What are sinister causes of headache?
- SAH/haematoma
- Infection - men or en
- Temporal arteritis/acute glaucoma (vision threatening)
- Intracranial pressure (SOL, hydrocephalus)
- Carotid dissection
What are non-sinister causes of headache?
- Tension headache
- Migraine
- Cluster headaches
- Trigeminal neuralgia
- Sinusitis
- Medication overuse headache
What are the features of a tension headache?
- Generalised - usually frontal or occipital - bilateral
- Gradual or acute onset
- Feels like a tight band (non-pulsatile)
- Lasts 3-4 hours
- Moderate
- ± scalp muscle tenderness
What can trigger a tension headache?
- Stress
- Exertion
- Lack of sleep
What investigations do you do for a tension headache?
None
How do you treat tension headache?
Simple analgesics
What are the features of headache in migraine?
- Unilateral
- Pulsating/throbbing
- Lasts 4-72h
- Moderate to severe
- Paroxysmal
What can make a migraine worse?
- Physical activity
- Stress
- Straining
What are associated symptoms of migraine that are sometimes present?
Premonitory phase (aura)
- Visual changes
- Aphasia
- Tingling or numbness
Which gender is more affected by migraines?
Female
What are possible triggers for migraines?
- Cheese
- OCP
- Caffeine
- Alcohol
- Stress
What investigations do you do for migraine?
None - unless other differentials suspected e.g. meningitis/SAH
What is conservative migraine management?
- Headache diary
- Ask them to avoid precipitating factors
- Rebreathing into paper bag
- Acupuncture
What medication can you not give to people who have migraines esp. if with aura?
OCP (increased risk of stroke)
How do you treat migraines ACUTELY?
- Sumatriptan
- NSAID
- Metoclopramide
How do you prevent migraines (prophylaxis)?
- 1st line - propanolol or topiramate (teratogenic)
- 2nd line - amitriptyline
What is there risk of when treating migraines?
Medication overuse headaches
What are the features of cluster headaches?
- Unilateral, behind the eye
- Acute onset, same time each day (often nocturnal)
- 15 min-3 hours
- Severe - can be disabling
- Clusters last 4-12 weeks then pain-free for months or 1-2 years
What are some associated non-essential symptoms in cluster headaches?
- Eyelid and forehead swelling
- Nasal congestion
- Horner’s syndrome
What are risk factors for cluster headaches?
- Male
- Smoking
What investigations do you do for cluster headaches?
None - unless other differentials suspected e.g. meningitis/SAH
How do you treat cluster headaches ACUTELY?
- 100% O2 via non-rebreathe mask (not if COPD) for 15 min
- S/C sumatriptan
How do you treat cluster headaches conservatively?
Avoid triggers e.g. alcohol
How do you prevent cluster headaches (prophylaxis)?
- Short term steroids
- Verapamil
- Lithium
