Headaches

Question 1

What re some examples of priamry and secondary headaches?

Answer 1

Primary - Migraines and trigeminal autonomic cephalgia.
Secondary - Thunderclap headache, raised ICP headaches, low ICP headaches and neuralgia

Question 2

What are some other causes of headaches?

Answer 2

Tension headaches, sinusitis, giant cell arteritis (single episode), glaucoma (single episode), medication overuse, hormonal, carbon monoxide poisoning, trigeminal neuralgia, meningitis, encephalitis (single episode)

Question 3

What are some headache red flag symptom’s?

Answer 3

1. Photophobia, fever r neck stiffness.
2. New neurological symptoms (haemorrhage or tumour)
   New onset cognitive dysfunction
3. Visual disturbance (giant cell arteritis),
4. Sudden occipital headache (SAH)
5. Worse on coughing or straining, bending over (raised ICP)
6. Vomiting,
7. History of trauma,
8. History of cancer,
9. Pregnancy

Question 4

Which headache patients should get imaging?

Answer 4

SSSNOPPP,
1. Systemic symptoms,
2. Secondary risk factors,
3. Seizures,
4. Neurological symptom,
5. Older age,
6. Progression,
7. Papilloedema,
8. Precipitated by cough/exertion/valsalva

Question 5

Which headache patient’s should get an LP?

Answer 5

CSF:
1. Change in nature of headache,
2. Systemic signs and features.
3. Focal neurological deficit.

Question 6

What is the presentation and criteria for tension headache?

Answer 6

Presentation: Tight band , bilateral.
Criteria
A. At least 10 episodes occurring on 1 day of the month.
B. Two of following: Bilateral, pressing/tightening quality, mild-mod and not aggravated by physical activity.
C. Both of following: No nausea/vomiting and no photophonophobia

Question 7

What is the diagnostic criteria for a migraine?

Answer 7

A. At least 5 attacks of:
B. Lasting 4-72h
C. Two of the following: Unilateral, pulsating quality, mod-severe pain and its aggravated by physical activity like walking.
D. One of the following: Nausea/vomiting or photophobia or phonophobia

Question 8

what are the common triggers for a migraine attack?

Answer 8

Tiredness, stress, alcohol, COCP, lack of food/dehydration, cheese, chocolate, red wines, cirtus fruits, menstruation, bright lights.

Question 9

What is a hemiplegic migrane?

Answer 9

Variant of migraine in which motor weakness is a manifestation of aura. Should get further investigations

Question 10

What are the phases of a migrane?

Answer 10

Prodrome - Yawning, polyuria, depression, poor sleep/concentration. This can last hours to days.
Aura - Can be visual, sensory, language or motor. 5-60mins
Headache - Throbbing headache, nausea/vomiting, photophonophia worse with activity.
Postdrome - Depression, euphoria, poor concentration (24-48 hours)

Question 11

What is the acute management of a migraine?

Answer 11

Avoid opiates.
Single dose of 900mg aspirin or
Triptans such as sumatriptan.
If persistent vomiting then give metoclopramide.

Question 12

What are the contraindications for triptans?

Answer 12

Hypertension, coronary artery disease previous stroke/TIA or myocardial infarction. This is due to vasoconstriction.

Question 13

What are the prophylaxis for migraines?

Answer 13

Lifestyle advice - avoid triggers,

Give pharmacological prophylaxis if >4 headaches a month. 1st line is propranolol, others include topiramate or amitriptyline. Switch if no benefit at 3 months

Headache diaries

Question 14

Describe features of cluster headaches

Answer 14

Intense stabbing pain around the eye lasting 15min-2 hours. May occur up to twice a day.
Pain accompanied by redness, lacrimation, lid swelling, nasal stuffiness, miosis or ptosis.
Patient’s are restless.
CLusters usually last 4-12 weeks.
Can be triggered by alcohol.

Question 15

What is the diagnostic criteria for cluster headaches

Answer 15

A. At least 5 attacks
B. Severe or very severe orbital/supraorbital pain lasting 15-180mins
C. One or both of following: autonomic features ipsilateral to headache or a sense of agitation/restless ness
D. Frequency of one every other day to 8 per day.

Question 16

What are the investigations and treatment for cluster headaches?

Answer 16

Investigations - MRI with gadolinium contrast.
Management - Acute: 100% oxygen and subcut triptan. Prophylaxis is with verapamil

Question 17

What is the treatment for trigeminal neuralgia?

Answer 17

Carbamazepine, failure to respond or atypical features should prompt referral to neurology
Decompression surgery.

Question 18

What is the management of tension headaches?

Answer 18

Reassurance and simple analgesia. If chronic then first line is amitriptyline

Question 19

Describe features of paroxysmal hemicrania?

Answer 19

Severe, unilateral headaches usually in orbital, supraorbital or temporal region. Usually associated with autonomic features.
Completely responsive to indomethacin

Question 20

Describe features of medication overuse headaches

Answer 20

Headache which is present for 15+ days per month. Patients using opioids or triptans are most at risk.
Withdraw medications - abruptly stop everything except opioids which must be weaned.

Question 21

Explain the presentation and management of a thunderclap headache

Answer 21

Presentation - Sudden onset, extremely severe. Can last up to 1h.
Management - Medical emergency, requires non contrast CT ASAP and if normal then a LP for blood products.
If LP normal then consider MRI, angiogram or venogram

Question 22

What is the management of a post LP headache?

Answer 22

Supportive care initially. If pain continues for more than 72 hours then treatment is indicated: blood patch, epidural saline or IV caffeine

Question 23

What are the features of trigeminal neuralgia?

Answer 23

Unilateral disorder with brief electric shock type pains limited to one or more division of the trigeminal nerve. Pain evoked by light tough.