Headaches - Part 1

Question 1

When taking a headache Hx from a patient, what are the 5 sinister causes of headache you have to rule out?

Answer 1

VIVID

• V: vascular - subarachnoid haemorrhage, haematuria (subdural or extradural), cavernous sinus thrombosis, cerebellar infarction
• I: infection - meningitis, encephalitis
• V: vision threatening - temporal arthritis, acute glaucoma, pituitary apoplexy, cavernous sinus thrombosis
• I: intracranial pressure - SOL (abscess, cyst), cerebral oedema, hydrocephalus, malignant hypertension
• Dissection: carotid dissection

Question 2

What are the non sinister causes of a headache?

Answer 2

• Tension-type headache
• Migraine
• Sinusitis (secondary headache)
• Medication overuse (secondary headache)
• TMJ syndrome
• Trigeminal neuralgia
• Cluster headache

Question 3

Non-sinister causes of headache: features of tension-type headache

Answer 3

◦ Very common (often bifrontal)
◦ Episodic, variable frequency, pain (tightening band), few hours
◦ Other than headache no other features (eg photophobia)
◦ Triggers: stress and fatigue

Question 4

Non-sinister causes of headache: features of migraine

Answer 4

◦ Common (2x more in women) 
	◦ Usually stereotyped, unilateral pattern and 1/3 of pts have aura 
	◦ Sensitivity to light, sound, smell 
	◦ 4h-72h  
	◦ Can be very disabling

Question 5

Non-sinister causes of headache: Rx for migraine

Answer 5

‣ 5HT agonists (sumatriptan)
‣ Analgesics: aspirin/paracetamol
‣ Anti-emetics: metoclopramide

Question 6

Non-sinister causes of headache: Sinusitis

Answer 6

◦ Facial pain + coryzal symptoms
◦ Tight pain exacerbated by movements
◦ Headaches last several days (consistent with infection time)
◦ Moderately severe but not disabling

Question 7

Non-sinister causes of headache: medication overuse headache (secondary headache)

Answer 7

◦ 5x more common in women
◦ Resembles migraine or tension type headaches
◦ Pts on very large quantities of meds
◦ Rx is withdrawal from analgesics - patients often very reticent to do so as will have period of a lot of pain before relief

Question 8

Non-sinister causes of headache: TMJ syndrome

Answer 8

◦ 4x more prevalent in women, age 20-40
◦ Dull ache in muscles of mastication that may radiate to jaw or ear
◦ Click or grinding noise when pts move their jaw

Question 9

Non-sinister causes of headache: trigeminal neuralgia

Answer 9

◦ V rare, more common in women, onset at 60-70 years
◦ Unilateral facial pain involving one or + branches of trigeminal nerve
◦ Lasts seconds but many times a day: triggers are eating, laughing, talking, touching
◦ Patients develop long lasting back pain
◦ Attacks rarely occur during sleep

Question 10

Non-sinister causes of headache: cluster headache

Answer 10

◦ Predominantly affects men 
◦ Clusters: 6-12 weeks every 1-2 years 
◦ Same time every day or night 
◦ Pain focused around 1 eye, very severe (suicide is contemplated) 
◦ Very disabling

Question 11

Basic questions during Hx taking

Answer 11

• Site of pain, and has it moved?
• Onset of pain: sudden/gradual and trigger?
• Character of pain: stabbing, dull, deep, superficial, etc
• Radiation: has it spread?
• Attenuating factors:
• Timing of pain: coming/going, how long?
• Exacerbating factors: does anything make it worse?
• Severity: 1-10 scale

Question 12

Red flag questions during Hx taking (8)

Answer 12

• Decreseased level of consciousness
◦ Hx of head injury: consider subarachnoid or subdural haematoma
◦ Meningitis/Encephalitis can also affect consciousness
• Suddent onset, worse headache ever: subarachnoid haemorrhage
• Seizures/focal neural deficit: limb weakness, speech difficulty (suggests intracranial pathology)
• Absence of previous episodes: recurrent episodes less sinister.
◦ Pt >50 ya: suspect temporal arthritis if 1st onset
• Reduced visual acuity
◦ Ambrosia fugax: TIA (headaches rare)
◦ Others: temporal arthritis, carotid artery dissection, acute glaucoma
• Persistent headache: worse lying down + early morning nausea
◦ Raised ICP
• Progressive/persistent headache: SOL (tumour, abscess, cyst, haematoma)
• General red flags: wt loss/fever (malignancy/TB) or chronic inflammation (temporal arthritis)

Question 13

What basic obs do you need when taking a headache Hx?

Answer 13

• Altered consciousness: GCS score
• Pulse and BP: check for malignant hypertension
• Temperature: meningitis/encephalitis

Question 14

What neuro signs/deficits should you be aware of when doing an exam on pt with PC of headache?

Answer 14

• Full upper, lower and cranial nerve exam
• Focal limb deficit = intracranial pathology more likely
• 3rd nerve palsy: ptosis, mydriasis and eye down and out
◦ Cause: ruptured subarachnoid aneurism of posterior communicating artery
• 6th nerve palsy: longest intracranial course t/g can get compressed by mass/raised ICP
• 12th nerve palsy: tongue deviation - can arise form carotid artery dissection
• Horner’s syndrome: should arise suspicion of carotid artery dissection or cavernous sinus lesion (ask about neck pain).

Question 15

What signs in the eyes should you be aware of when doing an exam on pt with PC of headache?

Answer 15

• Exophtalmos: cavernous sinus thrombosis/thyrotoxicosis
• Cloudy cornea: acute glaucoma
• Optic disc problems: raised ICP