Headache cases

Question 1

Case 1
History
o 34 Yr teacher
o Headaches since being student (early 20’s)
o Progressively worse over last 4 months, pressing, bifrontal
o Daily, lasts most of the day, does not wake her up
o Occasional nausea and vomiting (for few months)
o Difficult to concentrate at work due to headaches
o Worried about having a brain tumor

What additional question do you want to ask this patient?

Answer 1

What treatment does she take and how often?
o Patient has been taking increasing doses of analgesics including paracetamol, brufen,
tramadol and grandpa

Question 2

History
o 34 Yr teacher
o Headaches since being student (early 20’s)
o Progressively worse over last 4 months, pressing, bifrontal
o Daily, lasts most of the day, does not wake her up
o Occasional nausea and vomiting (for few months)
o Difficult to concentrate at work due to headaches
o Worried about having a brain tumor

What additional question do you want to ask this patient?
o What treatment does she take and how often?
o Patient has been taking increasing doses of analgesics including paracetamol, brufen,
tramadol and grandpa

Examination
o Slightly overweight
o Vitals normal, systemic exam including neurological exam is normal

Do you want to refer this woman for a CT brain?

Answer 2

No

Question 3

History
o 34 Yr teacher
o Headaches since being student (early 20’s)
o Progressively worse over last 4 months, pressing, bifrontal
o Daily, lasts most of the day, does not wake her up
o Occasional nausea and vomiting (for few months)
o Difficult to concentrate at work due to headaches
o Worried about having a brain tumor

What additional question do you want to ask this patient?
o What treatment does she take and how often?
o Patient has been taking increasing doses of analgesics including paracetamol, brufen,
tramadol and grandpa

Examination
o Slightly overweight
o Vitals normal, systemic exam including neurological exam is normal

What are the differential diagnosis?

Answer 3

Primary headache- tension type
o Plus analgesia overuse
o Nausea and vomiting likely due to gastric irritation from analgesics

Question 4

History
o 34 Yr teacher
o Headaches since being student (early 20’s)
o Progressively worse over last 4 months, pressing, bifrontal
o Daily, lasts most of the day, does not wake her up
o Occasional nausea and vomiting (for few months)
o Difficult to concentrate at work due to headaches
o Worried about having a brain tumor

What additional question do you want to ask this patient?
o What treatment does she take and how often?
o Patient has been taking increasing doses of analgesics including paracetamol, brufen,
tramadol and grandpa

Examination
o Slightly overweight
o Vitals normal, systemic exam including neurological exam is normal

How will you manage this patient?

Answer 4

Management
o Explain pathogenesis
o Importance of multi-angle approach including exercise, relaxation, stress management
o Analgesia needs to be withdrawn
o Start amitriptyline and increase as tolerated

Question 5

Case 2
 History
o 60 yr old man
o Brought by wife to OPD
o 2 months history of headaches
o No previous history of headaches
o Reluctant to discuss severity but claims it is mild to moderate
o Location holocephalic
o Wakes him up at night
o Withdrawn according to wife and sometimes forgetful

What other question do you want to ask the patient?

Answer 5

Symptoms of raised intracranial pressure such as worsening headaches with coughing,
sneezing, straining on the toilet, worsening on lying down

Question 6

Case 2
History
o 60 yr old man
o Brought by wife to OPD
o 2 months history of headaches
o No previous history of headaches
o Reluctant to discuss severity but claims it is mild to moderate
o Location holocephalic
o Wakes him up at night
o Withdrawn according to wife and sometimes forgetful

What other question do you want to ask the patient?
o Symptoms of raised intracranial pressure such as worsening headaches with coughing,
sneezing, straining on the toilet, worsening on lying down

Examination
o Gen examination including vitals, systemic exam, chest, heart and abdomen normal

What will you look for on neurological examination?

Answer 6

Fundoscopy looking for papilledema and focal signs such as hemiparesis, hemisensory
disturbance, cerebellar signs

o Neurological exam is normal aside from patient being withdrawn and reluctant to respond to
questions

Question 7

Case 2
History
o 60 yr old man
o Brought by wife to OPD
o 2 months history of headaches
o No previous history of headaches
o Reluctant to discuss severity but claims it is mild to moderate
o Location holocephalic
o Wakes him up at night
o Withdrawn according to wife and sometimes forgetful

What other question do you want to ask the patient?
o Symptoms of raised intracranial pressure such as worsening headaches with coughing,
sneezing, straining on the toilet, worsening on lying down

Examination
o Gen examination including vitals, systemic exam, chest, heart and abdomen normal

What will you look for on neurological examination?
o Fundoscopy looking for papilledema and focal signs such as hemiparesis, hemisensory
disturbance, cerebellar signs
o Neurological exam is normal aside from patient being withdrawn and reluctant to respond to
questions

Will you do additional investigations such as CT brain or will you start symptomatic treatment and
ask patient to come back in a month?

Answer 7

Investigate with brain imaging as new onset headaches in an older person is worrying.
Frontal lobe lesions may give you no focal signs if located in the prefrontal area

Question 8

Case 3
 History
o 73 yr old woman
o Increasing headaches for last 3 months
o Frontotemporal, aching
o Intermittently feeling hot for same period
o Jaw stiffness occasionally for few weeks
o Anxious for years
o Multiple somatic symptoms including dominant shoulder pain for months
o Routine exam including temperature and neurological exam is normal

Is there any other specific examination that you want to do?

Answer 8

o Palpate the temporal arteries for pulsation, tenderness, thickening
o Some tenderness over the whole temporal areas but temporal arteries cannot be located

Question 9

Case 3
 History
o 73 yr old woman
o Increasing headaches for last 3 months
o Frontotemporal, aching
o Intermittently feeling hot for same period
o Jaw stiffness occasionally for few weeks
o Anxious for years
o Multiple somatic symptoms including dominant shoulder pain for months
o Routine exam including temperature and neurological exam is normal

Is there any other specific examination that you want to do?
o Palpate the temporal arteries for pulsation, tenderness, thickening
o Some tenderness over the whole temporal areas but temporal arteries cannot be located

Is there any further investigations that you want to do such as brain imaging or blood tests?

Answer 9

ESR (and C-reactive protein)
- Raised in giant cell arteritis

o ESR is 100
Since she has a raised ESR, a chest Xray is done which is normal

Question 10

Case 3
 History
o 73 yr old woman
o Increasing headaches for last 3 months
o Frontotemporal, aching
o Intermittently feeling hot for same period
o Jaw stiffness occasionally for few weeks
o Anxious for years
o Multiple somatic symptoms including dominant shoulder pain for months
o Routine exam including temperature and neurological exam is normal
 Is there any other specific examination that you want to do?
o Palpate the temporal arteries for pulsation, tenderness, thickening
o Some tenderness over the whole temporal areas but temporal arteries cannot be located

Is there any further investigations that you want to do such as brain imaging or blood tests?
o ESR (and C-reactive protein)
- Raised in giant cell arteritis

o ESR is 100
- Since she has a raised ESR, a chest Xray is done which is normal

What treatment will you start

Answer 10

o Corticosteroids (40-60 mg) as the most likely diagnosis is giant cell arteritis
o One complication of giant cell arteritis is blindness, and in patients with visual symptoms a
higher dose of corticosteroids should be used

Question 11

Case 4
History
o 28 yr old woman
o Presents to casualty with severe headache (10/10) for 1 day
o Vomiting since prior to headache that morning
o History of headaches for 3 years
o Initially headaches intermittent and right side of head
o Last 6 weeks headaches both sides of head and present most days
o Usually pressing and bearable but sometimes thumping and associated with nausea and
vomiting and photo and phonophobia

Are there any other symptoms you want to enquire about?

Answer 11

o Aura symptoms such as scintillating scotoma, sensory symptoms, weakness, prior to or
during headache.
o Headaches as a teenager

Question 12

Case 4
History
o 28 yr old woman
o Presents to casualty with severe headache (10/10) for 1 day
o Vomiting since prior to headache that morning
o History of headaches for 3 years
o Initially headaches intermittent and right side of head
o Last 6 weeks headaches both sides of head and present most days
o Usually pressing and bearable but sometimes thumping and associated with nausea and
vomiting and photo and phonophobia

Are there any other symptoms you want to enquire about?
o Aura symptoms such as scintillating scotoma, sensory symptoms, weakness, prior to or
during headache.
o Headaches as a teenager

What do you think about the evolving constant nature of the headache?

Answer 12

Usually migraines are episodic, but this patient complained of constant headaches
o Migraines start off intermittently but may become chronic and daily over time
o Tension type and migraines can occur in the same patient

Question 13

Case 4
History
o 28 yr old woman
o Presents to casualty with severe headache (10/10) for 1 day
o Vomiting since prior to headache that morning
o History of headaches for 3 years
o Initially headaches intermittent and right side of head
o Last 6 weeks headaches both sides of head and present most days
o Usually pressing and bearable but sometimes thumping and associated with nausea and
vomiting and photo and phonophobia

Are there any other symptoms you want to enquire about?
o Aura symptoms such as scintillating scotoma, sensory symptoms, weakness, prior to or
during headache.
o Headaches as a teenager

What do you think about the evolving constant nature of the headache?
o Usually migraines are episodic, but this patient complained of constant headaches
o Migraines start off intermittently but may become chronic and daily over time
o Tension type and migraines can occur in the same patient

Treatment

Answer 13

Acute treatment
- Depends on the severity, response to treatment and the frequency.
- Simple analgesic may be effective, but if not triptans can be used.
- Treat nausea.

o Preventative treatment
- To decide whether to start preventative treatment again depends on the frequency
of acute attacks, the response to acute treatment and the patient’s preference.
- Amitriptyline (also used for tension-type headaches) or propranolol