Headache

Question 1

What patterns of pain can be seen in a headache?

Answer 1

• Acute onset= secs-mins, SAH, intra-cranial haemorrhage, coital, thunderclap
• Evolving= hours-days, infection, inflammation, inc ICP
• Chronic= weeks-months, chronic daily headache, inc ICP
• Episodic= migraine, cluster
• Chronic= medication overuse, chronic migraine, hemicrania continua

Question 2

What are red flags signs for headaches?

Answer 2

• Seizures
• Cognitive effects
• Fever
• Vomiting
• Visual disturbances
• Weight loss

Question 3

What are associated symptoms with headaches?

Answer 3

• Nausea & vomiting
• Diurnal variation/ postural element
• Photophobia/ phonophobia
• Autonomic features (horner/red eye/lacrimation)

Question 4

Name some primary headache syndromes

Answer 4

• Migraine
• Tension
• Cluster
• Coital
• Hypnic
• Ice-pick
• Exertional
• Paroxysmal hemicrania

Question 5

Name some secondary headache syndromes

Answer 5

• SAH
• Intra-cranial haemorrhage/stroke
• Giant cell arteritis
• Meningoencephalitis
• Intracranial venous thrombosis
• Benign intracranial hypertension
• Tumour with raised ICP
• Cervicogenic

Question 6

What are signs & symptoms of raised intracranial pressure?

Answer 6

• Papilloedema
• Lateralising signs
• Headache (worse lying or awakening)
• Vomiting
• Seizures

Question 7

What is raised intracranial pressure due to?

Answer 7

• Mass effect (brain tumour, abscess)
• Brain swelling (hypertensive encephalopathy)
• Inc venous pressure
• CSF outflow obstruction (hydrocephalus)
• Inc CSF production (meningitis/SAH)

Question 8

What is temporal arteritis?

Answer 8

• Temporal (cranial arteritis)
• Patients 60+ and female
• Association with PMR
• Weight loss
• Myalgia
• Jaw claudication
• Tender non-pulsatile temporal artery
• Transient loss of vision

Question 9

How is temporal arteritis managed?

Answer 9

• Commence immediate high dose steroids (prednisolone)
• Arrange temporal artery biopsy
• Check ESR

Question 10

What are the clinical features used to diagnose a migraine?

Answer 10

• Prodrome (fatigue/change in mood)
• Aura (typically visual) lasting up to 60mins
• Unilateral headache
• Nausea/dizziness photophobia
• Triggers: sleep deprivation/hunger/stress/ oestrogen
• Cortical spreading depression
• Hemiplegic
• Basilar: cranial neuropathies/ cerebellar signs

Question 11

How is pain felt in a migraine?

Answer 11

• Spreading depression
• Releases chemically active irritants
• Trigger sensory fibres in meninges
• Felt as pain

Question 12

How is a migraine managed?

Answer 12

• Brain imaging
• Conservative measures
• Analgesia
• Preventative treatment

Question 13

What is trigeminal autonomic cephalgias?

Answer 13

• Activation of trigeminal/ parasympathetic systems
• Short-lasting headaches
• Variable autonomic features
• Cluster headaches
• Paroxysmal hemicrania
• SUNCT

Question 14

How is trigeminal autonomic cephalgias managed?

Answer 14

• Pain relief (high flow O2)

- Prevention (prednisolone, verapamil, indomethacin)

Question 15

Describe tension headaches

Answer 15

• Featureless headache
• Constricting/tight band
• Relaxation & massage
• Acupuncture
• Frequent = small dose of amitriptyline

Question 16

Describe new daily persistent headaches

Answer 16

• Similar to tension headaches
• No previous history
• Caused by: Raised ICP (idiopathic intracranial hypertension) Low ICP (spontaneous intracranial hypotension), post head injury, chronic meningitis

Question 17

Describe chronic daily headaches

Answer 17

• Causes: De novo, previous (transformed migraine, hemicrania continua, chronic tension)
• Treatment limited
• Amitriptyline for transformed migraine