Headaches

Question 1

What are the different categories of headache disorders?

Answer 1

The international classification of headache disorders [2013]

• Primary headaches
  
  • Not assoicated with underlying condition
• Secondary headaches
  
  • Underlying local or systemic pathology
• Painful cranial neuropathies, other facial pains/headaches

Question 2

List five red flags for headaches

Answer 2

• Change in pattern of headache
• New headache at age 50+
• Fever, photophobia, neck stiffness
• Papilloedema
• Onset of seizures, personality change, neurological deficit
• Headache with systemic illness
• NaV
• Sudden onset severe headache
• Progressive or persistent headache with dramatic change
• Positional change
  
  • Worse standing - csf leak
  • Worse lying - SOL
• Recent trauma
• Onset on exertion
• PMH of malignancy
• Immunocompromised

Question 3

Give 3 differentials for an acute headache

Answer 3

• Subarachnoid haemorrhage
• Migraine
• Meningitis
• GCA

Question 4

Give 3 differentials for a chronic headache

Answer 4

• Tension headache
• Migraines
• Cluster
• Space occupying lesion
• Medication overuse

Question 5

Request three investigations for headaches

Answer 5

• BP: HTN
• Fundoscopy: papilloedema
• Neck movements
  
  • Kernig sign
  • Brudzinski sign
• Neurological examination

Question 6

Give five presenting features of cluster headaches

Answer 6

• Acute onset; unilateral
• Severe pain around eye: lasting 15-180min; 1-8 times a day
• Restlessness; agitation
• Eyes: watery eye; red eye; constricted pupil
• Eyelid swelling; ptosis
• Nasal congestion; rhinorrhoea
• Facial sweating

Question 7

What are the management options in cluster headaches?

Answer 7

• Conservative:
  
  • Headache diaries
  • Smoking cessation; reduce alcohol intake
• 1^st presentation: Inpatient neuroimaging to exclude SOL
• Acute attacks:
  
  • High flow O₂ + Triptans
• Prophylactic verapamil

Question 8

How do migraines present?

Answer 8

• Unilateral around the temples
• Severe pain (4-72h): pulsating or throbbing
• ± Aura: gradual onset; resolves <1h
  
  • Temporary partial vision loss
  • Numbness, pins and needles
  • Photophobia; phonophobia
  • Speech and balance difficulties
• NaV

Question 9

What is a menstrual migraine?

Answer 9

A migraine without aura that only occurs within 1-2 days of menstruation.

It is associated with the fall in oestrogen.

Only affects 10% of women. Consider menstrual associated migraines, which are managed differently.

Treat with COCP

Question 10

What are the management options for migraines?

Answer 10

• Headache diaries
• Trigger avoidance
• Acute episode: taken early while pain is mild
  
  • Simple analgesia: ibuprofen, aspirin, paracetamol
  • Sumatriptan
  • Consider anti-emetic
• Prophylaxis:
  
  • Propranolol; Topiramate
  • Amitriptyline
  • Behavioural interventions, acupuncture
• Follow up within 2-8 weeks

Question 11

How do tension headaches present?

Answer 11

• Bilateral ‘band-like’ around frontal-temporal, neck, shoulders
• Mild-moderate pain; persistent (30min - several days)
• Non-migranous
  
  • No aura, NaV

Question 12

What are the management options for tension headaches

Answer 12

• Reassurance
• Avoid triggers
  
  • Stress management
• Headache diary
• Advise exercise and posture
• Simple analgesia
• Amitriptyline

Be wary of medication overuse headaches

Question 13

Name five causes of secondary headaches

Answer 13

• Head and/or neck injury
• Stroke; TIA
• Vascular disorders
  
  • Intracerebral haemorrhage
  • Central venous thrombosis
  • GCA
• Malignancy
• Meningitis
• Acute glaucoma; sinusitis; temporomandibular disorder
• Idiopathic intracranial hypertension
• Hypoxia; hypercapnia; hyperglycaemia; HTN; hypothyroidism
• Withdrawal syndrome: ^eg. cocaine; opioids; triptans; alcohol
• Somatisation disorder; other mental illness

Question 14

Name two examples of painful cranial neuropathies

Answer 14

• Trigeminal neuralgia
• Optic neuritis

Question 15

What is trigeminal neuralgia?

Answer 15

Severe unilateral pain syndrome:

• Brief electric shocks; abrupt onset and termination
• Limited to divisions of trigeminal nerve
• Evoked by light tough: ^eg. washing, talking, brushing teeth

Question 16

How is trigeminal neuralgia managed?

Answer 16

• Carbamazepine
• Neurology referral: failure to respond or atypical features

Question 17

Provide three presenting features of optic neuritis

Answer 17

• Unilateral decrease in visual acuity over hr-days
• Reduced colour vision; ‘red desaturation’
• Pain worse on eye movement
• Relative afferent pupillary defect
• Central scotoma

Question 18

What is relative afferent pupillary defect?

Answer 18

• RAPD is a defect in the direct light response
• Due to damage of optic nerve or severe retinal disease
• During swinging light test, the affected pupil:
  
  1. Will not constrict during direct light
  2. Will constrict during indirect/consensual light
  3. Paradoxical dilatation upon direct light afterwards

Question 19

Name three causes of optic neuritis

Answer 19

• MS
• Bacterial infections: ^eg. Lyme disease; syphilis
• Viral infections: ^eg. measles; mumps; HSV; VZV
• Sarcoidosis; SLE
• Drugs: ^eg. amiodarone; ethambutol; isoniazid

Question 20

How is optic neuritis treated?

Answer 20

High-dose steroids: 4-6 weeks to resolve

Treat any underlying disease