Headache

Question 1

A 30 year old female sees her GP complaining of a severe, throbbing, left-sided headache. She says the headache came on suddenly over 10 minutes. She describes a strange fluttering of her vision before the headache. Paracetamol has not improved the pain.

What is the most likely diagnosis?

Answer 1

Migraine

Question 2

How are headaches classified?

Answer 2

Primary - not caused by an underlying condition

Secondary - caused by an underlying cause

Question 3

What are the primary causes of headaches?

Answer 3

• Migraine
• Tension
• Cluster
• Other

Question 4

What are the secondary causes of headaches?

Answer 4

• Vascular
• Non-vascular
• Infection
• Trauma
• Toxins and medications
• Disorders of haemostasis
• Ocular, ear or sinus related
• Psychiatric

Question 5

Headache history taking: presenting complaint

Answer 5

Site: unilateral, bilateral, occipital, temporal, peri-orbital

Onset: sudden or gradual

Character: throbbing, sharp, tension

Radiation:

Associated symptoms: aura, nausea, lacrimation, seizures, fever, neck stiffness

Timing: hours or days

Exacerbating factors: straining, lying flat, trauma

Severity: 0-10, pain wakes patient up at night, analgesia used

Question 6

Headache history taking: general principles

Answer 6

Past medical history

• Chronic disease eg HTN, migraine
• Trauma

Family history

• Migraine

Drug history

• Anticoagulants: essential to ask if the patient has a head injury
• Analgesia: medication overuse
• COCP: absolute contraindication in those with migraine with aura

Social history

• Narcotics

Question 7

Headache examination

Answer 7

• Evidence of trauma
• Temporal artery palpation
• Neurologcial deficit
• Oral cavity examination
• Eye examination
• Fundoscpoy

Question 8

Red flags in headache:

Answer 8

Raised ICP:

• Worse on lying flat
• Worse at night/morning
• Exacerbated by Valsava maneuver
• Vomiting
• Papilloedema
• Neurological deficit

Subarachonoid haemorrhage:

• Sudden-onset thunderclap occipital headache

Infection:

• Fever, neck stiffness, photophobia
• Reduced GCS

Question 9

Raised ICP causes:

Answer 9

• Space occupying lesion
• Intracranial bleed
• Congenital malformation
• Idiopathic intracranial HTN

Question 10

Headache investigations

Answer 10

• Bedside
  
  • Observations: Blood pressure, temperature
  • Glucose (hyperglycaemia can be associated with a headache)
  • Pregnancy test (pre-eclampsia)
• Bloods
  
  • Inflammatory markers: infection
  • ESR: giant cell arteritis
• Imaging
  
  • CT head: non-contrast imaging is first line for an intracranial bleed
  • MRI head: space occupying lesion
• Special tests:
  
  • Lumbar puncture: rule out infection and subarachnoid haemorrhage

Question 11

Definition of migraine

Answer 11

Primary headache characterised by severe pain with associated symptoms such as aura and photophobia

Question 12

Epidemiology of migraine

Answer 12

• Global prevalence of ~15%
• Often underdiagnosed

Question 13

Risk factors for migraine

Answer 13

• Age 25-55 years
• Female 3x more common
• Family history
• Obesity

Question 14

Triggers of migraine

Answer 14

Chocolate

Oral Contraceptive

Alcohol

Anxiety

Travel

Exercise

Question 15

What is aura?

Answer 15

Neurological deficit which precedes a headache

Question 16

Classification of migraine

Answer 16

• Migraine with aura
  
  • Typical aura
  • Atypical aura: brainstem symptoms or hemiplegia
• Migraine without aura
• Chronic migraine
  
  • ≥ 15 days per month for > 3 months

Question 17

Clinical features of migraine

Answer 17

• Severe, unilateral, pulsating headache
  
  • lasting up to 72 hours
  • Aggravated by exertion
• Nausea and vomiting
• Photophobia and phonophobia
• Aura

Question 18

Describe typical aura

Answer 18

Lasts 5-60 minutes and is fully reversible

• Visual symptoms eg flashing zigzag lines
• Paraestheia
• Speech disturbance

Question 19

Describe atypical aura

Answer 19

May last more than 60 minutes

• Motor weakness
• Diplopia
• Visual symptoms affecting one eye
• Vertigo and/or poor balance

Question 20

Management of migraine

Answer 20

• Analgesia
  
  • Aspirin 900mg or ibuprofen or paracetamol
  • Oral Triptan (nasal if aged 12-17) alone or in combination with paracetamol or NSAID
• Antiemetic
  
  • Metoclopramide or prochlorperazine
• Avoid opiates due to risk of medication overuse headache, dependence and worsening nausea

Question 21

Prophylaxis for migraine

Answer 21

• Propranolol: 80-160mg
• Topiramate: increased risk of congenital malformation

Question 22

Definition of tension headache

Answer 22

Primary headache characterised by mild to moderate, generalised pain, often radiating into the neck.

Question 23

Epidemiology of tension headache

Answer 23

• Most common primary headache
• Global prevalence 40-50%

Question 24

Risk factors for tension headache

Answer 24

• Age: onset 20-30 years of age
• Female: 1.5x more common
• Stress: most common trigger

Question 25

Clinical features of tension headache 1) Site 2) Severity 3) Effect of exertion 4) Duration 5) Associated symptoms 6) Nausea? 7) Photophobia or phonophobia?

Answer 25

1. Bilateral pressure 2. Mild to moderate in severity 3. Not affravated by exertion 4. Lasts for 30 minutes to 7 days 5. Associated trapezius tenderness 6. No evidence of moderate or severe nausea 7. No more than one of photophobia or phonophobia

Question 26

Acute management of tension headache

Answer 26

* Analgesia * Ibuprofen or aspirin or paracetamol * Avoid opiates: risk of medication overuse headache, dependence, and worsening nausea

Question 27

Chronic management of tension headache

Answer 27

* Acupuncture: up to 10 sessions over 2 months * Prophyaxis: low dose amitriptyline may be considered

Question 28

Definition of cluster headache

Answer 28

Rare cause of primary headache characterised by severe unilateral periorbital pain and autonomic features.

Question 29

Risk factors for cluster headache

Answer 29

* Age: onset 20-40 years of age * Male: 4x more common * Alcohol * Smoking * Head trauma

Question 30

Classification of cluster headache

Answer 30

* Episodic: pain free remission ≥ 3 months * Chronic: no remission period or remission period \< 3 months

Question 31

Clinical features of cluster headache

Answer 31

* Very severe unilateral periorbital pain * Lasts 15 minutes to 3 hours * Ipsilateral autonomic symptoms * Lacrimation * Conjunctival injection * Nasal congestion * Rhinorrhoea * Ptosis * Miosis * Nausea and vomiting * Clusters: frequency between one every day and 8 per day followed by periods of remission

Question 32

Acute management of cluster headache

Answer 32

* **Triptans**: subcutaneous or intranasal triptal provides symptomatic relief within 15 minutes in 75% of patients * **High flow oxygen**: symptomatic relief within 15 minutes in 70% of patients

Question 33

Prophylaxis for cluster headaches

Answer 33

Verapamil

Question 34

A 15-year-old female presents to her GP complaining of a new headache over the last month. She describes it as a pulsating pain in the front of her head on both sides and it usually lasts for over a day. When the headache occurs, she feels sick but denies any visual or auditory symptoms. The headaches have caused her to come home from school on four occasions, and paracetamol does not seem to help.

Answer 34

**Migraine** Migraine is a common condition in children. Diagnostic criteria for children are broader than for adults and **bilateral headaches are usually seen with children**, in comparison to unilateral headaches in adults. Additionally, a throbbing headache lasting over 24 hours is typical of a migraine. The absence of an aura does not exclude a migraine, as migraine without aura is actually more common.

Question 35

Triptans are which class of drugs?

Answer 35

5HT receptor agonists