9.2 headaches

Question 1

what are the differential diagnosis of acute?headache

Answer 1

vascular

• haemorrhage (subarachnoid, sub and extradural)
• thrombosis

infective

• meningitis
• encephalitis
• abscess
• temporal arteritis

opthalmic
- glaucoma

situational

• cough
• exertion
• coitus

Question 2

what is the difference between a primary and a secondary headache?

Answer 2

primary = due to the headache itself, not another cause e.g migraine

secondary = headache is present with another condition e.g meningitis/sinusitis

Question 3

what are the differential diagnosis of a chronic headache?

Answer 3

• migraine
• cluster headaches
• drug side effects
• tension headaches
• trigeminal neuralgia
• raised intracranial pressure
• temporal/giant cell arteritis

Question 4

what are the red flag symptoms of headaches?

Answer 4

SNOOP

Systemic signs or disorders e.g hypertension
Neurological symptoms
Onset new or changed and patient >50yrs
Onset in thunderclap presentation
Papilloedema

Question 5

what are the symptoms of a headache caused by a space occupying lesion?

Answer 5

gradual onset

progressive

associated neurological features

additional features of raised ICP

• early morning headache
• nausea and vomiting
• worse on coughing and bending

Question 6

what are the SQITARS for migranes?

Answer 6

S - unilateral, often frontal
Q - sudden or gradual onset, throbbing
I - moderate 
T - 4-72 hours, may be cyclical
A - photophobia
R - sleep improves, mediation also
S - aura and nausea and vomitting

Question 7

what are the triggers for migraines?

Answer 7

food, sleep, stress

Question 8

what are the SQITARS for tension type headaches?

Answer 8

S - bilateral frontal 
Q - squeezing, non pulsating
I - less severe 
T - worse at end of day, chronic is 15+ a month
A - stress, poor posture, lack of sleep
R - analgesics 
S - mild nausea 

over 50yrs = typical onset

Question 9

what is medication overuse headache?

Answer 9

headache present on at least 15 days a month

regular overuse greater than 3 months of

• triptans or opioids for 10 days a month
• paracetamol, aspirin or NSAIDS on at least 15 days a month
• resolves after 2 months following discontinuation of medicine
• gets worse before it gets better
• often co existing with depression/sleep disturbance

Question 10

what are the SQITARS for cluster headaches?

Answer 10

S - around/behind one eye
Q - sharp, penetrating
I - very severe and constant intensity
T - rapid onset, 15mins-3hrs, 1-2 a day, nocturnal. Last 2-12 weeks, remission lasts 3mo-3yrs.
A - head injury, alcohol, cigarettes
R - no radiation
S - red, watery eye, nasal congestion

onset is 20-40yrs

Question 11

what are the SQITARS for trigeminal neuralgia?

Answer 11

S - unilateral, over the eye
Q - stabbing, sharp, electric shock
I - severe
T - sudden onset, lasts a few seconds-2mins
A - light touch to face eating, cold wind, vibrations
R - radiates to eyes, lips nose and scalp
S - numbness and tingling before attack

onset is 50-60

Question 12

what can trigger a cluster headache?

Answer 12

alcohol, histamine, GTN, heat, exercise, solvents, lack of sleep

Question 13

what is the pathophysiology of trigeminal neuralgia?

Answer 13

most cases caused by compression of trigeminal nerve by a vascular malformation

can be found to be caused by neurones or skull base anomalies

Question 14

what investigations can be done for headaches?

Answer 14

dependant on cause e.g if subarachnoid haemorrhage then do a CT scan etc.

headache diary may be useful for chronic headaches

imaging if there are any red flags

Question 15

what treatment can be given for headaches?

Answer 15

Dependant on underlying cause

simple analgesia

triptans for migraine

cluster headaches may respond to high flow oxygen