Neurology: Headaches

Question 1

What are common causes of headaches?

Answer 1

Primary Headaches: TTH, Migraine, Cluster Headache, Others

Secondary Headache: Vascular, Infective, Neoplasia, Drugs, Inflammation, RICP, Trauma, Metabolic, Toxins

Other causes of headache

• Acute single episode: Meningitis, Encephalitis, Subarachnoid haemorrhage, Sinusitis, Glaucoma (acute closed-angle), Tropical illness e.g. Malaria
• Chronic headache: Chronically raised ICP, Paget’s disease, Psychological

Question 2

What are red flag symptoms/signs associated with headaches?

Answer 2

• Thunderclap Headache
• Stiffness
• Rash
• Photophobia
• Focal Neurology
• Nausea/Vomiting
• Characteristics of RICP headache: Present on waking, Worse if lying, Exacerbated by Valsalva/Bending/Cough, Papilledema
• Fever
• Recent onset or change of character

Question 3

What indicates a migraine when taking a history?

Answer 3

• Prior History or family history
• Negative neurological exam – (NB complicated migraine with hemiplegia, basilar artery signs)
• Migraine aura (*contraindication to COCP)
• Precipitating features

Question 4

What are characteristics of migraines?

Answer 4

Severe headache attacks lasting 4-72 hours (when untreated or unsuccessfully treated)

• Headache has at least two of the following four characteristics:
  
  • Unilateral location
  • Pulsating quality or throbbing in nature
  • Moderate or severe pain intensity
  • Aggravated by or causing avoidance of routine activities of daily living and physical activity (e.g. walking or climbing stairs). Patient often describe ‘going to bed
  • May be associated with aura, nausea and photosensitivity
• During headache, at least one of the following:
  
  • Nausea and/or vomiting
  • Photophobia and phonophobia

In women may be associated with menstruation

Question 5

What is the Acute Treatment of Migraines?

Answer 5

• 1^st line: offer combination therapy with an oral triptan and an NSAID, or an oral triptan and paracetamol
  
  • For young people aged 12-17 years consider a nasal triptan in preference to an oral triptan
• If the above measures are not effective or not tolerated offer a non-oral preparation of metoclopramide* or prochlorperazine and consider adding a non-oral NSAID or triptan
• Antiemetics

Question 6

When is Migraine Prophylaxis given?

Answer 6

Prophylaxis should be given if patients are experiencing 2 or more attacks per month. Modern treatment is effective in about 60% of patients.

Question 7

What is the prophylaxis given for Migraines?

Answer 7

• Medication: Topiramate or Propranolol (Amitriptyline can also be given)
  
  • Propranolol used in preference to topiramate in women of child bearing age due to teratogenicity and reduction of the effectiveness of hormonal contraceptives
• If the above measures fails NICE recommend ‘up to 10 sessions of acupuncture over 5-8 weeks’
• NICE advise ‘riboflavin (400 mg once a day) may be effective in reducing migraine frequency and intensity’
• Menstrual migraine treatment: NICE recommend either frovatriptan (2.5 mg twice a day) or zolmitriptan (2.5 mg twice or three times a day) as a type of ‘mini-prophylaxis’

Question 8

What is the last management option for Migraines?

Answer 8

• Erenumab (Aimovig)
• Fremanezumab (Ajovy)
• Galcanezumab (Emgality)
  
  • Licences, not NICE approved, expensive, evidence from trial quite short term, looks effective and well tolerated in the short term

Question 9

How can Migraines be affected by physilogical changes in and medications used by women?

Answer 9

• Migraines during pregnancy
  
  • 1^st Line: 1g Paracetamol
  • 2^nd Line: NSAIDs can be used in the 1^st and 2^nd trimester
    
    • Avoid aspirin and opioids such as codeine during pregnancy
• COCP is absolutely contraindicated in people who have migraine with aura due to an increased risk of stroke (relative risk 8.72)
• Migraine and menstruation
  
  • Frequency and severity of migraines may increase around the time of menstruation. SIGN recommend that women are treated with mefanamic acid or a combination of aspirin, paracetamol and caffeine. Triptans can be used in the acute situation
• HRT is safe to prescribe for patients with migraines but it may make migraines worse

Question 10

What are symptoms of Tension Headaches?

Answer 10

• Recurrent, non-disabling, bilateral headache, often described as a ‘tight-band’
• Sensation of tightness or pressure across your forehead or on the sides and back of your head.
• Tenderness on your scalp, neck and shoulder muscles
• Often triggered by stress. Not aggravated by routine activities of daily living

Question 11

What are some non-drug management for Tension Headaches?

Answer 11

• Manage and explain precipitating factors: stress, mood disorders, chronic pain, sleep disorders
• NHS information for patients
• Yoga, massage, exercise, cool flannel to forehead
• Course of up to 10 sessions of acupuncture over 5-8 weeks

Question 12

What is the drug management for Tension Headache?

Answer 12

• Simple analgesia
• Never opioids
• Chronic symptoms
  
  • Low Dose amitriptyline (10-75mg daily)
    
    • For people who do not respond — discontinue treatment and discuss with neurology.
    • For people who do respond — attempt withdrawal of medication if improvement is maintained for 4–6 months.
  • Careful to avoid analgesic overuse

Question 13

What are symptoms of Cluster Headache?

Answer 13

• Pain typical occurs once or twice a day, each episode lasting 15 mins - 2 hours with clusters typically lasting 4-12 weeks
• Unilateral intense pain around one eye (recurrent attacks ‘always’ affect same side)
• Severe (some patients suicidal) and short lived.
• Patient is restless during an attack
• Nasal congestion/rhinorrhoea/miosis/ptosis/conjunctival injection
• Accompanied by redness, lacrimation, lid swelling
  
  • Rule out acute sinusitis

Question 14

How often do Cluster Headaches occur?

Answer 14

Episodic – can be daily for weeks

• More common in men and smokers

Question 15

What is the treatment for Cluster Headache?

Answer 15

Acute:

• 100% oxygen at a flow rate of 12–15 litres per minute via a non-rebreather face mask for 15 to 20 minutes
  
  • 80% response rate within 15 minutes
• Subcutaneous Triptans (75% response rate within 15 minutes)
  
  • injectable/ nasal as well

Prophylaxis:

• Verapamil
• Evidence for tapering dose of prednisolone
• Address triggers – alcohol, smoking
• Lithium

Question 16

What are characteristics of medication overuse headaches?

Answer 16

• Results from pre-existing primary headache present and regular overuse of analgesics
  
  • NSAIDS/ paracetamol >15 d/month
  • Triptans, opioids > 10 d/month for 3 months+ are more at rise
• Developed or worsened whilst taking regular symptomatic medication
• May be psychiatric co-morbidity

Usually resolves after the overuse is stopped.

Question 17

What are symptoms of Trigeminal Neuralgia?

Answer 17

• Electric shock pain in the areas supplied by the Trigeminal nerve lasting lasting a few seconds to several minutes
• Can be spontaneous or triggered: touching the face, chewing, speaking or brushing teeth, breeze on the face
• Several attacks daily but can have pain free periods
• Can be more frequent and intense over time
• Constant aching, burning may occur before spasm-like pain of TGN.

Question 18

What are causes of Trigeminal Neuralgia?

Answer 18

• Spontaneous
• Neurovascular conflict
• Multiple Sclerosis
• Tumour
• Trauma/Iatrogenic
• Stroke

Question 19

How is Trigeminal Neuralgia managed?

Answer 19

Drug management

• Carbamezepine is 1st line
  
  • if contraindcated or non-effective
    
    • Baclofen, Oxcarbazepine, Lamotrigine, Phenytoin, Clonazepam, Gabapentin

Surgical management

• Microvascular decompression
• Brain stereotactic radiosurgery (Gamma knife)
• Rhizotomy (glycerol injection, balloon decompression, Radiofrequency thermal lesioning)

Question 20

What are characteristic signs of Temporal Arteiritis?

Answer 20

• Granulomatous large-vessel arteritis seen almost exclusively in people over 50
• F>M
• Rapid onset headache (e.g. < 1 month) of unilateral headache
• Associated with PMR
• Raised ESR

Question 21

What are clinical symptoms of temporal arteritis?

Answer 21

• Headache
  
  • Pain develops over inflamed superficial temporal and/or occipital arteries. Touching the skin over an inflamed vessel causes pain.
  • Arterial pulsation is soon lost, and it can become hard, tortuous and thickened
  • Tender Scalp over inflamed vessels may be red and rarely gangrenous patches appear. Palpable temporal artery
• Facial Pain
  
  • Pain in face, jaw and mouth caused by inflammation of facial, maxillary and lingual branches of external carotid artery in GCA.
  • Mouth opening and protruding the tongue becomes difficult. Painful ischaemic tongue occurs rarely
• Visual problems
  
  • Visual loss from arterial inflammation and occlusion occurs in 25% of untreated cases. Posterior ciliary artery occlusion causes anterior ischemic optic neuropathy in three-quarters of these
  • Other mechanism are central retinal artery occlusion, cilioretinal artery occlusion and posterior ischemic optic neuropathy
    
    • Posterior ciliary vessels are affected, ischaemic optic neuropathy causes the disc to become swollen and pale but retinal branch vessels usually remain normal
    • When the central retinal artery is occluded, there is a sudden permanent unilateral blindness, disc pallor and visible retinal ischaemia.
    • Bilateral blindness may develop with second eye being affected 1-2 weeks after the first
  • Amaurosis fugax may precede permanent blindness
• Neurological features
  
  • Mononeuropathy or polyneuropathy of arms or legs
  • TIA or stroke in distribution of carotid or vertebrobasilar arteries
  • Upper cranial nerve palsies
• Weight Loss
• Night Sweats
• Fever
• Joint Aching
• Intermittent jaw claudication (65%). Pain is characteristically worse on eating

Question 22

What is the management of Temporal Arteritis?

Answer 22

• Urgently refer all people with suspected GCA using a local GCA pathway for specialist evaluation (usually by a rheumatologist) on the same working day if possible, and in all cases within 3 working days
  
  • If there is visual loss (transient or permanent) — arrange an urgent (same day) assessment by an ophthalmologist.
• Immediately treat people with suspected GCA with oral prednisolone:
  
  • For people with visual symptoms — 60–100 mg as a one-off dose (they should be seen by an ophthalmologist the same day).
  • For people without visual symptoms — 40–60 mg daily (minimum 0.75 mg/kg).
• Temporal Artery Biopsy
• Document the person’s symptoms, signs, and level of function both before and after the onset of the condition to use as a baseline to compare response to treatment.

Question 23

What are blood tests for Temporal Arteritis?

Answer 23

• Liver function tests: about a third of people have mildly elevated liver function test results, particularly for alkaline phosphatase.
• Full blood count: normochromic normocytic anaemia and an elevated platelet count are common.
• C-reactive protein (CRP): the CRP level is typically elevated and may be a more sensitive indicator of inflammation in some people with giant cell arteritis.
• Erythrocyte sedimentation rate (ESR): the ESR is often greater than 50 mm/hour. However, the ESR may be normal at presentation and even during a flare of disease activity.

Question 24

What is the safety net advise for those presenting with Temporal Arteritis?

Answer 24

• To seek urgent (same-day) medical attention if they develop any visual disturbances (such as visual loss, double vision, or visual field defects).
• That the dose of prednisolone is normally reduced very slowly over several months. Treatment is often required for 1–2 years, but people may require low doses of corticosteroids for several years.
• Relapses may occur while taking prednisolone and are more common while the dose is being reduced.
• Frequent follow-up visits are required to monitor for relapses and adverse effects of corticosteroids.