Headaches

Question 1

Name some examples of primary and secondary headaches

Answer 1

Primary - Migraines and trigeminal autonomic cephalgia.
Secondary - Thunderclap headache, Raised ICP headaches, low ICP headaches and neuralgia

Question 2

What are the important history questions when taking a headache history?

Answer 2

• Any personal/family history?
• How many headache types have they had and then for each type ask:
• Age of onset, is it chronic/episodic, any premonitory symptoms (low mood/nausea), progression, location, character, intensity, precipitating factors, exacerbating or relieving factors, associated symptoms

Question 3

What are the examinations of the headache patient?

Answer 3

• Blood pressure is important, urine drip, pregnancy test, temp and weight.
• GCS,
• Palpation of skill, TMJ, nuchal rigidity,
• Fundoscopy (papilloedema), presence of cranial nerve palsy and test facial sensation.
• Any autonomic features,
• Skin exam, lymphadenopathy

Question 4

What are the investigations for a headache patient?

Answer 4

• Blood pressure is important,
• ECG incase you put patient on meds,
• Urinalysis,
• Bloods (UEs, LFT, CRP, ESR, thyroid function)
• LP (measure opening pressure)
• CT angiogram/MR angiogram
• CT venogram/MR venogram (VST)

Question 5

What headache patients should you image?

Answer 5

SSSNOOPPP
- Systemic symptoms,
- Secondary risk factors,
- Seziures,
- Neurological symptoms,
- Older onset (over age 50)
- Progression (change in type or intensity of headache),
- Papilloedema
- Precipitated by cough/exertion/valsalva

Question 6

What headache patients should get an LP?

Answer 6

CSF
- Change in nature of headache,
- Systemic signs and features,
- Focal neurological deficit

Question 7

What is the diagnostic criteria for tension type headaches?

Answer 7

A. At least 10 episodes occurring on 1 day of the month.
B. Two of following: Bilateral, pressing/tightening quality, mild-mod and not aggravated by physical activity.
C. Both of following: No nausea/vomiting and no photophonophobia

Question 8

What is the pathophysiology of a migraine?

Answer 8

• Interaction between multiple parts of the brain. Link with Calcitonin gene related peptide.

Question 9

What is the diagnostic criteria for a migraine?

Answer 9

A. At least 5 attacks of:
B. Lasting 4-72h
C. Two of the following: Unilateral, pulsating quality, mod-severe pain and its aggravated by physical activity like walking.
D. One of the following: Nausea/vomiting or photophobia or phonophobia

Question 10

What are the phases of a migrane?

Answer 10

Prodrome - Yawning, polyuria, depression, poor sleep/concentration. This can last hours to days.
Aura - Can be visual, sensory, language or motor. 5-60mins
Headache - Throbbing headache, nausea/vomiting, photophonophia worse with activity.
Postdrome - Depression, euphoria, poor concentration (24-48 hours)

Question 11

What are the key elements of aura?

Answer 11

• It evolves over 5-60mins with positive and negative elements but is fully reversible.
• Most common is visual, then sensory then language and finally motor

Question 12

What is the treatment of an acute mingrane?

Answer 12

• Avoid opiates.
• Single dose of 900mg aspirin or
• Triptans such as sumatriptan.
• If persistent vomiting then give metoclopramide.

Question 13

What are the prophylactic therapies for migranes?

Answer 13

• Lifestyle advice - avoid triggers,
• Give pharmacological prophylaxis if >4 headaches a month. 1st line is propranolol, others include topiramate or amitriptyline. Switch if no benefit at 3 months
• Headache diaries

Question 14

What prophylaxis meds can be used for migraines if all others have failed?

Answer 14

• Onabotulinimtoxin A (botox)
• CGRP inhibitors (Erenumab)

Question 15

What is the diagnostic criteria for cluster headaches

Answer 15

A. At least 5 attacks
B. Severe or very severe orbital/supraorbital pain lasting 15-180mins
C. One or both of following: autonomic features ipsilateral to headache or a sense of agitation/restless ness
D. Frequency of one every other day to 8 per day.

Question 16

What are the autonomic features associated with cluster headaches?

Answer 16

• Lacrimation,
• Rhinorrhoea,
• Eyelid oedema,
• Facial sweating,
• Facial flushing,
• Fullness in ear,
• Miosis/ptosis

Question 17

What is the treatment for trigeminal neuralgia?

Answer 17

• Carbamazepine,
• Decompression surgery

Question 18

Describe features of a raised pressure headache

Answer 18

• Headache worse when laying flat and in the morning.
• Persistent nausea and vomiting,
• Worse with Valsalva,
• Papilloedema,
• Impaired visual acuity,
• 3rd nerve palsy,
• Enlarged blind spot,

Question 19

Explain the presentation and management of a thunderclap headache

Answer 19

Presentation - Sudden onset, extremely severe. Can last up to 1h.
Management - Medical emergency, requires non contrast CT ASAP and if normal then a LP for blood products.
If LP normal then consider MRI, angiogram or venogram

Question 20

What are the causes of a thunderclap headache?

Answer 20

• Subarachnoid haemorrhage,
• intracerebral haemorrhage,
• Arterial dissection,
• Cerebral venous sinus thrombosis,
• Ischaemic stroke,
• Bacterial meningitis

Question 21

Explain the presentation of trigeminal neuralgia

Answer 21

• Severe, shooting/stabbing pain in the distribution of the trigeminal nerve