Headaches

Question 1

Primary vs secondary headaches

Answer 1

• primary: due to a headache condition - non life or sight threatening
• secondary: due to another condition - can be life or sight threatening

Question 2

Examples of primary headache disorders

Answer 2

Tension headache
Migraine
Cluster headache

Question 3

What are red flags for life threatening headaches?

Answer 3

SNOOP
- Systemic signs + disorders
- Neurological symptoms
- Onset new or changed
- Onset in thunderclap presentation
- Papilloedema, Pulsatile tinnitus, Positional provocation, Precipitated by exercise

Question 4

Pathophysiology of tension headache

Answer 4

Tension in muscles of head and neck e.g. occipitofrontalis

Question 5

Epidemiology of tension headache

Answer 5

• female > males
• young > older
• first onset > 50 is unusual

Question 6

Presentation of tension-type headache

Answer 6

• generalised to occipitofrontalis region
• bilateral
• +/- radiate to neck
• squeezing/band like constriction
• non pulsalitie
• mild-moderate intensity
• worse at end of day

Question 7

Aggravating factors of tension type headaches

Answer 7

• stress
• poor posture e.g. at a computer
• lack of sleep

Question 8

What is the commonest headache?

Answer 8

Tension-type headache

Question 9

Epidemiology of migraines

Answer 9

• female > male
• present early to mid-life
• most likely first attack by 30

Question 10

Pathophysiology of migraines

Answer 10

• unclear
• possibly due to inflammation of trigeminal sensory neurones > alters way pain is processed by brain > increased sensitivity

Question 11

Presentation of migraine

Answer 11

• unilateral + often frontal
• throbbing + pulsating
• moderate-severe (can be disabling)
• prolonged (4-72 hours)
• often family history
• associated symptoms - photophobia, photophobia, aura, nausea

Question 12

Aggregating factors of migraines

Answer 12

• certain foods
• menstrual cycle
• stress
• lack of sleep
• photophobia

Question 13

Relieving factors of migraines

Answer 13

Sleep
Simple analgesics
triptans

Question 14

Epidemiology of medication overuse headache

Answer 14

• female > male
• 30-40 years old
• in patients with pre-existing headache disorder
• patient uses analgesics on at least 10 days/month

Question 15

Pathophysiology of medication overuse headache

Answer 15

Up regulation of pain receptors in meninges

Question 16

Presentation of medication overuse headache

Answer 16

• presents of at least 15 days/month
• no improvement after OTC meds
• variable character
• often co-exists with depression + sleep disturbance

Question 17

Management of medication overuse headache

Answer 17

Discontinue medication

Question 18

Epidemiology of cluster headaches

Answer 18

• male > female
• smoking history
• 30-40 year olds
• 1 in 1000

Question 19

Pathophysiology of cluster headaches

Answer 19

• unkown
• possible due to hypothalamic activation with secondary trigeminal + autonomic involvement

Question 20

Presentation of cluster headache

Answer 20

• unilateral, around or behind eye
• sharp, stabbing + penetrating
• severe (often disabling)
• occurs in clusters with periods of remission
• usually at night
• associated symptoms: red, watery eye, nasal congestion + ptosis

Question 21

Aggregating factors of cluster headaches

Answer 21

• alcohol + smoking
• volatile smells
• warm temp
• lack of sleep

Question 22

Management of cluster headaches

Answer 22

Oxygen
Triptans

Question 23

Associated autonomic symptoms of cluster headaches

Answer 23

Red, watery eye
Nasal congestion
Ptosis

Question 24

Presentation of headache due to space occupying lesion

Answer 24

• gradual, progressive
• dull
• mild severity
• worse in mornings
• worsens on leaning forwards, coughing + valsalva manoeuvre
• associated neurological signs + symptoms

Question 25

Aggregating factors of headache due to space occupying lesion

Answer 25

- leaning forwards - cough - valsalva manoeuvre

Question 26

Epidemiology in trigeminal neuralgia

Answer 26

- female > male - 50-60 /increasing age

Question 27

Pathophysiology of trigeminal neuralgia

Answer 27

- compression of trigeminal nerve due to loop of blood vessel (most common) - tumours, MS or skull base abnormalities

Question 28

Presentation of trigeminal neuralgia

Answer 28

- unilateral - pain felt in 1+ division of trigeminal nerve - sharp, stabbing, ‘electric shock’ feeling - severe - lasting seconds - 2 mins - sudden onset - associated symptoms: tingling, numbness, radiating pain to areas of CN V distribution

Question 29

Aggravating factors of trigeminal neuralgia

Answer 29

- light touch to face - eating - cold wind - combing hair - vibrations

Question 30

first line treatment of trigeminal neuralgia

Answer 30

carbamazepine

Question 31

Investigations of headaches

Answer 31

- dependent on cause - headache diary for chronic - imaging if red flags

Question 32

Treatment of headaches

Answer 32

- depends on cause - simple analgesia - triptans for migraines - high flow oxygen for cluster headaches - carbamazepine for trigeminal neuralgia

Question 33

What is temporal arteritis?

Answer 33

Vasculitis involving small + medium sized arteries of head

Question 34

Epidemiology of temporal arteritis

Answer 34

- female > male - > 50 years (most commonly >75 years)

Question 35

When should temporal arteritis is considered?

Answer 35

Any patient > 50 year old with abrupt onset of headache + visual disturbance or jaw claudication

Question 36

What artery is commonly involved in temporal arteritis?

Answer 36

Superficial temporal artery

Question 37

What is an important risk of temporal arteritis?

Answer 37

Irreversible loss of vision de to ischaemia of optic nerve

Question 38

What is the cause of ocular complications in temporal arteritis?

Answer 38

Anteior Ischaemic optic neuropathy Due to occupation of posterior ciliary artery (branch of Opthalamic artery) > ischaemia of optic nerve head

Question 39

Investigations of temporal arteritis

Answer 39

- temporal artery biopsy - inflammatory markers

Question 40

Treatment of temporal arteritis

Answer 40

- if not visual loss: **high dose oral prednisolone** - if visual loss: **IV methylprednisolone** - urgent ophthalmology review