Headaches can be split into Primary and Secondary Types, what would be signs of a secondary headache?
- First or worst ever headache
- Thunderclap onset
- A new daily & persistant headache
- A change in the headaches pattern or type
- Other symptoms such as jaw claudication, fevers, neuro signs/symptoms or worsened by position
List 2 things that could cause a thunderclap style headache?
Sub arachnoid haemorrhage
What causes most subarachnoid haemorrhages?
How would we approach a subarachnoid haemorrhage?
Immediately CT the brain and do an LP after 12 hours from onset
Early coiling or clipping
Define a thunderclap headache?
High intensity peaking instantly or within 1 minute of onset
What would indicate a thunderclap headache to be caused by CNS infection?
If the patients headache comes with fever, rash or:
Meningitis - STiff neck, photo/phonophobia, n&V
Encephalitis - Altered mental state, seizures, focal neuro symptoms/signs
What could raise or lower Intracranial pressure?
- Cerebral Abscess
- Venous sinus infarct
- Dural CSF leak either spontaneously or after LP
What are the specific signs of raised ICP?
Progressively worse headache
Worse in morning/wakes them up
Worse on flat, valsalva (shit/cough/strain) or on exertion
Visual Obscurations and pulsatile (whooshing) tinnitus
What indicates a intracranial hypotension and how do appraoch it?
Headache appearing/worsening on standing and lessening/resolving on lying down
Sagittal MRI of brain and spine will show an empty subarachnoid space
Bed rest, fluids, analgesia, caffeine
Epidural Blood patch (to stimulate healing of a CSF leak)
What is an epidural blood patch?
A treatment for leaking CSF leading to lowered ICP
Put some of the patietns blood in their epidural space which will cause irritation leading to healing of the leak
What is Giant Cell Arteritis and what about a headache would indicate it?
Giant cell granulomatous inflammation of the arteries causing narrowing which can cause an infarction to the brain and/or optic nerve
The headache is diffuse persistant and may be severe
What are the symptoms of giant cell arteritis?
- Diffuse, persistant and maybe severe headache
- Jaw claudication
- Visual Disturbance
- Scalp Tenderness
What investigations and treatment are there for suspected GCA?
ESR/CRP/Platelets all elevated
Treat with high dose prednisolone and confirm with a temporal artery biopsy
What are the main types of Primary Headache?
- Medication Overuse Headache
- Trigeminal Neuralgia
And the Trigeminal Autonomic Cephalagias:
!) Cluster HEadache
“) Paroxysmal Hemicrania
Define a Tension-Type HEadache?
- Most frequent Primary headache
- Mild, bilateral
- Often pressing or tightening
What are the subtypes of Tension Type HEadache?
Episodic - <15 days a month
Chronic - >15 days a month
How do you treat tension type headache?
Aspirin, paracetamol or NSAIDs
Can prevent with Tricyclic Antidepressants
Define a Migraine?
A chornic disorder of episodic attacks featuring headaches, phono/photophobia, functional disability and nausea.
And in 33%, an aura
The most frequent disabling primary headache
What causes a migraine?
We dont know the cause but it can be triggered by lots including:
- Oestrogen changes e.g. menstruation
- Sleep Disturbance
What is an “aura”?
A set of transient neurological symptoms lastig 15-60 minutes.
It moves from one area to the next so might appear as vision then sensory then speech problems (can be mistaken for a TIA)
What defines a Chronic Migraine?
Headaches >15 days a month for >3 months
Of which atleast 8 a month must be migraines
How do we treat migraines?
- Aspirin & NSAIDs
- Tricyclic Antidepressants
What should we be aware of in women with migraines?
Dont give antiepileptics to those of child-bearing age as they’re teratogenic
Treat pregnant women with paracetamol or propanolol/Amitriptyline prophylactically
Define a medication overuse headache?
HEadache >15days a month developed or worsened on regular symptomatic medications
What causes a medication overuse headache?
More than 10 days a month
Or simple analgesics more than 15 days a month
Also caffeine overuse
Where do Trigeminal Autonomic Cephalagias present with pain?
In the orbital, supraorbital and temporal regions
What do SUNA/SUNCT stand for?
Short Lasting Unilateral Neuralgiform headache
With either Autonomic symptoms
or Conjunctival injection and Tearing
Describe a cluster headache?
- Unilateral sharp/throbbing pain
- Rapid onset and 15-180 minutes duration
- Incredibly severe (nicknamed “suicide Headache”)
- Often comes with migranous symptoms such as nausea, aura and photo/phonophobia
Also remember Autonomic symptoms with all TACs
Why are cluster headaches called cluster headaches?
They are episodic, occuring in clusters typically lasting 1-3 months wiht anything from 1-8 a day during a bout.
The bouts may be triggered by alcohol and may feature continuous background level pain
They may show circadian rythmicity with bouts coming the same time every year and attacks the same time each day
How do you treat a cluster headache?
100% O2 ro SC sumatriptan for the attack
Occipital Depomedrone injection for the bout
Verapamil for prevention
Describe a paroxysmal hemicrania?
Unilateral sharp/throbbing pain Rapid onset, duration 2-30 minutes Very severe Possible Continuous bacground pain 2-40 attacks per day without circadian rythm
How do we treat Paroxysmal Hemicrania?
Prophylactic Indometacin (An NSAID)
Unilateral Stabbing/pulsing pain Short 10-240 second duration Triggered by wind/cold/touch/chewing 3-200 attacks a day Comes with conjunctival injection (red eye) and tears
How do we treat SUNCT?
Lamotrigine prophylactically (an anti-epileptic, same for SUNA)
Describe Trigeminal Neuralgia
Unilateral stabbing pain, unlike TACs its to the maxillary/mandibular regions. 5-10 second duration Also triggered by wind/cold/touch/chew 3-200 a day unlikely to have autonomic symptoms
How do we treat Trigeminal Neuralgia?
What kind of autonomic symptoms come with the Trigeminal Autonomic Cephalagias?
- NAsal Congestion/rhinorrhoea
- Eyelid Oedema
- Facial Sweating
- Miosis (Constricted Pupil) /Ptosis (Drooping eyelid)
Name a tricyclic antidepressant and what headaches its used for?
Name a tricyclic antidepressant and what headaches its used for?
- Prophylaxis of Tension Type Headaches
- Prophylaxis of Migraines
How do you differentiate the types of TACs?
CH = 1-8 PH = 1-40 SUNCT = 3-200
CH = 15-180 mins PH=2-30mins SUNCT = 5-240 seconds
I.e. frequency and duration are inversely proportional
Pain is sharp and throbbing in CHs & PHs but stabbing/pulsing or burning in SUNCT
All have a very severe pain
CH most likely to show circadian rythmicity
Summary of Treatments for Headache Types:
Thunderclap - Probably SAH - Coiling/clipping
Tension Type Headache - Aspirin/NSAID/Paracetamol + Amitryptiline
Migraine - Aspirin/NSAID/Triptan + Propanalol/Anti-epileptic/Amitryptiline
Medication Overuse Headache - Use less meds
Trigeminal Neuralgia - Carbamazepine
Cluster Headache - 100% O2/SC Sumatriptan + Verapamil
Paroxysmal Hemicrania - Prophylactic Indometacin NSAID
SUNA/SUNCT - Anti-epileptic Lamotrigine