Headache

Question 1

What is the difference between primary and secondary headaches?

Answer 1

• Primary = headache and it’s associated features are the disorder, not caused by underlying structural changes
• Secondary = headache secondary to underlying cause

Question 2

What do CN III, IV and VI look like?

Answer 2

Question 3

What are the red flag symptoms for headache? (SNOOPT)

Answer 3

• Systemic symptoms
• Neurological signs or symptoms
• Older age at onset (>50 years)
• Onset is acute (<5mins)
• Previous headache history different/absent
• Triggered headache (i.e. valsalva or posture)

NB - Also increasing frequency/severity, immunocompromise and papilloedema

Question 4

What are the features of high pressure CSF headache?

Answer 4

• Worse in the morning
• Persistent nausea/vomiting
• Worse with physical exertion
• Worse lying flat, improved standing up
• Worse on valsalva
• Transient visual obscuration with change in posture

Question 5

What examination findings are seen in high pressure CSF headaches?

Answer 5

• Optic disc swelling
• Impaired visual acuity
• Restricted visual fields/enlarged blind spot
• 3rd nerve palsy
• 6th nerve palsy
• Focal neurological signs

Question 6

What are the causes of high pressure CSF headache?

Answer 6

• Mass effect (tumour, infarction with oedema, subdural, extradural, intracerebral haematoma, abscess)
• Increased venous pressure (cerebral venous sinus thrombosis, obstruction of jugular venous system)
• Obstruction to CSF flow/absorption (hydrocephalus, meningitis)
• Idiopathic (idiopathic intracranial hypertension)

Question 7

What are the features of a low pressure CSF headache?

Answer 7

• Worse on sitting/standing up and relieved by lying down
• Results from CSF leakage

Question 8

What are the causes of low pressure CSF headache?

Answer 8

• Post lumbar puncture
• Spontaneous intracranial hypotension (results from spontaneous dural tear, can occur following valsalva)

Question 9

What are the features of migraine? (remember POUND)

Answer 9

• Most patients report triggers (hormonal, weather, stress, hunger, sleep disturbance, exertion, alcohol excess, foods - cheese, chocolate)
• Some have aura (visual, sensory, speech and mixed)
• Photophobia
• Phonophobia
• Osmophobia
• Mood disturbance
• Diarrhoea
• Autonomic disturbance
• POUND:
  
  • Pulsatile
  • hOurs in duration (4-72 hours)
  • Unilateral in 60%, can radiate
  • Nausea and vomiting
  • Disabling intensity

NB - Hemiplegic migraine includes motor weakness (<24 hours)

Question 10

What is the pathophysiology of migraine?

Answer 10

• Primary dysfunction of brainstem nuclei (V, VII-X)
• Pin results from pain sensitive cranial blood vessels and their innervating trigeminal fibres
• Vascular hypothesis (intracranial vasoconstriction with reflexive secondary vasodilation)
• Neurovascular hypothesis (migraine is disroder of endogenous pain modulating systesm, particularly subcortical structures)

Question 11

What are the causes of thunderclap headache (abrupt onset of severe headache which reaches maximal intensity <5mins and lasts >1hr)?

Answer 11

• Subarachnoid haemorrhage (SAH)
• Intracerebral haemorrhage
• Arterial dissection (vertebral or carotid)
• Cerebral venous sinus thrombosis
• Bacterial meningitis
• Spontaneous intracranial hypertension (rare)
• Pituitary apoplexy (rare)
• Primary headaches

Question 12

Management of migraine

Answer 12

• Headache diary
• Acute
  
  • Triptans (oral or nasal)
  • NSAIDs
  • Aspirin
  • Anti-emetic
• Prophylaxis
  
  • Consider if 2+ attacks a month causing >3 days disability
  • Topiramate
  • Propranalol
  • Amitryptyline
  • Contraception

Question 13

Features and management of cluster headache

Answer 13

• Severe and unilateral around orbits/temporal region
• Lasts 15-180 minutes and can occur 8x a day
• Accompanied by ipsilateral conjunctival congestion, lacrimation, orbital oedema, nasal congestion, facial swelling, miosis/ptosis, restlessness/agitation
• Usually males, smokers, clusters with remission for months/years, begin during sleep
• Manage with high flow O² and triptans
• Verapamil for prophylaxis

Question 14

Features and management of trigeminal neuralgia

Answer 14

• Severe sudden shock-like facial pain
• Triggered by light touch (washing, eating, cold wind)
• Lasts seconds but an occur in quick succession
• Unilateral, can affect one or all three branches
• Usually >50 years
• Usually results from damage to the myelin sheath around the trigeminal nerve due to compression (MS/tumour infiltration)
• Treat with AEDs (carbamazepine), antidepressants and surgical decompression

Question 15

Features of central sinus venous thrombosis

Answer 15

• More common in women due to high thrombotic states (OCP, pegnancy)
• Can present suddenly of insidiously
• Diagnosis bt CTV or MRV
• Treat with heparin

Question 16

Management of a high pressure headache

Answer 16

• LP >25mmHg in obese (20mmHg in normal BMI)
• Weight management
• Therapeutic LPs
• Acetazolamide
• VP shunt

Question 17

Chronic medicaiton overuse

Answer 17

• Very comon in patients with migraine
• Patients underplay amount of analgesics
• Too much:
  
  • Triptans, ergots, opioids and combination - >10 days a month
  • Simple analgesics - >15 days a month

Question 18

Features and management of a tension headache

Answer 18

• Bilateral, tight - band around head
• Muscle tenderness
• Management:
  
  • Reassurance
  • Address triggers
  • Simple analgesia
  • Amitryptyline for chronic