Headaches

Question 1

What are the two types of headaches, which is more likely to be dangerous? Give examples of both

Answer 1

• primary headache disorder e.g. tension headache, migraine, cluster headache (one side, often around eyes, with nasal congestion/ watery eyes)
  Non- life or sight threatening
  Many chronic

Secondary due to another condition
E.g. extradural haemorrhage, space occupying brain lesion, stroke, intracranial haemorrhage (subarachnoid haemorrhage), intracranial infections (abscess, meningitis), hydrocephalus💀,
medication related (overuse painkillers for headaches, CCB), acute sinusitis, hypertension, pre-eclampsia,
temporal (giant cell arteritis 👁 ), acute glaucoma 👁
Some are life or sight threatening
Many acute

Question 2

Red flags for headaches

Answer 2

SNOOp

Systemic signs and disorders (meningitis - fever, neck stiffness. HIV, cancer, pregnant)

Neurological symptoms (SOL, ICH, glaucoma)

Onset new or changed and patient >50yrs (malignancy, GCA)

Onset in thunderclap presentation (vascular haemorrhage)

Papilledema, pulsatile tinnitus, positional provocation, precipitated by exercise (raised ICP)

Question 3

Clinical examination of headaches

Answer 3

Vital signs - BP, PR, temp

Neurological examination (cranial and peripheral nerves)

Guided by history

Question 4

What are the 4 most common types of headache in order

Answer 4

Commonest: tension type headaches

Migraine

Medication over use

Cluster headache

Question 5

Tension headaches
Risk factors
Pathophysiology
History

Answer 5

Female
Young (teens/ young adults 20-39)

Tension in muscles of head and neck

Front/ back/ band/ tight
Generalised predilection for frontal and occipital
Mild - moderate
Worse at end of day
Recurrent (30m-1hr)
Stress/ poor posture/ lack of sleep - triggers
Responds simple analgesia

Question 6

Migraine
Risk factors
Pathophysiology
History

Answer 6

Females
15% population
Presents early to mid life (most by 30)

Unclear - vasodilation of meningeal Bvs

Unilateral, temporal/ frontal
Throbbing, pulsating
Moderate- severe
4-72 hrs
Triggers: certain food, menstrual cycle, stress, lack sleep, FH
Can respond simple analgesics (May need triptans)
Nausea, vomiting, dislike light/ sound - photophobia/ funnel-phobia, neurological features (aura- sensory, hallucinations- can have without headache), sweating

Clinical exam: neurological deficit

Question 7

Medication over-use headache
Risk factors
Treatment

Answer 7

Painkillers for headaches over used (primary-> secondary)

Females
Often at least 15days/ month (constant)
Pre-existing headache disorder
Using regular analgesics (10+days/ month) worst cocodamol
Co- exists with depression and sleep disturbance

✅discontinue mediation (worse first, resolves by 2months)
- shouldn’t take more than 2 days a week normally

Question 8

Cluster headache
Risk factors
History
Treatment

Answer 8

Males
1/1000 rare
Usually begins 30-40yrs

One of worst pains - intents
Autonomic features (nasal congestion, watery eyes, ptosis)
Pain around/ behind eye
Unilateral
Sharp/ stabbing
15m-3 hrs (occurs in clusters, periods of remission 3m-3yrs)
Triggers: alcohol, lack sleep, smoking, volatile smells, hot

✅high flow O2 and triptans used

Clinical exam: may autonomic features if during attack

Question 9

Most common 4 secondary headaches

Answer 9

Meds over- use

Raised ICP
Trigeminal neuralgia
Temporal (giant cell) arteritis

Question 10

Space- occupying lesion SOL

History
Clinical exam
Treatment

Answer 10

Headache rarely occurs in absence of other suspicious findings

• gradual progressive
  Dull, character varies
  Mild,
  worse in mornings
  Worsened with posture (leaning forwards, cough, valsalva manoeuvre)
  Nausea, vomiting, focal neuralgia, visual (behavioural/ personality changes, seizures)

✅simple analgesics initially -> imaging

Clinical exam: focal (unilateral) neurological signs, papilloedema

Question 11

Trigeminal neuralgia

Risk factors
Pathophysiology
History

Answer 11

Females
Rare
50-60yrs

Most compression CN5 due to loop of BV
5% due tumours/ skull base abnormalities or AV malformations

Unilateral
Pain felt 1+ CN 5 Divisions
Sharp, stabbing, electric shock, burning
Severe lasts few secs- 2 mins
Sudden onset
Triggers: light touch face/ scalp, easing, cold wind, combing hair
Preceding symptoms: tingling, numbness, pain radiate areas within CN5 divisions

✅difficult

Question 12

Temporal arteritis
History
Risk factors

Answer 12

Females
Vasculitis involving small/ medium arteries head
>50yrs

Abrupt onset headache + visual disturbance or jaw claudication

Risk of irreversible loss of vision due to ischaemia of CN1

Temporal artery often involved

Question 13

Symptoms of giant cell arteritis

Answer 13

Involvement of cranial vessels: headache, jaw claudication, scalp tenderness, loss vision, abnormal, abnormalities of temporal artery (pain, modules, absent pulse)

Involvement of great vessels (aorta and branches of aorta): claudication of extremities (esp arm)

Systemic inflammation: fever, night sweats, weight loss

Polymyalgia rheumatica: mainly proximal myalgia, stiffness in neck/ shoulder/ pelvic girdles