Headaches can either be Primary due to a headache disorder OR Secondary to another condition.
List 3 types of Primary Headache Disorder
- Tension headache
- Migraine
- Cluster headache
List 6 types of Secondary headache
- Intracranial lesion (tumour, haemorrhage)
- Meningitis/ infection
- Temporal arteritis
- Glaucoma
- Medication overdose headache
- Trigeminal neuralgia
What are the Red Flag features of headaches?
SNOOP
- Systemic symptoms/ disorders (Infection, Pregnancy etc)
- Neurological symptoms
- Onset new/ changed and patient >50
- Onset in Thunderclap presentation
- Papilloedema, Positional Provocation, Precipitated by exercise (suggest raised ICP)
Describe the presentation of a headache caused by a Space Occupying Lesion
- Gradual onset
- Progressive
- Associated neurological symptoms
- Addition features of raised ICP (Nausea, Worse on coughing/bending, early morning headache)
What would you look at in a clinical examination in someone with a headache
- Full neurological exam (Cranial + Peripheral)
- Vital signs (BP, RR, Temp, Pulse etc)
- Other relevant systems)
Describe the epidemiology of Tension headache
- Most common
- More common in females
- More common in young people (teens & adults)
- Unusual if first onset is > age of 50 (possible malignancy)
Describe the pathophysiology of Tension headache
- Tension in Head+Neck muscles (E.g Occipitofrontalis)
- Usually no family history
Describe the Site, Quality, Intensity and Timing of Tension headache
Site: Bilateral frontal, can radiate to neck
Quality: Tight/ band-like, constricting, non pulsatile
Intensity: Mild to moderate
Timing;
- Worse at end of day
- Chronic if >15 times per month, otherwise Episodic
Describe the Aggravating, Relieving factors and Secondary Symptoms of Tension headache
Aggravating;
- Stress
- Poor posture
- Lack of sleep
Relieving;
- Simple analgesics
Secondary symptoms;
- Sometimes mild nausea
Describe the epidemiology of Migraine
- More common in females
- Most had 1st attack before 30
- Severity decreases as age increases
Describe the pathophysiology of Migraine
Unclear but possibly;
- Inflammation of CN V sensory neurones innervating large vessels and meninges
- Brain sensitised to otherwise ignored stimuli-> Pain
- Clear family history
Describe the Site, Quality, Intensity and Timing of Migraine
Site: Unilateral, often frontal
Quality: Sudden/ gradual onset, Pulsatile
Intensity: Moderate-severe, often need to lie down
Timing;
- Lasts 4-72 hours
- Possibly cyclical (menstrual cycle)
Describe the Aggravating, Relieving factors, Secondary Symptoms and Triggers for Migraine
Aggravating;
- Photophobia or Phonophobia (loud sounds)
Relieving;
- Sleep/ lying down
- Simple analgesics (Triptans)
Secondary symptoms;
- May have Aura
- Nausea + Vomiting
Triggers;
- Some foods (cheese, chocolate)
- Lack of sleep
- Stress
Describe the epidemiology of Medication Over-use Headache
Describe its Pathophysiology
- 3rd most common
- Often 30-40 years old
- More common in Females
- Upregulation of pain receptors in meninges
List clinical features of Medication Over-use headache
- Present at least 15 days a month
- No improvement after OTC medication
- Using analgesics at least 10 days a month
- Various symptoms (Dull/ tension type/ migraine type)
- Often coexists with Depression and sleep disturbance
Describe the management of Medication Over-use headache
Discontinuing of medication, but will get worse before it gets better
Describe the epidemiology of Cluster headache
- More common in males
- 1 in 1000 people
- Smoking is a risk factor
- Usually begins at 20-40
Describe the Site, Quality, Intensity and Timing of Cluster headache
Site: Around/ behind one eye, no radiation
Quality: Sharp/ penetrating
Intensity: Very severe, constant intensity, makes it difficult to sit still
Timing;
- Rapid onset
- Attacks last 15 min-3 hours, 1-2 times a day
- Usually at night
- Remissions between attacks can be 3 months- 3 years
Describe the Aggravating, Relieving factors and Secondary Symptoms for Cluster headache
Aggravating;
- Head injury
- Smoking
- Alcohol
Relieving;
- Simple analgesics ineffective, use O2 and Triptans
Secondary Symptoms (decreased sympathetic activity);
- Ptosis
- Nasal congestion
- Red, watery eye
List 8 triggers for cluster headache
- Alcohol
- Heat
- Exercise
- Solvent inhalation
- Lack of sleep
- Smoking
- Histamine (hayfever)
- GTN
Describe the epidemiology of Trigeminal Neuralgia
Describe its Pathophysiology
- Peak incidence 50-60, increasing with age
- More common in females
- Most cases: Compression of CN V
- Some cases: Due to Tumours/ MSK or Skull base abnormalities
- More common in those with a history of chronic pain
Describe the Site, Quality, Intensity and Timing of Trigeminal Neuralgia
Site: Unilateral often over one eye, Radiates to eyes, lips, nose, scalp
Quality: Sharp/ stabbing, Electric shock feeling
Intensity: Severe
Timing: Sudden onset, lasts from seconds-minutes
Describe the Aggravating, Relieving factors and Secondary Symptoms for Trigeminal Neuralgia
Aggravating;
- Light touch to face
- Eating
- Cold wind
- Vibrations
Relieving;
- Difficult to alleviate, simple analgesics ineffective
Secondary Symptoms;
- Possible numbness and tingling before attack
Describe the epidemiology of Temporal arteritis
Describe its Pathophysiology
- More common in females
- Often over 50 (usually over 75)
- Vasculitis of large and medium sized arteries of head
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Nervous System Topography45
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Psychotic Disorders27
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Mood Disorders24
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Anxiety Disorders30
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Subarachnoid Haemorrhage & Meningitis31
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Raised Intracranial Pressure33
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Stroke32
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Headache28
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Dementia and Delirium34
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Neuropathology36
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Consciousness30
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Higher Cortical Funtion37
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Motor Disorders32
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Motor System35
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Visual System36
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Blood Supply to The Brain20
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The Somatosensory System43
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Cellular Physiology Of The Brain45
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Nervous System Development36
