Headache

Question 1

What is the estimated prevalence for headache over the past year?

Answer 1

Half of adult population estimated

Question 2

Pain sensitivity of cranial structures - what is pain sensitive?

Answer 2

Pain sensitive: cranial venous sinuses with afferent veins
Arteries at the base of their brain and their major branches
Arteries of the dura
Dura near the base of the brain and large arteries
Dural cranial and extracranial nerves
All extracranial structures

Question 3

Neurotransmitters - headaches

Which neuromodulators and neuropeptides are involved?

Answer 3

Serotonin, dopamine, glutamate, oxytocin, noradrenalin

CGRP, PACAP, orexin, neurokinin A, Substance p

Question 4

Headache classifications

Answer 4

Question 5

What headaches are primary headaches?

Answer 5

Question 6

Define migraine

Answer 6

Brain disorder caused by altered regulation (neurotransmitters) due to dysfunction of central brain stem functions, and therefore control of sensory afferents (pain sensitive structures)

Question 7

Phenotype the headache

Answer 7

Presenting headache:
constant or episodic
Site: unilateral or bilateral/holocranic
Headache load: frequency/duration/severity
Character of pain: throbbing, stabbing etc
Precipitating factor
Previous history of headaches

Question 8

… level of serotonin are associated with migraines

Answer 8

Low levels

Useful for proposing treatment (Triptan’s - serotonin agonist)

Question 9

What to be wary of when taking sumatriptan?

Answer 9

High blood pressure, uncontrolled due to vasoconstriction affect

Question 10

… hypersensitivity leads to the associated symptoms of migraine which include
Nausea, vomiting
Yawning

Answer 10

Dopamine hypersensitivity

Question 11

Cortical spreading depression helps explain

Answer 11

Aura

Question 12

Migraines are more common in who?

Answer 12

Females - more prevalent around menstruation

Question 13

Are migraines increased or reduced during pregnancy?

Answer 13

Reduced - increase in oestrogen

Question 14

Treatment for migraine

Answer 14

Lifestyle - avoid triggers, hydrate, reduce caffeine, alcohol
Regular meals
Good sleep hygiene
Exercise
Triptans - decrease CGRP release
NSAIDS - decrease prostaglandin secretion
Antiemetic - decrease dopamine sensitivity
Botox in small doses

Question 15

Tension headache

Answer 15

Pain > 4 hours
No migraine features
Often bilateral
Prefers to be still

Question 16

Migraine

Answer 16

Pain > 4 hours
+++ migraines features
Unilateral or bilateral
Prefers to be still

Question 17

Cluster headache

Answer 17

Pain <4hours
Prominent autonomic symptoms
Side-locked
Agitated

Question 18

Tension headache - common causes

Answer 18

Stress, anxiety, depression, lack of sleep, poor posture

Question 19

Red flags in clinical assessment - headache

Answer 19

Question 20

Giant cell arthritis:

Answer 20

Question 21

Classification of headache

Answer 21

Question 22

Red flags in headaches

Answer 22

Question 23

Tension headaches

Answer 23

Associated with stress
Symmetrical (30mins - 7hours)
Gradual onset
Band of pressure around forehead
Acute management - NSAID, paracetamol 
Prevention - stress relief (yoga, massage, cool flannel to forehead, acupuncture)
Prophylaxis such as amitriptyline

Question 24

Migraine

Answer 24

Migraine - unilateral, pulsating, associated with aura, N+V, photophobia, phonophobia
Risk factors such as FH, previous episodes, unavoidable exposure to trigger
Aura may precede headache (5-60min before)
4-72 hour lasting

Question 25

Management of headache (overview)

Answer 25

Propranolol over topiramate in women of childbearing ages (Reduced hormonal contraception effectiveness and teratogenic potential) Propranolol - not in asthma, depression or vascular disease

Question 26

Temporal arteritis (also known as …)

Answer 26

GCA Sudden onset unilateral localised headache with scalp tenderness Jaw claudication and visual changes (partial or total visual loss in one or both eyes) Risk factors include poly myalgia rheumatica, female and over 55 years old To investigate, temporal artery biopsy which will show skip lesions in temporal arteritis - also useful to do bloods such as CRP and ESR

Question 27

GCA is a medical emergency ! How do we detect and manage?

Answer 27

Jaw claudication Visual loss Intermittent Diplopia (double vision) Treat with prednisolone 60mg and aspirin 75mg and urgent rheumatologist review If any visual symptoms - same day ophthalmology review essential Temporal arteritis but no visual changes or jaw claudication, start on prednisolone 40mg and aspirin 75mg and refer to rheumatology within 3 days Signs and symptoms resolve - continue prednisolone for 12-18 months Give PPI and blue steroid card!

Question 28

What is given in GCA?

Answer 28

Prednisolone 60mg Aspirin 75mg Urgent rheumatology review (+/- ophthalmology if visual changes)

Question 29

Cluster headache - overview

Answer 29

Severe pulsating periorbital pain - autonomic symptoms such as Lacrimation, Ipsilateral eyelid oedema, ptosis, rhinorrhea, conjunctival injection and sweating Pain tends to be short lived and is relieved by physical activity Patients during an episode appear restless and pace during episodes Long periods of time without any headache, and then suddenly have a cluster (episodic) Chronic cluster headache - do not go longer than a month without Acute treatment - 100% high-flow O2 mask through a non-rebreathe mask for at least 20 mins SC/Nasal triptans in acute attacks If first attack, refer to neuro for diagnosis for prophylactic treatment such as verapamil Stop smoking and reduce alcohol

Question 30

Cluster headache management

Answer 30

Acute treatment - 100% high-flow O2 mask through a non-rebreathe mask for at least 20 mins SC/Nasal triptans in acute attacks If first attack, refer to neuro for diagnosis for prophylactic treatment such as verapamil Stop smoking and reduce alcohol

Question 31

Severe pulsating periorbital pain - autonomic symptoms such as Lacrimation, Ipsilateral eyelid oedema, ptosis, rhinorrhea, conjunctival injection and sweating Pain tends to be short lived and is relieved by physical activity Patients during an episode appear restless and pace during episodes What headache is this?

Answer 31

Severe pulsating periorbital pain - autonomic symptoms such as Lacrimation, Ipsilateral eyelid oedema, ptosis, rhinorrhea, conjunctival injection and sweating Pain tends to be short lived and is relieved by physical activity Patients during an episode appear restless and pace during episodes Long periods of time without any headache, and then suddenly have a cluster (episodic) CLUSTER HEADACHE

Question 32

Trigeminal neuralgia - overview

Answer 32

Unilateral facial pain that’s described as a shooting pain in territory of trigeminal nerve (cheek/jaw) Irritation of the nerve = makes it worse (Cold air, closing jaw, touch) Autonomic symptoms also Attacks = few seconds to several minutes May have remission for a long time Caused by compression of the trigeminal nerve (intracranial mass, MS, aneurysm, stroke, trauma, iatrogenic) Management - carbamazepine

Question 33

No red flags in trigeminal neuralgia, treat with…

Answer 33

Carbamazepine | If red flags, refer to secondary care

Question 34

Subarachnoid haemorrhage, also known as…

Answer 34

Thunder clap headache Sudden onset severe headache with reduced cognition/consciousness Meningism

Question 35

Thunder clap headache is called….

Answer 35

Subarachnoid headache ‘Thunder clap headache’ Sudden onset severe headache with reduced cognition/consciousness Meningism

Question 36

Subarachnoid headache - 2 types?

Answer 36

Traumatic - head injury Spontaneous - absence of trauma RF for spontaneous = PKD, Ehlers-Danlos syndrome and neurofibromatosis as they cause intracranial aneurysms (berry aneurysms) to develop

Question 37

RF for spontaneous subarachnoid haemorrhage?

Answer 37

= PKD, Ehlers-Danlos syndrome and neurofibromatosis as they cause intracranial aneurysms (berry aneurysms) to develop

Question 38

PKD, Ehlers-Danlos syndrome and neurofibromatosis are all risk factors for subarachnoid haemorrhage - why?

Answer 38

= PKD, Ehlers-Danlos syndrome and neurofibromatosis as they cause intracranial aneurysms (berry aneurysms) to develop

Question 39

Investigations in subarachnoid haemorrhage

Answer 39

CT head - hyperdense areas, indicative of an acute bleed 12 hours later - Lumbar puncture can be done to confirm if CT was negative Positive lP = Xanthochromic and a normal or raised opening pressure Can do a CT intracranial angiogram to visualise the source of the bleed such as the aneurysm High risk of re bleeding - so refer to neurosurgeons if confirmed diagnosis

Question 40

Venous Sinus thrombosis - overview

Answer 40

Less common than other headache causes - half of patients with this will have sagittal sinus thrombosis Cerebral infarction can happen Risk factors - history of sinusitis, meningitis, facial cellulitis, otitis media, dehydration, pregnancy, COCP

Question 41

Risk factors for venous sinus thrombosis

Answer 41

Risk factors - history of sinusitis, meningitis, facial cellulitis, otitis media, skull fracture, dehydration, pregnancy, COCP

Question 42

Presenting signs and symptoms in …

Answer 42

venous sinus thrombosis

Question 43

venous sinus thrombosis - signs and symptoms?

Answer 43

CN6 - reduced eye abduction

Question 44

How to diagnosis venous sinus thrombosis?

Answer 44

MR venogram | Raised intracranial pressure - MRI brain or CT head non-contrast

Question 45

There are several red flags that are essential to determine in the history that may indicate a serious underlying cause of headache that requires further investigation. These can be remembered by the mnemonic ‘HEADACHE PAINS’:

Answer 45

H - Head injury (any history of trauma?) E - Eye pain +/- autonomic features A - Abrupt onset (i.e. thunderclap headache) D - Drugs (analgesia overuse or since new drug started) A - Atypical presentation or progressive headache C - Change in the pattern or recent-onset new headache H - High fever and systemic symptoms E - Exacerbating factors (worse on lying/standing, sneezing, coughing, exercise) P - Pregnancy or puerperium A - Age (onset > 50 years) I - Immunosuppressed (e.g. systemic therapy, HIV) N - Neoplasia (current or past history of cancer) S - Swollen optic discs (papilloedema)

Question 46

Low-risk features There are a number of features that act as indicators that the cause of headache is unlikely to be secondary to a serious underlying disorder. The presence of all these features is usually a good indicator that further investigations (e.g. imaging) are not required.

Answer 46

Age ≤ 50 years Presence of typical features of primary headaches History of similar headache No abnormal neurologic findings No concerning change in usual headache pattern No high-risk comorbid conditions No new or concerning findings on history or examination

Question 47

Some of the major findings on clinical examination that would be considered high risk include;

Answer 47

``` Focal neurological deficits Global reduction in consciousness Cranial nerve neuropathy Seizure activity Meningism (headache, neck stiffness, photophobia) Fever Presence of papilloedema ```

Question 48

Examples of possible imaging modalities include:

Answer 48

CT head (without contrast): useful in acute situations to quickly screen for major pathology (e.g. bleeding, space-occupying lesion) CT head (with contrast): may be requested if there is a concern of a metastatic deposit or infective cause CT angiography: this uses contrast and assesses the cerebral vessels. Essential if there is concern about a vessel abnormality (e.g. dissection, aneurysm) CT venogram: this is utilised if there is suspicion of a cerebral venous thrombosis MRI head: provides a very detailed assessment of the brain and surrounding structures to assess for secondary causes of headache

Question 49

Lumbar puncture A lumbar puncture involves the insertion of a spinal needle into the subarachnoid space to take a sample of cerebrospinal fluid (CSF). The CSF can then be analysed for a variety of components to enable a formal diagnosis. Examples include:

Answer 49

Subarachnoid haemorrhage: analyse for breakdown products of blood (e.g. bilirubin, xanthochromia) Meningitis: analyse for microscopy, culture and sensitivity with a viral PCR IIH: check the opening pressure, which will be elevated

Question 50

It is estimated that among patients who present to A&E with a ‘thunderclap headache’ only …% will have a subarachnoid haemorrhage.

Answer 50

It is estimated that among patients who present to A&E with a ‘thunderclap headache’ only 8% will have a subarachnoid haemorrhage.

Question 51

The most concerning of these causes is a subarachnoid haemorrhage. However, other causes of a ‘thunderclap headache’ can include:

Answer 51

``` Arterial dissection Cerebral venous thrombosis Reversible cerebral vasoconstriction syndrome Intercerebral haemorrhage Meningitis Pituitary apoplexy ```

Question 52

Exacerbating and relieving factors This involves establishing what make the headache better and what makes the headache worse. It is important to determine whether there are any features of a low or high-pressure headache that refers to changes in intracerebral pressure:

Answer 52

Low-pressure headache: worse on sitting or standing. Known as an orthostatic headache. Results from not enough CSF (e.g. a leak). Other features include dizziness, tinnitus, and visual changes. High-pressure headache: worse or lying down, bending over or straining. Typically worse in the early morning. May be associated with nausea, vomiting, visual changes and low consciousness (depending on acuity and severity). Results from any cause of a raised intracranial pressure (e.g. tumour, IIH, abscess).