Headache

Question 1

Classifications of headaches

Answer 1

1. Hemorrhagic
   Caused by a bleed in the cranium
2. Inflammatory
   Vasculitis of the vessels in the cranium
3. Dissection
   Dissection of the carotid/vertebral arteries
4. Stroke
   Ischaemic 
2. Hemorrhagic – intracranial bleed

Question 2

What are risk factors and causes of intracranial

hemorrhage?

Answer 2

• Causes
• PRIMARY – Trauma
• SECONDARY – rupture of cerebral aneurysm/vascular malformation
  • Risk factors
• Recent trauma
• Coagulopathy – clotting disorders
• Anticoagulant use – antiplatelets, anticoagulant medications
• Advanced age (>65 years)

Question 3

What does each type of bleed present as in terms of a headache? (intracranial haemorrhage)

Answer 3

• Extradural – Severe headache with lucid interval
• Subdural – constant/fluctuating headache, gradually deteriorating
• Subarachnoid – “thunderclap” headache (sudden onset 10/10) radiating to occiput (back) of head

Question 4

What are other associated symptoms of headache?

Answer 4

• Nausea and vomiting
• Lowered Glasgow Coma Score
• This is a score out of 15 with 3 components
• Eye response, Verbal response and Motor response
• Intracranial bleeds can cause lowered score in all 3
• Altered mental status – confusion, loss of consciousness
• Bladder and bowel incontinence
• Weakness and sensory changes
• Fluid leaking out of nose/ears

Question 5

What is dangerous about it and gives it the label of ‘acute’?

Answer 5

• Neurological deficits with variable recovery rate
• Coma
• Can then lead onto stroke from pressure compressing on arteries
• Brain herniation
  
  • When the pressure forces the brain out of the normal compartments
  • Most dangerous is out of the foramen magnum
  • This cuts off the blood supply to the brain stem from compression, leading to death from loss of basic life functions (breathing etc)

Investigations
- CT scan

Question 6

What is vasculitis?

Answer 6

• Usually - autoimmune inflammation of the blood vessels in the brain
• Giant Cell arteritis
• Autoimmune inflammation of the large/medium sized arteries
• Commonly associated with polymyalgia rheumatica, an autoimmune disease
that causes weakness and pain in the proximal limbs
• Causes and risk factors
• Polymyalgia rheumatica, age >50 years, female sex, northern European ancestry

Question 7

How does giant cell arteritis (GCA) present clinically?

Answer 7

• Headache – non-specific
  
  • But Associated with tenderness/pain of the scalp “pain on brushing hair”
  • Therefore, new onset headache + scalp tenderness = GCA?
• Aching and stiffness worse after rest in limbs neck
  
  • Sign of GCA itself/underlying polymyalgia rheumatica
• Less common symptoms
  
  • Loss of vision
  • Tongue and jaw pain – unilateral, painful when eating/chewing
  • Abnormal fundoscopy (eye)

Question 8

What is the danger of vasculitis and why is it ‘acute’?

Answer 8

• Irreversible blindness
• 17x risk of developing thoracic aortic aneurysms, 2.4x risk to develop
abdominal aortic aneurysms
• Incidence of aortic aneurysm after GCA diagnosis up to 30%

Investigations (in either case start treatment first, High dose glucocorticoids)

• Vascular ultrasound
• Blood tests – CRP, ESR (inflammatory markers)
• Temporal artery biopsy

Question 9

What is a dissection and where can they occur?

Answer 9

• Blood going into intramural (within
the wall) space
• Can either clot = blockage or rupture
= hemorrhage

• Carotid artery
• Vertebral artery

Question 10

How does a dissection present clinically?

Answer 10

• Causes
  
  • Trauma
  • Spontaneous
  • Predisposing factors – connective tissue disease, hypertension
• Presentation
  
  • Headache + scalp, eye, neck pain
  • Horner syndrome – unilateral eye with droopy lid + small pupil
  • Weakness and numbness on one side of body
  • Trouble speaking/understanding speech
  • Other neurological deficits – impaired blood flow to brain

Question 11

Why is a dissection acute and dangerous?

Answer 11

• Consequences of reduced blood flow to brain
• Reversible (TIA)/ irreversible neurological deficit
• Vision loss
• If clot detaches, it becomes a embolus that can travel to the brain =
stroke
• All the consequences of stroke

Investigations
- Ultrasound scan

Question 12

What is a stroke?

Answer 12

• When a clot that formed somewhere else (dissection, AF) embolises and
travels to the brain where it gets stuck

• Types of stroke
  
  • Hemorrhagic (15%) – refer to the first category
  • Ischaemic (85%) what we are talking about here

Question 13

Clinical presentation of ischaemic stroke?

Answer 13

• Causes and risk factors
  
  • Atrial fibrillation (AF), hx of cardiovascular disease (HTN, cholesterol)
• Clinical presentation
  
  • Headache (non-specific)
  • FAST (Facial drooping, Arm weakness, Speech difficulty, Time to call 999)
  • Gaze deviation
  • Sensory changes – numbness
  • Nausea and vomiting
  • Decreased level of consciousness

Question 14

Why is a stroke acute and dangerous?

Answer 14

• May transition into hemorrhagic stroke
• Death
• Time sensitive
  
  • Thrombolysis window – 4.5 hours after onset of symptoms
• Missing the window – risk of permanent neurological deficit

Diagnosis

• CT to differentiate between ischaemic and hemorrhagic! (treatments are opposites
• ECG for underlying AF

Question 15

What is the treatment for migraines?

Answer 15

Acute treatment (to take during the 
attack):
 Triptan (oral, nasal)
 +/- Paracetamol/NSAIDs (Aspirin 900mg)
 Antiemetics (metoclopramide, 
prochlorperazine)

Prophylaxis (regularly, months-
years):
 Prevent attacks, reduce severity.
 Topiramate (hormonal 
contraceptives/pregnancy)
 Beta blocker: Propranolol
 TCAs: Amitriptyline
 Riboflavin may be effective.
 Acupuncture

Question 16

Function of topiramate:

Answer 16

 MAO inhibitor
 Blocker of NMDA receptors & Voltage dependent Na channels
 Enhances GABA
 Side effects: altered tase, nausea, paraesthesia, wt loss, fatigue,
behavioural/cognitive changes

Question 17

Function of triptans:

Answer 17

 5HT 1B/1D agonists
 Inhibit the release of substance P & CGRP
 Inhibit the activation of the trigeminal nerve & vasodilation.
 Cautions:
 Ischaemic heart disease
 Stroke
 Pregnancy
 Side effects: flushing, dizziness, fatigue, nausea.

Question 18

Cluster headache treatment:

Answer 18

Acute treatment:
 100% Oxygen
 Triptan (SC, nasal)
 Paracetamol/NSAIDs, opioids, PO 
Triptans Not offered in the acute Rx

Prophylaxis:
 Verapamil, NICE!
 Others: Topiramate, steroids, melatonin.

Question 19

What are the secondary headache types?

Answer 19

 Giant Cell arteritis (>50yrs, jaw claudication)
 Intracranial neoplasm (worse in the morning)
 Intracranial infection (abscess, meningitis) (fever)
 Trauma (whiplash, intracranial bleeding)
 Subarachnoid haemorrhage (worse ever, severity max in <60s)
 Cerebral venous thrombosis
 Idiopathic Intracranial Hypertension
 Substance use or its withdrawal (alcohol, cocaine)