S8) Headache

Question 1

Headache is a common presenting complaint.

How can it be categorised?

Answer 1

– Primary (due to a headache disorder) - more common

– Secondary to another condition - less common but can be sight/life threatening

Question 2

Majority of the headaches are …

Answer 2

Majority are benign (non-life threatening) due to primary headache disorder

Question 3

Headache is most commonly caused by a primary headache disorder.

Describe the clinical features of a primary headache disorder.

Answer 3

– Non- ‘life or sight’ threatening
– Many chronic (i.e. recurrent)

Question 4

Headache is most commonly caused by a primary headache disorder.

Describe the clinical features of a secondary due to another condition.

Answer 4

– Some are life or sight threatening

– Many acute

Question 5

Identify examples of primary headache disorder.

Answer 5

– Tension headache

– Migraine

– Cluster headache

Question 6

Identify examples of secondary headaches.

Answer 6

Life threatening:

– Intracranial lesion e.g. tumour (benign, malignant or metastases) e.g. haemorrhage (?trauma or aneurysm)

– Meningitis

Sight threatening:

– Giant cell (temporal) arteritis

– Acute glaucoma

Non- life/sight threatening causes:

– sinusitis

– medication overuse headache

– trigeminal neuralgia

– drug side effects/ medication related and medication overuse e.g. CCBs, statins

– Systemic: hypertension, pre-eclampsia

Question 7

Differential diagnosis of headache (primary headache in green, secondary headache in red.

Conditions requiring immediate emergency assessment are labelled ‘A&E’).

Secondary headaches occur because of another condition.

Skim through the notes.

Answer 7

Question 8

Diagnosing Cause: patient’s history is key and history taking

Answer 8

o History
→ Full HPC using SOCRATES/SQITARS
→ What might be causing/triggering the headache? → PMH of headache?

→ Drug history
• Analgesics

• Side effects causing headache (e.g. vasodilators)

→ FH

• E.g. migraine with aura has some heritability
→ SH
• Stress

• Diet (some foods can trigger migraine)
• Hydration

Question 9

What are the red flags for potentially life threatening headaches?

Answer 9

Red flag features of headaches (i.e. those features which make us worry)

– Systemic signs and disorders (e.g. of meningitis or hypertension)

– Neurological symptoms

– Onset new or changed and patient >50 yo (can be suggestive of malignancy e.g. brain metastases

– Onset in thunderclap presentation (suggests vascular cause such as SAH)

– Papilloedema (suggests raised ICP)

Question 10

Using the red flags of headaches, identify causes behind them.

Answer 10

Red flag features of headaches (i.e. those features which make us worry)

– Systemic signs and disorders (e.g. of meningitis or hypertension)

– Neurological symptoms

– Onset new or changed and patient >50 yo (can be suggestive of malignancy e.g. brain metastases

– Onset in thunderclap presentation (suggests vascular cause such as SAH)

– Papilloedema (suggests raised ICP)

Question 11

What clinical examination would you do for someone with a headache?

Answer 11

• Vital signs e.g. BP, PR, temp - e.g. raised ICP can cause bradycardia / hypotension.
• Hypertension itself can cause headache*
• Neurological examination (cranial and peripheral nerve examination, Glasgow-coma scale)
• Other relevant systems, guidance by history (e.g. if associated
• feelings of faintness then examine CVS)*
• Be alert to presence of red flags

Question 12

List the common headaches from most common to less common in order.

Answer 12

– Tension -type headache (primary headache disorder) – MOST COMMON

– Migraine (primary headache disorder)

– Medication overuse (secondary headache)

–Cluster headache (primary headache disorder)

Question 13

In whom can we see tension-type headaches in?

Answer 13

Most common type of headache

F>M

Common Young (teenagers) and young adults [20-39 yr])

First onset >50yr unusual

Question 14

What is the pathophysiology of tension-type headaches?

Answer 14

Pathophysiology thought due to tension in muscles of head and neck e.g. occipitofrontalis

Usually no family history

Question 15

How can someone with tension type headache present?

Answer 15

– Generalised- predilection for frontal and occipital regions

– Tight/ band like, constricting, +/- radiating into neck

– Mild-moderate intensity

– Worse at end of the day; recurrent (30m-1hr)

– Few associated symptoms-may be slight nausea

Question 16

Describe the clinical features of tension type headaches.

Answer 16

– Site

• Bilateral frontal • Can radiate to neck

– Quality

• Squeezing / band-like constriction
• Non-pulsatile

– Intensity

• Mild-moderate

– Timing

• Worse at end of day (as stress builds up)
• Chronic if > 15 times per month
• Episodic if <15 times per month

– Aggravating factors

• Stress
• Poor posture (e.g at a computer)

• Lack of sleep

– Relieving factors

• Simple analgesics can help

– Secondary symptoms

• Sometimes mild nausea

Question 17

What would the clinical examination of tension type headache be like?

Answer 17

Clinical examination is normal

Question 18

What are the triggers for the tension type headaches?

Answer 18

stress, poor posture, lack of sleep often aggravates

Question 19

How can we treat tension type headache?

Answer 19

Often responds to simple analgesics + give reassurance

Question 20

In whom can we see migraines in?

Answer 20

F>M (1 in every 5 F) -Twice as many females as males

Common (15 in every 100)

Presents early to mid-life

Most have first attack by 30

Severity decreases as age increases

Question 21

What is the pathophysiology for migraine?

Answer 21

– Pathophysiology unclear

– Possible theories proposed e.g.

• neurogenic inflammation of trigeminal sensory neurons innervating large vessels and meninges
• Alters way pain processed by brain; area becomes sensitized to otherwise ignored stimuli (Areas of those nerves become more sensitised to the presence of stimuli)

– Usually family history

Question 22

How does someone with migraines present?

Answer 22

– Unilateral, temporal or frontal

– Throbbing, pulsating

– Moderate-severe, often disabling (need to lie down)

– Prolonged headache- between 4-72 hours

– Associated symptoms? e.g. photophobia, photophonia (sensitivity to sound), nausea +/- vomiting, aura (peculiar sensory signs e.g. visual or neurological signs e.g. speech disturbance)

Question 23

Describe the clinical features of migraines.

Answer 23

– Site

• Unilateral, often frontal

– Quality

• Onset can be sudden or gradual. Throbbing / pulsating

– Intensity

• Moderate

– Timing

• Lasts between 4 and 72 hours, possibly with cyclical character

– Aggravating factors

• Photophobia / phonophobia (dislike of loud noise)

– Relieving factors

• Sleep helps
• A number of medications are available (e.g. triptans)

– Secondary symptoms

• May have aura (characteristic feeling preceding attack)
• Nausea and vomiting

Question 24

What are the triggers for migraines?

Answer 24

Triggers:

– certain food e.g. cheese, chocolate

– menstrual cycle

– stress

– lack of sleep

– strong familial links - usually a family history of someone else suffering from migraines

Question 25

What would the clinical examination be like in a person with migraines?

Answer 25

Clinical examination is **normal** - can occur between episodes of migraines and also during the migraine attack unless there is evidence of neurological dysfunction that occur as a part of an aura.

Question 26

How would you treat migraines?

Answer 26

Can respond to **simple analgesics** (may need triptans); **tend to want to lie down**

Question 27

In whom can we see medication overuse headache?

Answer 27

F\>M 30-40 yr Headache present on at least 15 days/month (constant) This is a **secondary headache** → occurs in **patients with pre-existing headache disorder** e.g. history of tension headaches or migraines who's been taking analgesics (overusing them) + has now developed this secondary headache on top of their primary headache disorder.

Question 28

How does medication over-use cause headaches? (pathophysiology)

Answer 28

Using **regular analgesics (presents on at least 10 days/month)** - when you overuse analgesia - it leads to an upregulation of pain receptors, eventually headaches no longer respond to the painkillers so pts keep taking more → makes it worse! – **Headache not responding** **Related to upregulation of pain receptors in meninges**

Question 29

What are the clinical features of medication overuse headaches?

Answer 29

– Present on at least 15 days per month – No improvement after OTC medication (e.g. paracetamol) – Diagnostic criteria are not important for you to know, but you need to know that patients who get this headache are using analgesics on at least 10 days per month – This headache only seems to come about in people who are taking analgesia for headache in the first place – Can get a variety of symptoms – Often co-exists with depression and sleep disturbance

Question 30

How can medication overuse headaches present?

Answer 30

**Variable character**- can be dull, tension-type or migraine-like ## Footnote **Co-exists with depression and sleep disturbance**

Question 31

How can we treat medication over-use headache?

Answer 31

**Discontinue medication** (headache worsens before improves) - break the cycle of overuse -(following this will get worse before getting better) – Typically resolved completely by 2 months

Question 32

In whom can we see cluster headaches?

Answer 32

M \>F Smoking history = risk factor 1 in 1000 Usually begins 30-40 years

Question 33

What is the pathophysiology of cluster headaches?

Answer 33

**Pathophysiology unknown** → ?hypothalamic activation with secondary trigeminal and autonomic involvement

Question 34

How does a cluster headache present?

Answer 34

– **Unilateral,** around or behind **eye** – Sharp, stabbing, penetrating, often at night – Severe, **intense, often disabling, agitated** – **15 mins- 3 hours;** **occur in clusters** **with periods of remission** **(3m-3 years)** ---////////-----///////-----/////-- – Ipsilateral **autonomic symptoms** e.g. red, watery eye, blocked runny nose, ptosis

Question 35

Describe are the clinical features of cluster headaches?

Answer 35

– Site • Around / behind one eye • No radiation – Quality • Sharp and penetrating – Intensity • Very severe • Constant intensity – Timing * Rapid onset * Attacks last 15 min – 3hrs and occur 1-2 times per day * Usually at night * Clusters of attacks last 2-12 weeks * Remissions between clusters can last 3 months – 3 years – Aggravating factors * Head injury * Alcohol * Smoking – Relieving factors • Simple analgesics can help – Secondary symptoms • Features associated with decreased sympathetic activity: - Red, watery eye - Nasal congestion - Ptosis

Question 36

What are the triggers for cluster headaches?

Answer 36

Triggers: – alcohol – cigarettes – volatile smells – warm temp – lack of sleep – Histamine (hayfever) – GTN – solvent inhalation

Question 37

Describe what the clinical examination would be like in a person with cluster headaches?

Answer 37

* *Clinical examination** – evidence of autonomic features (during attack) - examination normal during remission (i.e. period of no attack)

Question 38

What is the treatment for cluster headaches?

Answer 38

**Simple analgesics often ineffective**; oxygen and triptans used

Question 39

Identify examples of secondary headaches.

Answer 39

– **Intracranial haemorrhage\***- some can cause signs/symptoms of meningism e.g. subarachnoid haemorrhage (blood can irritate meninges - headache, neck stiffness, photophobia) *- sudden onset* – **Raised ICP** due to a **space occupying lesions** e.g. a tumour *- gradual onset due to growth of tumour size* – Trigeminal neuralgia – Temporal (giant cell) arteritis

Question 40

Space occupying lesion can also cause headaches. How does it cause this?

Answer 40

Causing **raised intracranial pressure** Note: **Headache rarely** occurs in **absence of other suspicious historical or exam findings**

Question 41

Describe the presentation of a space-occupying lesion causing headaches.

Answer 41

– **Gradual,progressive** – Dull, but often variably described; key is progressiveness of severity – May be mild in severity, **worse in mornings** – **Early-morning**, **on waking** (rarely: headache wakes them) – **Worsened with posture** (leaning forward), cough, Valsalva manoeuvre, straining – **Nausea, vomiting**, focal neurological or visual symptoms *(other neurological signs could include behavior/ personality change, seizures)*

Question 42

What symptoms can be seen in headaches caused by space occupying lesion?

Answer 42

o Associated neurological features – E.g. visual disturbance or focal signs o o Additional features of raised ICP – Early morning headache – Nausea and vomiting – Worse on coughing and bending

Question 43

Describe the clinical examination of space-occupying lesion causing headache.

Answer 43

**Clinical examination** – focal (unilateral) neurological signs, papilloedema

Question 44

What is the treatment for space-occupying lesion?

Answer 44

**Simple analgesics may be effective in early stages**

Question 45

In whom can we see trigeminal neuralgia?

Answer 45

F\>M 25/100,000 UK popn. 50-60 years

Question 46

What is trigeminal neuralgia caused by?

Answer 46

– **Most caused** by **compression of CN V** due to **loop of a blood vessel (by a vascular malformation)** – **5%** due to **tumors/skull base abnormalities, MS or AV malformations**

Question 47

Describe the presentation of trigeminal neuralgia.

Answer 47

– **Unilateral, pain felt in ≥1 divisions of CN V**: *if involves CNVa often described as headache* – Sharp, stabbing, ‘electric’ shock (sometimes burning) - often fearful of next episode due to how it manifests – Severe, lasts few seconds- 2 mins – **Sudden onset** – Maybe preceding symptoms: tingling, numbness; pain can radiate to areas within CNV distribution

Question 48

Describe the clinical features seen in trigeminal neuralgia.

Answer 48

– Site * Unilateral, often over one eye * Radiates to eyes, lips, nose and scalp (think distribution of CN V) – Quality * Sharp and stabbing * ‘Electric shock’ feeling – Intensity • Severe – Timing * Sudden onset * Lasts a few seconds to 2 minutes – Aggravating factors * Light touch to face * Eating * Cold wind • Vibrations – Relieving factors • Can be difficult to alleviate – Secondary symptoms • Can have numbness and tingling preceding an attack

Question 49

Describe the clinical examination of trigeminal neuralgia?

Answer 49

**Clinical examination** –normal

Question 50

What are the triggers for trigeminal neuralgia?

Answer 50

– Light touch to face/scalp – eating – cold wind – combing hair

Question 51

What is the treatment for trigeminal neuralgia?

Answer 51

Simple analgesics not effective; can be difficult to treat

Question 52

What is temporal arteritis?

Answer 52

**Vasculitis** of **large and medium sized arteries of head** (often affects branches of the external carotid artery) seen in F\>M \>50 years (most common in \>75)

Question 53

Describe the typical presentation of temporal arteritis.

Answer 53

F\>M \>50 years (most common in \>75) Consider in **any \>50 year old** with **abrupt onset of headache + visual disturbance or jaw claudication** (pain in jaw)

Question 54

What are the symptoms seen in temporal arteritis?

Answer 54

Question 55

In temporal arteritis, which artery is commonly involved?

Answer 55

**superficial temporal artery** commonly involved

Question 56

What is the risk of temporal arteritis?

Answer 56

Risk of **irreversible loss of vision** due to **involvement of blood vessels supplying CN II (optic)**

Question 57

What is the treatment for temporal arteritis?

Answer 57

steroids may be do a biopsy to confirm the diagnosis

Question 58

Answer 58

Question 59

Answer 59

Question 60

Generally for headaches, what investigation can we do?

Answer 60

– Clearly, dependent on cause (e.g. if subarachnoid haemorrhage then investigate accordingly – Headache diary can be useful for chronic headaches – Imaging may be indicated if red flags

Question 61

Generally for headaches, what treatment can be given?

Answer 61

– Dependent on underlying cause – Simple analgesia – Triptans for migraine – Cluster headaches may respond to high flow oxygen

Question 62

Headaches need to be referred if there is:

Answer 62

→ Suspicion of a tumour → Suspicion of raised ICP → Recent onset seizures → Previous cancer → Unexplained focal deficit → Unexplained cognitive/personality changes

Question 63

General approach to headache …

Answer 63

Question 64

SUMMARY on both sides

Answer 64

Question 65

Headaches ….

Answer 65