Lecture 5.2: Headaches

Question 1

Examples of Primary Headaches

Answer 1

• Migraine
• Tension Headaches
• Cluster Headaches

Question 2

Reasons for Secondary Headaches

Answer 2

• Head Trauma
• Medication Overuse
• Cancer
• Infection
• Vascular

Question 3

Mechanisms of Headaches (6)

Answer 3

• Skeletal Muscle Tension
• Arterial Dilatation
• Traction on Arteries
• Traction or Dilatation on Venous Sinuses
• Inflammation
• Referred Pain

Question 4

Stages of Migraines (4)

Answer 4

• Prodromal Fatigue (vague change in mood/appetite)
• Aura Phase
• Headache Phase
• Resolution

Question 5

Acute Management of Migraines (3)

Answer 5

• Analgesia
• Triptans
• Antiemetic

Question 6

Chronic Management of Migraines (3)

Answer 6

• Precipitant Avoidance
• Beta Blockers/Topiramate
• Acupuncture

Question 7

Precipitating Factors of Migraines (6)

Answer 7

• Foods
• Alcohol
• Emotion
• Menses
• Bright Light
• COCP

Question 8

How common are Tension Headache?

Answer 8

Most common type of headache in primary care

Question 9

Characteristics of Tension Headaches (6)

Answer 9

• Bilateral Pressure
• Rarely Systemic Upset
• No Aura
• Gets worse during the day
• Lasts 30mins to 7days
• Ranges from infrequent attacks to daily pain

Question 10

Management of Tension Headaches: Lifestyle (6)

Answer 10

• Stress
• Alcohol
• Exercise
• Mood
• Medication Abuse
• Reassurance

Question 11

Management of Tension Headaches: Medications (3)

Answer 11

• OTC medicine – paracetamol, ibuprofen
• NB – avoid codeine based products
• Low dose amitriptyline >2days/week

Question 12

Characteristics of Migraine Headaches (4)

Answer 12

• Unilateral
• Pulsatile
• Aura
• Triggers

Question 13

Characteristics of Cluster Headaches (6)

Answer 13

• Bouts of severe orbital pain lasting from 15mins to
  3hrs
• a/w conjunctival injection, lacrimation and nasal
  blockage
• Occasionally ptosis and Horner’s syndrome
• Makes patient restless (unlike migraine)
• Occur frequently (daily for several weeks)

Question 14

Acute Management of Cluster Headaches (2)

Answer 14

• Oxygen
• Triptan

Question 15

Prophylaxis of Cluster Headaches (3)

Answer 15

• Specialist Advice
• Verapamil / Li
• Avoidance of Triggers (alcohol, nicotine)

Question 16

Causes of Secondary Headaches (10)

Answer 16

• Temporal Arteritis
• Trigeminal Neuralgia
• Subarachnoid Haemorrhage
• Medication Overuse Headache
• Raised Intracranial Pressure
• Tumour
• Idiopathic Intracranial Hypertension (benign
  intracranial hypertension)
• Sinusitis
• Toothache
• Meningitis

Question 17

Red Flags for Headaches (12)

Answer 17

• Worsening headache with fever
• Sudden-onset headache reaching maximum intensity
  within 5 minutes
• New-onset neurological deficit
• New-onset cognitive dysfunction
• Change in personality
• Impaired level of consciousness
• Recent (typically within the past 3 months) head
  trauma
• Headache triggered by cough, Valsalva (trying to
  breathe out with nose and mouth blocked) or sneeze
• Headache triggered by exercise
• Orthostatic headache (headache that changes with
  posture)
• Symptoms suggestive of giant cell arteritis
• Symptoms and signs of acute narrow-angle glaucoma

Question 18

What is Chronic Pain? (2)

Answer 18

• Pain which persists beyond the natural healing time * Usually >3months

Question 19

Chronic Pain a Vicious Cycle (6)

Answer 19

• Acute Pain
• Immobility
• Increasing BMI
• Further Pain
• Increased Immobility/BMI
• Further Injury

Question 20

What does Inflammation Alter? (4)

Answer 20

• Ion channels on Neurones
• Sensitivity of Neurones/Receptors
• Decreases the threshold for firing
• Alters the trigger for firing

Question 21

Central Effect of Chronic Pain (4)

Answer 21

• Spontaneous Firing from Dorsal Horn
• Altered Descending Inhibition
• Personality/Perception
• Psychology

Question 22

Complex Region Pain Syndrome (CRPS)

Answer 22

• COMPLEX: Varied and dynamic clinical presentation
• REGIONAL: Non-dermatomal distribution of symptoms
• PAIN: Out of proportion to the precipitating events
• SYNDROME: Constellation of signs and symptoms

Question 23

What is Complex Region Pain Syndrome (CRPS)?

Answer 23

A broad term describing excess and prolonged pain and inflammation that follows an injury to an arm or leg

Question 24

Complex Region Pain Syndrome: Type 1

Answer 24

No identifiable lesion (5-10%)

Question 25

Complex Region Pain Syndrome: Type 2

Answer 25

• After nerve injury (causalgia)
• Linked to the sympathetic nervous system
• Triggered by variety of stimuli
• Minor trauma, bone fracture, surgery, stroke,
  myocardial infarcts

Question 26

Presentation of Complex Region Pain Syndrome (7)

Answer 26

• Triad of Symptoms: Autonomic, Sensory, Motor
• Pain (spontaneous, hyperalgesia, allodynia)
• Distal Oedema
• Skin Temperature Changes
• Skin Colour Changes
• Altered Sweating
• Bone Changes (peri-articular osteoporosis, joint
  stiffness)

Question 27

Motor Symptoms of CRPS (4)

Answer 27

• Weakness
• Tremor
• Dystonia
• Myoclonus

Question 28

Mechanism of CRPS (3 Hypothesis)

Answer 28

• Neurogenic inflammation
• Autonomic dysfunction
• Neuroplastic changes in CNS

Question 29

Management of Complex Regional Pain Syndrome (7)

Answer 29

• Steroids
• Analgesia
• Neuropathic Meds
• Physiotherapy
• Occupation Therapy
• Psychotherapy – CBT
• Sympathetic Nerve Blocks