Headaches and Migraines

Question 1

What are the types of headache?

Answer 1

primary - no underlying pathology, is more common

• migraine
• tension headache
• cluster headache

secondary - attributed to an underlying pathology

• origin may be infectious, neoplastic, vascular or drug-induced
• requires referral

Question 2

What is a migraine?

• symptoms
• duration
• frequency

Answer 2

characterised by unilateral (affects one side of the head), moderate-severe throbbing pain

builds up over minutes to hours
usually occurs every few weeks
lasts 4-72 hours

associated with nausea and vomiting, sensitivity to light and sound

can occur with or without aura (sensory disturbances)

is disabling, impacts daily living

Question 3

What is aura?

Answer 3

prodomal phase
- is the early sign/symptom of migraines
= usually occurs before migraine onset

Question 4

What is the difference between migraines with and without aura?

Answer 4

migraine without aura is more common than with aura

aura causes sensory disturbances that typically affect vision but can also affect movement and speech

• blind spots or coloured spots
• zigzags
• flashes of light
• tingling or pins and needles in arms/legs
• numbness in the face or one side of the body
• tinnitus
• slurred speech

in both cases. people can feel the typical symptoms of a migraine
- nausea, vomiting, sensitivity to light/sound/touch/smell

Question 5

What is the theory about the cause of migraines?

Answer 5

related to dilation of blood vessels within or around skull

Question 6

What is a tension headache?

• symptoms
• duration
• frequency

Answer 6

characterised by bilateral pain (affects both sides of the head), generalised ache and a tight band around head spreading to top of head

do not normally cause any other symptoms

can be

• episodic = occur less than 15 days a month (are less frequent
• chronic = occur at least 15 days a month (are more frequent)

Question 7

What is the theory behind tension headaches?

Answer 7

muscle spasm in neck & scalp/tension in muscles resulting in constricted capillaries, reducing blood flow = lack of oxygen

Question 8

What are cluster headaches?

• symptoms
• duration
• frequency

Answer 8

characterised by sever, unilateral pain (occur on one side of the head) within and above the eye and temporal region

lasts 15mins - 3hours for 2-3 months
occur once every other day to 8 times a day often with circadian rhythm

can occur at same time of day and clusters at same time each year

Question 9

What symptoms are cluster headaches associated with?

Answer 9

lacrimation - excessive tearing
rhinitis - runny nose, sneezing, itching
facial sweating
restlessness or agitation
redness of the eye

Question 10

What is a chronic daily headache?

Answer 10

headache on 15 days or more per month (is frequent)

pain appears to be there from morning to night (all day)
varies from an ache to dull throb (severity varies)

Question 11

What are the different types and causes of secondary headaches?

Answer 11

analgesic overuse
traction headaches
space occupying lesion
spasm or fatigue of ciliary and periorbital muscles of eye 
- eye strain
glaucoma
dental pain
- jaw
sinusitis
muscle strain or pulled ligaments in neck/upper back
shingles affecting scalp or eyes
temporal arteritis
hypertension (rarely)
haemorrhage (subarachnoid/subdural)

Question 12

How does analgesic overuse cause a secondary headache? How often must they be used to cause this type of reaction?

Answer 12

analgesic overuse causes an increase in number of pain receptors that are switched on
- first by pain itself then by increased sensitisation of receptors

results in an exaggerated response of receptors that
more frequent or potent analgesics do not stop
- is a vicious cycle

usually caused by taking simple or combination analgesic on more than 3 days per week

Question 13

What is a tension headache?

• symptoms
• duration
• frequency

Answer 13

caused by:
- inflammation (e.g. meningitis, encephalitis), tumours, haematoma (bleeding outside of blood vessels - e.g. in head injury)
= result in irritation and stretching of meninges (three layers of membranes that cover and protect your brain and spinal cord)

results in increased intracranial pressure
- headche

Question 14

What is a space occupying lesion?

Answer 14

tumours and cerebral abscesses compress brain tissue against skull
- result in increased intracranial pressure which leads to a headache

Question 15

What are the differences between migraines and tension headaches?

Answer 15

migraines

• moderate-severe pain
• usually unilateral
• pulsating
• aggravated by normal activities
• often accompanied by sensitivity to light, nausea and vomiting

tension headaches

• mild-moderate pain
• bilateral
• non-pulsating
• not aggravated by normal activities
• usually has no other symptoms

Question 16

What should you ask when suspecting a headache?

Answer 16

location 
speed of onset 
duration 
intermittent or constant
frequency
severity of pain
aggravating or relieving factors
medication 
CNS symptoms

other symptoms that may cause it

• fever = sinusitis, viral infection
• visual disturbances = glaucoma, stroke
• neck stiffness = injury, meningitis

Question 17

What are the different locations for pain with a headache? What are the types of headaches and causes they indicate?

Answer 17

frontal
- idiopathic headache, sinusitis, nasal congestion

occipital (back of the head)
- tension, anxiety (especially if pain radiates over the top and sides of head)

hemicranial (unilateral)
- migraine, sinusitis (can spread to both sides later), shingles, trigeminal neuralgia (facial pain/unilateral)

orbital (behind/around the eyes)
- sinusitis, migraine, shingles, glaucoma

temporal (temples on the sides of the head)
- temporal arteritis (over 50yrs + sensitivity to touch on temples)
= inflammation of blood vessels

Question 18

What are the different types of pain for a headache? What are the types of headaches and causes they indicate?

Answer 18

sudden pain
- haemorrhage

throbbing/pounding pain
- vascular cause (vasodilation caused by fever or migraine)

constant/nagging pain
- tension headache

moderate-severe pain
- migraine

Question 19

When should headaches be referred?

Answer 19

headache associated with injury/trauma
headache associated with high temperature (>38◦C)
severe headache of more than 4 h duration
headache in children under 12 years
severe occipital headache (across the back of the head)

headache that is worse in the morning and then improves
- may be a sign of increased intracranial pressure
associated with drowsiness, unsteadiness, visual disturbances or vomiting
- CNS
neck stiffness

Question 20

How should headaches due to medication overuse be treated?

Answer 20

medication overuse headache is usually a chronic headache (>15 days a month)
- most commonly seen when triptans (e.g. sumatriptan), opioids (codeine), ergots analgesia (taken for >10 days a month) and NSAIDS (take for >15 days a month)

must stop the usage of analgesics completely and abruptly
- headaches are likely to get worse in the short term before improving

Question 21

What are the different methods of treatment for headaches?

Answer 21

paracetamol - 1st line
- analgesic and antipyretic but not anti-inflammatory

ibuprofen (NSAID) - 1st line

• analgesic, antipyretic and anti-inflammatory
• maximum daily dose allowable for OTC use is 1200 mg
• can be irritating to the stomach so should be taken with or after food

aspirin (NSAID) (1st line but after P+I)

• analgesic, antipyretic and anti-inflammatory
• more irritating to the stomach than paracetamol and ibuprofen
• cannot be used for under 16 years old

opioids - codeine, dihydrocodeine (2nd line)
- ADRs = constipation is common

caffeine

• analgesic combination
• claimed that caffeine increases the effectiveness of analgesics (potentiate activity and absorption)

antihistamine
- buclizine for nausea = buccastem

sumatriptan

Question 22

What is sumatriptan? How does it work?

Answer 22

5-HT1 agonist

• can be used OTC if they are aged 18-65
• cannot be used prophylactically

method of action
1 - works by narrowing blood vessels in the head
- acts on 5-HT1 receptors on blood vessels causing vasoconstriction and increased blood flow to intracranial arteries

2 - stops pain signals from being sent to the brain
- decreases peripheral nociception

3 - blocks the release of certain natural substances that cause pain, nausea, and other symptoms of migraine
- calcitonin gene-related peptide, substance P

Question 23

What are herbal supplements that can be used to treat headaches?

Answer 23

feverfew
- herb that has been used in the prophylaxis of migraine

Valerian, hops, St John’s Wort
- relieves stress that can trigger headaches