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what is a cluster headache?

severely disabling episodic headaches.
more common in men and smokers.


how do cluster headaches present?

rapid onset excruciating pain around one eye
eye becomes watery, bloodshot, lids swollen, lacrimation
facial flushing
pain is strictly unilateral, will usually affect one side only
course - headaches last 15-60min, once or twice a day, often nocturnal
clusters last 4-12 weeks, then they might have months/years before next cluster


how do you treat cluster headaches?

acute attack - 100% oxygen for 15 mins via non-rebreathe, sumitriptan SC or nasal spray at onset (nasal spray not licensed).
preventative - verapamil (start at 40mg and build up to 960mg max, requires ECG monitoring for AV block once at high doses/whilst raising dose)
prednisolone (second line, but can be preferred as started at top dose - then quickly wean off! may relapse)
lithium - if verapamil not tolerated, requires lots of monitoring
other options:
sodium valproate


give some possible triggers for cluster headaches

- alcohol precipitates attacks when in a cluster, but can be drunk between clusters
- histamine and nitroglycerine
- for some patients - heat, exercise and solvents
- disruption to sleep patterns (e.g. by shift work, jet lag, etc)


list some headache red flags that should prompt further investigation

- change in pattern of headache.
- new headache at age > 50.
- onset of seizures.
- headache with systemic illness.
- personality change.
- symps suggestive of raised ICP (morning headache, headache with coughing, sneezing, straining).
- acute onset of the worst headache ever (possible intracranial aneurysm).


list some differentials to consider for an acute single episode of headache

with meningism (stiff neck etc):
- meningitis
- encephalitis
- subarachnoid haemorrhage
head injury
glaucoma (acute closed-angle)
tropical illness e.g. malaria, typhus


what features of an acute single episode of headache would make you consider meningitis?

meningism - acute, severe headache felt all over with neck stiffness.
fever, photophobia, purpuric rash (although not always!)

admit urgently for CT head/LP if CT negative


what features of an acute single episode of headache would make you consider encephalitis?

neck stiffness, fever, odd behaviour, fits, reduced consciousness
admit urgently for CT head/LP if CT negative


what features of an acute single episode of headache would make you consider subarachnoid headache?

SUDDEN ONSET, 'worst ever' headache, often occipital (been kicked in back of head), stiff neck, focal signs, reduced consciousness
admit urgently for CT head/LP if CT negative


what features of an acute single episode of headache would make you consider head injury? what would prompt you to consider further investigations?

hx of trauma!
pain usually around site of trauma, but can be generalised.
CT head to exclude subdural/extradural haemorrhage if drowsiness ± lucid interval or focal signs.


what features of an acute single episode of headache would make you consider sinusitis? how do you treat it?

dull, constant ache over frontal or maxillary sinuses, with tenderness ± postnasal drip. pain worse on bending over. preceding coryzal symptoms. lasts 1-2 weeks.
if bacterial (likely Strep pneumoniae, haemophilus influenzae, moraxella catarrhalis) treat with abx - amoxicillin - although some evidence says this doesn't achieve anything.


give some home treatment measurers you would advise for a patient with acute sinusitis

- paracetamol/ibuprofen for pain/fever.
- intranasal decongestant (oral is not recommended for sinusitis) for a max of a week.
- nasal irrigation with warm saline solution.
- warm face packs, which may provide localised pain relief.
- adequate fluids and rest.


what features of an acute single episode of headache would make you consider acute angle-closure glaucoma?

elderly, long-sighted people
constant, aching pain develops round one eye, radiating to forehead.
markedly reduced vision, visual haloes, N&V.
red congested eye, cloudy cornea, dilated non-responsive pupil (may be oval), reduced acuity.

seek urgent expert help, if delay in treatment >1hr likely start acetazolmide 500mg IV, plus lay supine and give any topical agents not contra-indicated in the patient
topical agents inlude:
Beta-blockers - eg, timolol, cautioned in asthma.
Steroids - prednisolone 15 every 15 minutes for an hour, then hourly.
Pilocarpine 1-2% (in patients with their natural lens).
Phenylephrine 2.5% (in patients who do not have their own lens).


what are tension headaches?

main cause of bilateral, non-pulsatile headache ± scalp muscle tenderness, with no vomiting/sensitivity to movement. often described as band round scalp, pressure, tightness.

divided into
- episodic TTH. This occurs on fewer than 15 days each month. It can evolve into the chronic variety.
- chronic TTH. This occurs on more than 15 days each month and has all the features of the episodic TTH.

chronic is more likely due to medication overuse.


how should you manage tension type headache?

reassurance, advise on stress management, hydration, risk of medicines overuse.
drug therapy - avoid codeine, ibuprofen first line (OTC), naproxen second. can try paracetamol but usually not as effective.
if nothing's working - try amitriptyline.


what are the characteristic features of headache due to raised ICP?

worse on waking, lying, bending forward, coughing.
vomiting, papilloedema, odd behaviour, false localising signs.
must image before do LP - contraindicated otherwise!


what is a medication overuse headache?

chronic daily headache (> 15 days per month, with opiate/triptan use on >10 or paracetamol/NSAIDs on >15) due to overuse of analgesics - mixed opiates and paracetamol (Cocodamol) common culprit.


how do you manage a medication overuse headache?

withdrawal of analgesia - warn patient headache will worsen initially.
headache should resolve in 10 days or so.


what are the symptoms of trigeminal neuralgia? what are the common triggers?

paroxysms of intense stabbing pain, lasting seconds, in trigeminal nerve distribution (facial).
unilateral, typically maxillary/mandibular.
may have preceding symptoms e.g. tingling, numbness.
triggers - washing affected area, shaving, eating, talking, dental prostheses.
typical pt >50yo, woman (F:M = 2:1)


what are some red flags in a trigeminal neuralgia history that should prompt referral/further investigation?

Sensory changes, deafness or other ear problems.
Difficulty achieving pain control, poor response to carbamazepine.
History of any skin lesions or oral lesions that could lead to perineural spread.
Ophthalmic division only or bilateral as suggestive of benign or malignant lesions or multiple sclerosis.
Age of onset under 40 years.
Optic neuritis.
Family history of multiple sclerosis.

if investigation needed it'd normally be a brain MRI.


list some possible causes of secondary trigeminal neuralgia

- compression by anomalous or aneurysmal intracranial vessels or a tumour
- chronic meningeal inflammation
- MS
- varicella zoster
- skull base malformation e.g. Chiari malformation

MRI needed to exclude these causes.


how do you treat trigeminal neuralgia?

carbamazepine PO at 100mg every 12hrs, max 400mg/6hrs.

then try lamotrigine, phenytoin or gabapentin.
if drugs fail, surgery - rhizotomy, microvascular decompression, stereotactic gamma knife surgery can work.


list some differential diagnoses for facial pain

trigeminal neuralgia
post-herpetic neuralgia - shingles
cervical disk pathology
bone neoplasia
temperomandibular joint dysfunction
dental problems
giant cell arteritis
cluster headaches


what is giant cell arteritis?

needs excluding in anyone >50yrs with headache lasting a few weeks.
systemic immune-mediated vasculitis affecting medium-sized and large-sized arteries, particularly the carotid artery and its extracranial branches. associated with PMR in 50%.
can cause sudden bilateral vision loss so considered an emergency.


how does giant cell arteritis present?

recent onset temporal headache, myalgia, fever. temporal artery and scalp tenderness (e.g. when combing hair), jaw claudication (pain comes on gradually when chewing), amaurosis fugax or sudden blindness.
extracranial symps - dyspnoea, morning stiffness, unequal/weak pulses.


how do you manage a patient presenting with possible giant cell arteritis?

do an ESR blood test and give high dose (40mg) prednisolone immediately - if claudication give 60mg, if visual symptoms admit for IV methylpred.
other Ix - CRP, platelets, alk phos all raised, might see anaemia. get a *temporal artery biopsy* within 7 days of starting treatment.
typically a 2 yr course before it resolves - reduce pred once symps controlled and ESR reduced, but don't be afraid to bump it back up as necessary.


how do migraines present?

- visual (or other) aura for 15-30 mins before onset within 1hr of severe, throbbing, unilateral headache
- headache without aura
- aura without headache
- headache is incredible severe with N&V, photo/phonophobia
- lasts 4-72h


what are the criteria for diagnosing a headache as migraine if there's no aura?

5+ headaches lasting 4-72hrs plus N&V or photo/phonophobia plus any 2 of the following:
- unilateral
- pulsating
- impairs usual activity


what are the possible triggers for migraine?

Oral contraceptives


what kinds of aura may be experienced in migraine?

visual - chaotic distorting lines/shapes/patterns, hemianopia
somatosensory - paraesthesiae spreading from fingers to face
motor - dysarthria and ataxia (basilar migraine), ophthalmoplegia or hemiparesis
speech - dysphasia or paraphasia