S9 L2 Headache

Question 1

What are the different reasons for a headache?

Answer 1

Primary → due to a headache disorder

Secondary → caused by something else

Question 2

What are the examples of primary headache disorders?

Answer 2

Non life or sight threatening, many chronic (recurrent)

• Tension type headaches
• Migraine
• Cluster headache

Question 3

What are the examples of secondary headache disorders?

Answer 3

Some are life or sight threatening
Many acute
- Vascular
→ Haemorrhage (subarachnoid, subdural, extradural)
→ Thrombosis (venous sinus thrombosis)
- Infective/ Inflammatory (meningitis, encephalitis, abscess, temporal arteritis
- Ophthalmic (glaucoma)
- Situational (exacerbating factors) - cough, exertion, coitus
Some chronic
- Drug side effects (analgesics, caffeine, vasodilators)
- Trigeminal neuralgia difficult to classify but probably secondary due to vascular anomaly
- Raised ICP
- Temporal/ giant cell arteritis
- Systemic - hypertension, pre-eclampsia, phaemochromocytoma - rare

Question 4

How do you go about determining the causes of headache?

Answer 4

Thorough history taking important
- PC - SQUITARS
- PMH - previous headaches or conditions causing headaches
- DH - analgesic use, other drugs
- FH - migraines
- SH - stress, sleep (lack), diet, hydrations, alcohol and caffeine consumptions
Ensure you enquire about red flag symptoms

Question 5

What are the red flag symptoms of headache?

Answer 5

SNOOP
S- systemic signs and symptoms (meningitis, hypertension, immunosuppresses, pregnant, cancer)
N- Neurological symptoms (SOL, ICH, glaucoma (visual))
O- Onset of new or change and patient >50 years old (malignancy, GCA)
O- Onset in thunderclap presentation (vascular haemorrhage)
P- Papilledema (positional provocation, precipitated by exercise) (indicators of ↑ICP)

Question 6

What are the clinical examinations you would carry out?

Answer 6

1. Vital signs/ obs → BP, PR, temp, ↑ICP, bradycardia/hypertension
2. Neurological examination- full peripheral and cranial nerve exam
3. Other relevant systems, guidance by history

Question 7

What is a tension headache?

Answer 7

Site → Generalised- usually frontal and occipital regions
Quality → Tight/ band like, constricting, +/- radiating into the neck
Intensity → Mild-moderate intensity
Time → Worse at the end of the day, recurrent (30mins- 1hr)
→ Chronic >15 times/month
→ Episodic <15 times/month
Aggravating → stress, poor posture lack of sleep
Relieving → analgesics
Secondary symptoms →Few associated symptoms- nausea

Question 8

What is the epidemiology of a tension headache?

Answer 8

F>M
Common
Young (teenagers) and young adults (20-39yr)
First onset >50yrs is unusual

Question 9

What is the suspected pathophysiology of a tension headache?

Answer 9

Tension in muscles of head and neck

Usually no family history

Question 10

What are the causes of tension headaches?

Answer 10

Stress
Poor posture
Lack of sleep often aggravates

Question 11

How are tension headaches treated?

Answer 11

Clinical examination - normal

Simple analgesics

Question 12

What is a migraine?

Answer 12

Unilateral- temporal or frontal
Throbbing or pulsating
Moderate-severe, often disabling (need to lie down)
Pronlonged headache between 4-72 hours

Question 13

What is the epidemiology of migraines?

Answer 13

F>M (1 in every 5 F)
Common (15 in every 100)
Present early to mid-life
Most have first attack by 30

Question 14

What is the pathophysiology of a migraine?

Answer 14

Possible theories proposed

• Neurogenic inflammation of trigeminal sensory neurones innervating the large vessels and meninges
• Alters the way pain is processed, sensitised to otherwise ignored stimuli

Question 15

What are the clinical features of migraine?

Answer 15

Site → Unilateral- temporal or frontal
Quality → Onset can be sudden or gradual, throbbing pulsating pain
Intensity → Moderate
Time → Lasts between 4-72hours, possibly with cyclical character
Aggravating factors → photophobia, phonophobia
Relieving factors → Sleep, number of medications (triptans)
Secondary symptoms → May have aura (characteristic feeling preceding attack), nausea and vomiting

Question 16

What are the triggers for migraines?

Answer 16

Certain foods (cheese, chocolates), menstruation
Lack of sleep
Stress

Question 17

What is the clinical management for migraines?

Answer 17

• Clinical examination - normal between attacks, probably normal during attacks unless neurological signs or symptoms
• Variety of medication (triptans)
• Want to lie down

Question 18

What is a headache due to medication over-use?

Answer 18

Headache present on >15 days/month
Patient with pre-existing headache disorder
Using regular analgesics a least 10 days/month with no response
Variable character → dull, tension-type or migraine like
Often co-exist with depression or sleep disturbances

Question 19

What are the epidemiology of a medication over-use headache?

Answer 19

3rd most common
F>M
30-40yrs olds
1-2% of UK population

Question 20

What is the pathophysiology of medication over-use headaches?

Answer 20

Upregulation of pain receptors in the meninges

Question 21

How are medication over-use headaches managed?

Answer 21

Discontinuation of medication
Headache often worse before it improves
Typically resolves completely by 2 months

Question 22

What are cluster headaches?

Answer 22

Site → Unilateral, around/ behind one eye, no radiation
Quality → Sharp, stabbing and penetrating
Intensity → Very severe, constant intensity
Time → Rapid onset, 15mins-3hrs, 1-2times per day, often at night, remission 3m-3years
Aggravating factors → Head injury, alcohol, smoking
Relieving factors → Simple analgesics often ineffective, oxygen and triptans used
Secondary symptoms → ipsilateral sympathetic symptoms- red, watery eye, blocked runny nose, ptosis

Question 23

What is the epidemiology of cluster headaches?

Answer 23

M>F
Smoking history= risk factors
1/1000
Usually begins 30-40 years

Question 24

What is the pathophysiology of cluster headaches?

Answer 24

Unknown

Potentially hypothalamic activation with secondary trigeminal and autonomic involvement

Question 25

What are the triggers for cluster headaches?

Answer 25

``` Smoking Alcohol Histamine (hayfever) GTN Heat Exercise Solvent inhalation Lack of sleep ```

Question 26

What is the management for cluster headaches?

Answer 26

Clinical examination- evidence of autonomic features | Simple analgesics are often ineffective - oxygen and triptans

Question 27

What are the space occupying lesions?

Answer 27

RARE Result in raised intracranial pressure Gradual, progressive Dull but often variably described- key is progressiveness of severity Maybe mild in severity, worse in the mornings Headache rarely occurs in the absent of other neurological signs Worsened with posture - leaning forward, cough, valsalva manoeuvre, straining Secondary symptoms→ focal neurological or visual symptoms Clinical examinations → focal (unilateral) neurological signs, papilloedema Simple analgesics -maybe effective in the early stages

Question 28

What is trigeminal neuralgia?

Answer 28

Unilateral pain felt in >1 division of CNV (if involved CNV1 often described as headache) Site → Over one eye, radiates to eyes, lips, nose and scalp Quality → Sharp and stabbing, electric shock feeling Intensity → Severe Time → Sudden onset, lasts a few seconds to 2 minutes Aggravating factors → light touch to face, eating, cold wind, vibrations, combing hair Relieving factors → Difficult, simple analgesics don't work Secondary symptoms → can have numbness and tingling preceding an attack Clinical examination normal

Question 29

What is the epidemiology of trigeminal neuralgia?

Answer 29

F>M 25/100,000 population 50-60years

Question 30

What is the pathophysiology of trigeminal neuralgia?

Answer 30

Compression of trigeminal nerve by vascular malformation- loop of blood vessel Few cases caused by tumour (5%), MS or skull base abnormalities Most common in those with history of chronic pain (central sensitisation??)

Question 31

What is temporal arteritis?

Answer 31

Vasculitis of large and medium sized arteries in the head - usually involving the superficial temporal artery F>M >50 yrs

Question 32

What specific symptoms should alert you to potential temporal arteritis?

Answer 32

Abrupt onset of headache + visual disturbances or jaw claudication (pain) Risk of irreversible loss of vision die to involvement of blood vessels supplying the CNII (optic nerve)

Question 33

What investigations can be done for headaches?

Answer 33

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

Question 34

What are the treatment options?

Answer 34

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

Question 35

What is the criteria for referral?

Answer 35

Focus on principles, not necessarily on the specifics Headaches need to be referred if there is - suspicion of tumour - suspicion of raised ICP - recent onset of seizure - previous cancer - unexplained focal deficit - unexplained cognitive/personality changes