an attack
Describe the clinical examination of trigeminal neuralgia?
Clinical examination –normal
What are the triggers for trigeminal neuralgia?
– Light touch to face/scalp
– eating
– cold wind
– combing hair
What is the treatment for trigeminal neuralgia?
Simple analgesics not effective; can be difficult to treat
What is temporal arteritis?
Vasculitis of large and medium sized arteries of head (often affects branches of the external carotid artery)
seen in F>M
>50 years (most common in >75)
Describe the typical presentation of temporal arteritis.
F>M
>50 years (most common in >75)
Consider in any >50 year old with abrupt onset of headache + visual disturbance or jaw claudication (pain in jaw)
What are the symptoms seen in temporal arteritis?
In temporal arteritis, which artery is commonly involved?
superficial temporal artery commonly involved
What is the risk of temporal arteritis?
Risk of irreversible loss of vision due to involvement of blood vessels supplying CN II (optic)
What is the treatment for temporal arteritis?
steroids
may be do a biopsy to confirm the diagnosis
Generally for headaches, what investigation can we do?
– Clearly, dependent on cause (e.g. if subarachnoid haemorrhage then investigate accordingly
– Headache diary can be useful for chronic headaches
– Imaging may be indicated if red flags
Generally for headaches, what treatment can be given?
– Dependent on underlying cause
– Simple analgesia
– Triptans for migraine
– Cluster headaches may respond to high flow oxygen
Headaches need to be referred if there is:
→ Suspicion of a tumour
→ Suspicion of raised ICP
→ Recent onset seizures
→ Previous cancer
→ Unexplained focal deficit
→ Unexplained cognitive/personality changes
General approach to headache …
SUMMARY on both sides
Headaches ….
