Headaches

Question 1

Name some examples of common types of headaches

Answer 1

• Migraine,
• Cervicogenic (bad positioning of the neck),
• Systemic illness,
• Analgesia overuse,
• Muscular tension

Question 2

What are serious causes of headaches

Answer 2

• Subarachnoid haemorrhage,
• Low cranial pressure,
• Cerebral venous sinus thrombosis,
• Temporal arteritis,
• Raised intracranial pressure,
• Infection (meningitis)

Question 3

What are important questions to ask when taking a headache history?

Answer 3

• Duration,
• Position on the head,
• Character (pressure, dislike of light or noise),
• Frequency?
• Diurnal variation,
• Change in character,
• Nausea/vomiting,
• Postural (worse lying down?)
• Other neurological symptoms?
• Medicines (use of analgesia more than 15 days in the month indicates analgesic abuse headache),
• PMH, FH.

Question 4

What is the history of symptoms which present when patient has tension headache

Answer 4

• Headache can last for weeks, months or even years.
• Feels like tightness or pressure round the head,
• Pain is constant but worse towards evening,
• Often frequent use of analgesia,
• Rarely presents with nausea

Question 5

What is the treatment for tension headaches

Answer 5

• Reassure! and explain it won’t go away over night.
• Use relaxation exercises,
• Reduce analgesia,
• Give low dose amitriptyline
• Discuss muscles around head

Question 6

What are the symptoms of migraines?

Answer 6

• Classically presents on one side and most patients presenting with headaches and nausea are migraines!
• Can be unilateral or bilateral and usually lasts for hours or days.
• Present with photophobia, phonophobia and gut symptoms (IBS can be gut migraine),
• Pulsating and sharp character of pain,
• More common in women especially at mid cycle or newly at menopause.
• Can present with aura (visual, weakness (can look like hemiplegia) or sensory, black and white scotoma)

Question 7

What is coloured scotoma associated with?

Answer 7

Danger sign associated with epilepsy

looks like pulsating flashing lights around visual feild

Question 8

What are some causes of migraines?

Answer 8

• Mechanism is unclear but has vascular/neural theories but often has family history.
• So look for triggers (food/ alcohol/ timing) maybe keep a diary,
• May be exacerbated by exercise of head trauma

Question 9

What is the treatment of acute migraines?

Answer 9

• Aspirin and paracetamol
• Anti-nausea medication (prochlorperazine or metocloperamide)
• Triptans (agonists of 5HT -1b/d receptors) such as sumatriptan, rizatriptan. (thought to be best)

Question 10

Describe the treatment of migraines which occur more than 2 a month?

Answer 10

Prophylactic treatment; Beta blockers (propranol), low dose amitriptyline, pizotifen (5HT antagonist), topiramate, sodium valproate, candesartan, flunarazine, lisinopril or methysergide.

Question 11

What are some other migraine treatments?

Answer 11

• Botulinum toxin injection (every 90 days),

- Anti CGRP monoconal antibodies eg, erenumab,

Question 12

Women with migraines and auras should not be given??

Answer 12

OCP as it increases stroke risk

Question 13

What are trigeminal autonomic cephalagia?

Answer 13

Rare condition s which are cluster headaches or paroxysmal hemicrania

Question 14

Describe features of cluster headaches

Answer 14

Unilateral, usually around the eye.

• Striking circadian rhythm (same time of day)
• Presents with recurrent pain in trigeminal distribution with autonomic features (water eyes, nasal congestion or redness) and is more common in males

Question 15

Describe features of paroxysmal hemicrania

Answer 15

• More common in women with shorter more frequent attacks.

- Respond to indomethacin (differentiator between this and cluster headaches)

Question 16

What is the treatments of trigeminal autonomic cephalagia

Answer 16

• Triptans,
• High sode oxygen,
• High dose verapamil (calcium channel blocker),
• Indomethacin for P hemicrania

Question 17

How does medication overuse headaches present?

Answer 17

• Medications have been used for over 15 days of the month and the headaches worsened while analgesia has been used.

Question 18

What are features of thunderclap headaches

Answer 18

• Instant/rapidly appearning with very severe pain.
• Must consider sub-arachnoid haemorrhage which requires urgent investigation of head CT followed by LP after 12 hours to look for blood, billirubin or oxyhaemaglobin in CSF.
• Could be exertional (coital cephalgia) which is a type of migraine from vasospasm which quickly reverses with rest

Question 19

What are causes of cervicogenic headaches?

Answer 19

• Poor posture in bed,
• Over exertion,
• Spinal degeneration (spondylosis),
• Usually muscular if not presenting with neurological compromise,
• Use anti-inflammatory or pain treatment

Question 20

What is another cause of early morning headaches?

Answer 20

Sleep apnoea with CO2 retention which occurs in obese patients or patients with a history of snoring. It is tested by monitoring chest movements and treated with positive pressure oxygen.

Question 21

What is the presentation of raised intracranial pressure headaches?

Answer 21

• Headaches are usually mild and have diurnal variation (worse in morning and gone by lunch) and have mild nausea

Question 22

What is the neurological features of raised intracranial pressure and the treatmetn

Answer 22

look for Bilateral papilloedema. Treatment of raised ICP headaches is urgent scan and referal

Question 23

How does meningitis present and what is the treatment?

Answer 23

Presentation - Feverm photophobia, neck stiffness, altered consciousness, petechial rash from meningococcal meningitis.
Treat - Ceftriaxone/cefotaxime or benzyl penicillin. (however most are viral)

Question 24

Describe the presentation of temporal arteritis

Answer 24

• Nevere occurs below age 50,
• Jaw claudication,
• Polymyalgia (tired and stiff) in morning followed by temporal headache,
• Can caused embolism into the eye

Question 25

What are the tests of temporal arteritis

Answer 25

- Palpation of temporal arteries for tenderness, - Test for raised erythrocyte sedimentation rate (ESR>50), - Use ultrasound or temporal artery biopsy for inflammation

Question 26

What is the treatment for temporal arteritis

Answer 26

High dose steroids as early as possible but side effects include - osteoporosis, hypertension, muscle wasting and truncal obesity.

Question 27

Describe the presentation of cerebral venous sinus thrombosis

Answer 27

- Severe headache, - Raised ICP often with papilloedema and seziures, - Haem seen bilaterally on MRI, - Empty delta sign - Patients are often female and on OCP.

Question 28

Describe the presentation and treatment of low ICP and how it can occur

Answer 28

- Can occur following LP and thought to be due to leak of CFS through hole left by needle (reduce incident by using atraumatic needles). - Presents with headaches on standing which is eased with lying. Can develop into fits and even death if left untreated. - Treatment is blood patch for post-LP headache (squirt patients own blood over hole to form clot over hole.)