Why is my Head Sore?

Question 1

What are the common types of headache?

Answer 1

• Tension / muscular
• Migraine
• Analgesia overuse
• Systemic illness
• Cervicogenic

Question 2

What are the serious differentials associated with headache?

Answer 2

• Subarachnoid haemorrhage
• Meningitis
• Tumours
• Other SOL
• Temporal arteries
• Strokes (including CV sinus thrombosis)

Question 3

What are the questions which should be asked in a history of headache?

Answer 3

• How long?
• Position on head?
• Character (not intensity)?
• Frequency? When?
• Diurnal variation?
• Change in character?
• Nausea / vomiting?
• Postural?
• Other neurological symptoms? E.g. double vision.
• PMH, FH (often migraines run in families).
• Medicines (analgesic abuse headache is suggested if pain medication is taken more than 15 days per month).

Question 4

Describe the history of a patient with a tension headache.

Answer 4

• Headache
  
  • ​Weeks, moths, years
  • ‘Tightness’, ‘pressure’
  • Constant, or worse towards the evening
  • Rarely associated with nausea
• Treatments
  
  • ​Reassurance (you don’t have a brain tumour…)
  • Explain the muscles around the head
  • Reduce analgesia
  • Use relaxation exercised
  • Low dose amitriptyline
  • Tell the patient that this headache will not go away overnight

Question 5

Describe migraine.

Answer 5

• Most headaches with nausea will be migraine.
• With or without aura, spreads over minutes.
• Unilateral or bilateral, usually hours-days.
• Photophobia, phonophobia, gut symptoms.
• Pulsating and sharp.
• More common in women, especially mid-cycle (ovulation), at period and menopause (oestrogen).
• Look for triggers (e.g. foods, alcohol, beginning or end of working week).
• Keep a diary to help decide pattern and treatments.
• Mechanisms unclear, vascular and neural theories, spreading depression of Leao (2-5mm/min).
• May be exacerbated by physical activity.
• Often a family history.

Question 6

Describe the available migraine treatments.

Answer 6

• Acute
  
  • ​Triptans - agonists at 5HT-1b and 5HT-1d receptors (sumatriptan, rizatriptan, naratriptan, zolmitriptan etc.).
  • Aspirin, paracetamol.
  • Anti-nausea (prochlorperazine, metoclopramide).
• Prophylactic (if >2/month)
  
  • Beta blockers
  • Low dose amitriptyline
  • Pizotifen (5HT-2aand 2c antagonist, antihistamine, anticholinergic)
  • Topiramate
  • Sodium balproate
  • Candesartan
  • Flunarzine
  • Lisinopril
  • Methysergide (retriperitoneal fibrosis)

Question 7

What are the other migraine treatments available if the conventional treatments have failed?

Answer 7

• Botulinum toxin injection (usually every 90 days), approved in the UK.
• Anti-CGRP monoclonal antibodies, erenumab, licensed in 2018 for >4 migraines / month UK, (s/c monthly injection), must have tried at least 3 other prophylactics.
• Acupuncture

Question 8

Which medication should women with migrain with aura never be put on?

Why?

Answer 8

• Combined oral contraceptive pill.
• You can induce a stroke.

Question 9

What is trigeminal autonomic cephalagia (TAC)?

Answer 9

• A very rare form of migraine.
• Recurrent pain in trigeminal distribution with autonomic features (eye watering, nasal congestion, redness of eye).
• Commonest of these is cluster headache: unilateral (striking circadian rhythm, same time of day, clustering in periods usually a few weeks).
• Paroxysmal hemicranias (half the head affected) (women get this more frequently than men), shorter, more frequent attacks, responds well to indamethacin.

Question 10

How are trigeminal autonomic cephalagias (TACs) treated?

Answer 10

• Triptans
• Oxygen
• High dose verapamil (up to 960mg/day).
  
  • An old calcium channel blocker which acts on the heart.
• Indomethacin for paroxysmal hemicrania.

Question 11

Describe thunderclap headache.

Answer 11

• Instant or rapidly appearing (<60 seconds).
• Must consider SAH, but can be exertional (coital cephalgia).
• Requires urgent investigation, CT head, LP after 12 hours, look for bilirubin and oxyHb).

Question 12

Describe the headache associated with raised intracranial pressure.

Answer 12

• Headache usually mild.
• Diurnal variation - worse in the morning, often gone by lunchtime.
• Often mild nausea.
• Neurological features.
• Look for papilloedema.
• Tumours, abscess, CSF blockage.
• Urgent referral and scan.

Question 13

Describe temporal arteritis.

Answer 13

• Never occurs in patients <50 years.
• Maybe features of polymyalgia.
• Jaw claudication (pain around the jaw when chewing because the blood supply is limited).
• Tender temporal arteries.
• Raised ESR (erythrocyte sedimentation rate).
• Can use USS or terporal artery biopsy (sample error; you could get a big of the temporal artery which is unaffected by the problem).
• Danger of blindness, use steroids only (usualy high dose).
  
  • BUT be careful of steroid side-effects.

Question 14

What is cerebral venous sinus thrombosis?

Answer 14

• Thrombosis in cerebral veins
• Often presents with papilloedema and seizures.
• Often bilateral.
• Causes headache, often severe.
• MRI / MRV
• Often females, particularly those on the contraceptive pill.

Question 15

Describe the headache associated with low intracranial pressure.

Answer 15

• Can happen after lumbar puncture.
• Headache on standing, eased with lying.
• Can occur spontaneously.
• Blood patch for post LP headache.

Question 16

Describe early morning headaches.

Answer 16

• Often in those who are obese.
• Often there is a history of snoring.
• Maybe concurrent COPD.
• Waking up with headache in the morning.
• Diagnosis = sleep apnoea with CO₂ retention.

Question 17

What is transient global amnesia?

Answer 17

• Thought to be a variant of migraine.
• Often during stress / exposure to cold.
• For a period of time, patient cannot lay down any new memories. Usually lasts a few hours but can be less.
  
  • The key thing is ‘did they keep asking the same questions over and over’?
• This is a benign condition.
• Clinical diagnosis.