8b.) Headaches

Question 1

Headaches can be primary or secondary; what do we mean by this?

Answer 1

• Primary: due to a headache condition
• Secondary: due to another condition

Question 2

Are the majority of headaches benign, non-life threatening headaches due to a primary headache disorder?

Answer 2

Yes

Question 3

Are primary headache disorders life or sight threatening?

Answer 3

No, primary headache disorders are non-life threatening and non-sight threatening. Many of them are chronic

Question 4

State 3 examples of primary headache disorders

Answer 4

• Tension headache
• Migraine
• Cluster headache

Question 5

Secondary headaches can be life or sight-threatening; true or false?

Answer 5

True

Question 6

State some broad causes for secondary headaches

Answer 6

• Space occupying lesions (although we think that secondary often present acutely- a SOL will often present with a chronic, gradually progressing headache)
• Intracranial haemorrhage
• Intracranial infections
• Other infections: e.g. sinusitis
• Opthalmic: e.g. acute glaucoma
• Temporal arteritis (giant cell arteritis)
• Medication-related and medication overuse
• Systemic: e.g. pre-eclampsia, hypertension

Question 7

Describe some important aspects of the history that you take from someone presenting with a headache

Answer 7

• History of presenting complaint: SQITARS
• Past medical history: have you had headaches in past? How do they compare? Any conditions that could pre-dispose to headaches?
• Drug history: analgesic use- need to know what, how often and if it works to see if it is
• Family history: e.g. of migraines
• Social history: e.g stress, sleep, alcohol, caffeine, diet (triggers)

Question 8

State what you typically find on clinical examination for a:

• Primary headache
• Secondary headache

Answer 8

• Primary: clinical examination typically normal
• Secondary: clinical examination MAY be abnormal

Question 9

Describe some red flag features of a headache (include what each of the red flags could indicate)

(SNOOP)

Answer 9

• Systemic signs & disorders: e.g. of meningitis would have neck stiffness etc, hypertension, pregnant (could be pre-eclampsia)
• Neurological symptoms: point towards space occuping lesion, intracranial heamorrhage, glaucoma
• Onset new or changed & patient >50yrs: malignancy, giant cell arteritis
• Onset in thunderclap presentation: vascular (haemorrhage)
• Papilloedema, pulsatile tinnitus, positional provocation, precipitated by exercise: indicating raised ICP

Question 10

Describe what your clinical examination, on someone who has presented with headache, should include

Answer 10

• Vital signs (BP, HR, temp)
• Neurological examination (cranial & peripheral)
• Other relevant systems to be guided by history

Question 11

Order these headaches in terms of how common they are:

• Cluster headache
• Migraine
• Medication over-use
• Tension-type headache

Answer 11

MOST COMMON:

• Tension-type
• Migraine
• Medication over-use
• Cluster headache

Question 12

Who are tension type headaches more common in; males or females?

At what age are tension type headaches common?

Answer 12

• More common in females
• Young (teens & young adults). If first onset is >50yrs unusual

Question 13

Describe the pathophysiology of tension-type headaches

Answer 13

Thought to be due to tension in muscles of head & neck

Question 14

Describe tension-type headaches, include:

• Where headache is felt
• Intensity
• When it is worse
• Aggrevating factors
• Response to simple analgesia
• Associated symptoms?
• Clinical examination findings

Answer 14

• Generalised in frontal & occipital regions (may be described as a band around head) and can radiate to neck. Non-pulsatile
• Worse at end of day
• Aggrevating factors: stess, posture, lack of sleep
• Often responds to simple analgesia
• Few associated symptoms- maybe nausea
• Clinical examination normal

Question 15

Who are migraines more common in; males or females?

At what age do migraines typically present?

Answer 15

• Females
• Most have first attack early to mid-life (so should present before 30yrs if not unusual)

Question 16

Are migraines common?

Answer 16

Yes (15 in every 100)

Question 17

Describe the pathophysiology of a migraine

Answer 17

• Pathophysiology unclear
• Possible theories proposed e.g. vasodilation of meningeal vessels

Question 18

Describe migraine headaches, include:

• Where headache is
• Quality of the headache
• Severity
• Duration
• Possible triggers
• Family history
• Response to simple analgesia
• Associated symptoms
• Clinical examination findings

Answer 18

• Unilateral (often in temporal or frontal region)
• Throbbing, pulsating
• Moderate-severe (disabling)
• Prolonged headache (4-72hrs)
• Triggers: certain foods, menstrual cycle, stress, lack of sleep
• Often there is family history
• Can respond to simple analgesia but may need triptans
• Associated symptoms: nausea & vomitting, photophobia & sometimes phonophobia, neurological symptoms (some get aura before migraine and some can get aura and no migraine)
• Clinical examination is normal

Question 19

Who are medication over-use headaches more common in; males or females?

How often do medication over-use headaches ofen present?

Answer 19

• Females
• Present at least 15 days a month (constant)

Question 20

Who do medication over-use headaches occur in?

Answer 20

ONLY occur in patients who are using analgesics regularly for headaches (has to be for headaches not analgesia for other pain and by regular we mean at least 10 days a month) due to underlying primary headache disorder. And the medication (over the counter medication) no longer works

Question 21

What is a medication over-use headache?

What does it often co-exist with?

Answer 21

• Headache that is present for at least 15 days a month (constant) due to regular use of analgesics (at least 10 days a month) for a primary headache disorder leading to the headache not responding and hence causing a secondary headache disorder
• Co-exists with depression and sleep distuance

Question 22

What analgesic is the most common cause/commonly used to create medication-over use headaches?

Answer 22

Co-codamol

Question 23

How do you treat medication over-use headaches?

Answer 23

Discontinue medication (headache worsens before improves. Typically completely resolved by 2 months)

Question 24

Describe the pathophysiology of medication over-use headaches

Answer 24

Up-regulation of pain receptors in meninges

Question 25

Generaly what happens to the severity of migraines with age?

Answer 25

Severity generally decreases with age

Question 26

Who are cluster headaches more common in; males or females? What is the usual age of onset/presentation of cluster headaches?

Answer 26

* MALES * 20-40yrs

Question 27

Describe the pathophysiology of cluster headaches

Answer 27

Unknown but its questions whether this is hypothalamic activation with secondary trigeminal and autonomic involvement

Question 28

Describe cluster headaches, include: * Where the headache is * Quality of headache * Severity * Duration * Remission * Triggers * Effect of simple analgesia * Associated symptoms * Clinical examination findings

Answer 28

* Unilateral, around or behind eye * Sharp, stabbing, penetrating * Very severe/intense, often disabling and pt may be agitated * Rapid onset and can last between 15mins and 3hrs and happen 1-2 times a day. Cluster attacks may last up to 12 weeks * Have remissions between clusters which can last anywhere between 3 months-3 years * Triggers: alcohol, cigarettes, volatile smells, warm temp, lack of sleep, histamine (hayfever), exercise, * Simple analgesia often ineffective hence use oxygen and triptans * Ipsilateral autonomic symptoms due to decreased sympathetic activity: * Red, watery eye * Nasal congestion * Ptosis * Clinical examination shows autonomic features during attack *

Question 29

If a headache is due to a space occupying lesion it often has other suspicous historical or examination findings; true or false?

Answer 29

True

Question 30

Describe a headache due to a space occupying lesion, include: * Onset * Quality of pain * Severity * Aggravating factors * Use of simple analgesics * Associated symptoms * Clinical examination findings

Answer 30

* Graudal onset, progressive *(this is unusal for secondary headaches)* * Dull * Mild in severity but worse in morning or on waking * Aggravating factors: leaning forward, cough, Valsalva manoeuvre * Simple analgesics may be effective in early stages but perhaps not in later stages * Associated symptoms: nausea, vomitting, focal neurological or visual symptoms and potentially others e.g. personality/behaviour change, seizues etc.. * Clinical examination- focal (unilateral) neurological signs, papilloedema

Question 31

Describe the pathophysiology of headaches caused by space-occupying lesions

Answer 31

Raises ICP (could also compress structures)

Question 32

Who is trigeminal neuralgia more common in; males or females? At what age is the peak incidence?

Answer 32

* Females * 50-60yrs

Question 33

Describe headaches caused by trigeminal neuralgia, include: * Where headache is * Quality of pain * Severity * Duration * Onset * Aggravating factors * Simple analgesia use * Precding symptoms * Clinical examination findings

Answer 33

* Unilateral, pain often felt in \>1 division of trigeminal nerve * Sharp, stabbing, electric shock, burn * Severe * (lasts few seconds-mins) * Sudden onset * Aggravating factors: * Light touch to face * Eating * Cold wind * Combing hair * Vibrations * Simple analgesics not often effective- difficult to treat * Preceding symptoms: * Tingling or numbness * Clinical examination often normal

Question 34

Describe the pathophysiology of trigeminal neuralgia

Answer 34

Most cases caused by compression of CNV by a vascular malformation; alternatively could be compressed by tumours, skull base abnormalities or as symptom of MS.

Question 35

Who is temporal arteritis more common in; males or females? At what age is temproal arteritis most common in?

Answer 35

* Females * \>50yrs, common in \>75yrs

Question 36

Describe the pathophysiology of temporal arteritis include whcih artery is often invovled

Answer 36

* Vasculitis involving small & medium sized arteries of head * Superficial temporal artery

Question 37

Who must you consider temporal arteritis in? *HINT: 4 identifaible features*

Answer 37

Consider in anyone \>50yrs with abrupt onset of headache + visual disturbance or jaw claudication

Question 38

Why is it VITAL that you don't miss a headache due to temporal arteritis?

Answer 38

It is sight threatening

Question 39

How would you treat someone who has suspected temporal arteritis?

Answer 39

Immediate high dose steroids (don't wait for biopsy results)

Question 40

State some symptoms, other then headaches and loss of vision, of temporal arteritis

Answer 40

Question 41

State some ways we can investigate causes of headaches

Answer 41

* Headache diary for chronic headaches * Imaging may be indicated if red flags * THOROUGH history

Question 42

Discuss how we treat headaches

Answer 42

Depends on underlying cause: * Simple analgesia * Triptans for migraines * Cluster headaches may respond to high flow oxygen * Remove aggravating factors

Question 43

Suggest some circumstances in which you may refer soemone with a headache to be investigated by specialists

Answer 43

* Suspicion of tumour * Suspicion of raised ICP * Recent onset seizures * Previous cancer * Unexplained focal deficit * Unexplained cognitive or personality changes

Question 44

How do you determine if tension headaches are: * Chronic * Episodic

Answer 44

* Chronic: \>15 times per month * Episodic: \<15 times per month