What is primary headache disorder?
Non life or sight threatening headache
Mainly chronic or recurrent
What headaches fall under primary headache disorder?
- Tension headache
- Migraine
- Cluster headache
What is secondary headache disorder?
Headache due to another condution
Some are life or sight threatening
Many are ‘acute’
Gives some examples of things that can cause a secondary headache?
- Subarachnoid/ intracranial haemmorhage
- Tumour/ Space occupying lesion
- Hydrocephalous
- Meningits / intra cranial infections
- Temporal giant cell arteritis
- Acute, closed angle glaucauma
- Medication related
- Systemic hypertension/ pre-eclampsia
What are some of the flags for potentially life or sight threatening headaches?
SNOOP mneumonic
- Systemic signs e.g. meningitis fever, neck stiffness. Pregnant, cancer?
- Neurological symptoms e.g. SoL, ICH, glaucoma (visual)
- Onset (new or changed & patient >50 years) e.g. Malignancy, closed angle glaucoma
- Onset thunderclap e.g. vascular haemorrhage
- Papilledema, pulsatile tinnitus, positional provication, precipitated by exercise → raised ICP
How may a patient desribe a tension type headache?
- Generalised to the frontal / occipital regions
- Tight, band like +/- radiating to the neck
- Mild- moderate intensity
- Worse at the end of the day
- Recurrent (30mins-1 hr)
- Aggrevated by stress, poor posture, lack of sleep
- Often responds to simple analgesics
- Few associated symptoms
- Clinical examination is normal
What is the pathophysiology behind a tension type headache?
Thought to be due to tension in the muscles of the head and neck
What demographics do tension type headaches affect?
- More common Female > Male
- Young adults and teens
- First onset >50 years unusual
What are the demographics of a migraine patient?
- More common females > males (1 in every 5 females)
- Common (15 in 100)
- Presents early- mid life
- Most have had first attack by age 30
How may a patient with migraine present?
- Unilateral (temporal or frontal lobes)
- Throbbing/ pulsating
- Moderate- severe, often disabling
- Prolonged headache, between 4-72 hours
- Triggers; certain foods, menstrual cycle, stress, lack of sleep, often have family history
- Can respond to simple analgesics
- Associated symptoms; photophobia, nausea + vomiting, aura, neurological symptoms
- Clinical examination is normal
Explain what occurs to cause a medication over use headache
- Regular use of analgesics to treat preexisting headache and headache not responding
- Most common caused by cocodamol
- Co-exists with depression and sleep disturbance
- Female > Male
- Headache present on at least 15 days/month
How do you treat a medication over use headache?
Stop medication
Heache will worsen before it improves
Typically resolved completely by 2 months
What are the demographics of a cluster headache?
- Affect Males > Females
- Rare 1 in 1000
- Usually begin age 30-40 years
What is thought to be the underlying pathophysiology behind a cluster headache?
Possibly due to hypothalamic activation with secondary trigeminal and autonomic involvement
How would a patient with cluster headache present?
- Headache around/ behind the eye, unilaterally
- Sharp, stabbing, penetrating pain often at night
- Severe, intense, often disabling, agitated
- Last 15mins- 3 hours
- Occur in clusters with periods of remission
- Triggers; alcohol, cigarettes, volatile smell, warm temp, lack of sleep
- Ipsilateral autonomic symptoms; red watery eye, runny nose, ptosis, constricted pupil
- Simple analgesics often ineffective → need O2 and triptans
- Will have evidence of autonomi symptoms on examination (only if having headache at time)
How does headache due to a space occupying lesion present?
- Gradual, progressive
- Dull, variably described
- May be mild in severity, worse in mornings/ on waking
- Worsened by leaning forward, cough, valsalva manoeuvre
- Simple analgesics may be affective in early stages
- May be associated with nausea & vomiting, focal neurological or visual symptoms
What is the pathophysiology of trigeminal neuralgia?
- Mainly caused by compression of trigeminal nerve due to a loop of blood vessel
- 5% are due to tumours/ skull base abnormalities or AV malformations
What are the demographics of trigeminal neuralgia?
- Affecfs females > males
- 25/ 100,000 UK
- 50-60 years peak incidence
How does a patient with trigeminal neuralgia usually present?
- Unliateral, pain felt in >1 divisions of the CN V
- sharp, shooting pain - electric shock/ burning
- Severe, lasts 2s-2mins
- Sudden Onset
- Triggers; light touch to face/ scalp, eating, cold wind, combing hair
- Simple analgestics not effective, difficult to treat
- May get preceding symptoms; tingling, numbness, pain can radiate to CN 5 distribution
- Clinical examination is usually normal
What is temporal arteritis?
Vasculitis involving small and medium sized arteries of the head
- Females > Males
- <50 years (most common in > 75 years
- Abrupt onset headache, visual disturbance or jaw claudication
Which artery is most commonly affected by temporal (giant cell) arteritis?
Superficial temporal artery
What is the main risk of temporal (giant cell) arteritis)?
Risk of irreversible loss of vision due to ischemia of cranial nerve 2
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Introduction and basic topography39
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Somatosensory system34
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Retina and Central Visual Pathway21
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Arterial Blood Supply To the Brain17
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The Motor System23
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Movement Disorders20
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Higher Cortical Function22
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Reticular Formation and Conciousness26
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Neuropathology32
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Confusion in the elderly28
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Headache22
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Stroke34
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Raised ICP23
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Meningitis and Sub-arachnoid haemorrhage46
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Intro to psychiatry7
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Anxiety34
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Mood Disorders31
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Psychosis23
