Lecture 22: Headache

Question 1

What defines a primary headache?

Answer 1

No underlying structural or biochemical cause; examples include migraine, tension-type headache (TTH), cluster headache

Question 2

What defines a secondary headache?

Answer 2

Caused by an identifiable underlying condition such as SAH, meningitis, or tumour

Question 3

What is the lifetime prevalence of migraine in men and women?

Answer 3

10% in men, 22% in women

Question 4

What are the four phases of migraine?

Answer 4

Premonitory, aura, headache, postdrome

Question 5

What are common aura symptoms in migraine?

Answer 5

Visual, sensory, speech symptoms; gradual onset lasting 15–60 minutes

Question 6

What are features of the migraine headache phase?

Answer 6

Unilateral, throbbing, moderate–severe intensity, nausea, photophobia, phonophobia

Question 7

What are complications of migraine?

Answer 7

Chronic migraine, medication overuse headache (MOH), migraine with brainstem aura, status migrainosus

Question 8

What defines medication overuse headache (MOH)?

Answer 8

Headache ≥15 days/month worsened by regular use of acute medications

Question 9

What are risk factors for MOH?

Answer 9

Triptans, opioids, combination analgesics >10 days/month; simple analgesics >15 days/month; caffeine overuse

Question 10

How is MOH managed?

Answer 10

Education, withdrawal of overused medication, expect worsening for 2–4 weeks, consider preventatives

Question 11

Compare location of migraine

Answer 11

TTH

Question 12

Compare quality of migraine

Answer 12

TTH

Question 13

Compare intensity of migraine

Answer 13

TTH

Question 14

Compare duration of migraine

Answer 14

TTH

Question 15

Compare associated symptoms of migraine

Answer 15

TTH

Question 16

Compare behaviour during migraine

Answer 16

TTH

Question 17

What are acute treatments for migraine?

Answer 17

NSAIDs, aspirin, triptans, rimegepant (CGRP antagonist)

Question 18

What are preventative treatments for migraine?

Answer 18

Propranolol, amitriptyline, topiramate, candesartan, flunarizine

Question 19

What are advanced treatments for chronic migraine?

Answer 19

Botox, CGRP monoclonal antibodies, gepants

Question 20

What lifestyle advice helps migraine?

Answer 20

Sleep hygiene, hydration, regular meals, stress management

Question 21

What are acute and preventative treatments for TTH?

Answer 21

Acute: paracetamol, NSAIDs; Preventative: amitriptyline

Question 22

What are abortive treatments for cluster headache?

Answer 22

Subcutaneous sumatriptan, high-flow oxygen

Question 23

What are transitional treatments for cluster headache?

Answer 23

Oral prednisolone taper, greater occipital nerve block

Question 24

What are preventative treatments for cluster headache?

Answer 24

Verapamil (ECG monitoring), lithium, topiramate, melatonin

Question 25

List red flags for secondary headache.

Answer 25

New onset >50 years, thunderclap onset, change in pattern, fever/neck stiffness, focal signs, worse lying down, immunosuppression, cancer, pregnancy, jaw claudication

Question 26

What defines a thunderclap headache?

Answer 26

Sudden, maximal intensity within 1 minute; must exclude SAH

Question 27

What are causes of thunderclap headache besides SAH?

Answer 27

CVST, dissection, pituitary apoplexy, spontaneous intracranial hypotension (SIH)

Question 28

What are features of subarachnoid haemorrhage (SAH)?

Answer 28

Thunderclap headache, vomiting, neck stiffness, loss of consciousness

Question 29

What investigations are used in SAH?

Answer 29

CT head (within 6 hrs), LP (>12 hrs), CT angiogram

Question 30

How is SAH managed?

Answer 30

Coiling/clipping, nimodipine, manage complications

Question 31

What are features of meningitis and encephalitis?

Answer 31

Headache, fever, meningism; encephalitis adds altered consciousness, seizures, focal signs

Question 32

How are meningitis and encephalitis investigated and treated?

Answer 32

LP, blood cultures, imaging; empirical antimicrobials and supportive care

Question 33

What are features of raised intracranial pressure (ICP)?

Answer 33

Headache worse lying down, visual obscurations, vomiting, papilloedema

Question 34

What causes raised ICP?

Answer 34

Tumour, hydrocephalus, idiopathic intracranial hypertension (IIH)

Question 35

How is raised ICP investigated and managed?

Answer 35

MRI, LP (if safe); treat cause, acetazolamide (IIH), surgery if needed

Question 36

What are features of intracranial hypotension?

Answer 36

Postural headache worse upright, better lying down

Question 37

What causes intracranial hypotension?

Answer 37

Spontaneous or post-LP CSF leak

Question 38

How is intracranial hypotension managed?

Answer 38

Fluids, caffeine, epidural blood patch

Question 39

What are features of giant cell arteritis (GCA)?

Answer 39

Age >50, new headache, scalp tenderness, jaw claudication, visual symptoms

Question 40

How is GCA investigated and treated?

Answer 40

Raised ESR/CRP; start high-dose steroids immediately, arrange temporal artery biopsy

Question 41

What are features of trigeminal neuralgia?

Answer 41

Sudden, unilateral stabbing pain (V2/V3 > V1), triggered by touch, chewing, wind

Question 42

What causes trigeminal neuralgia?

Answer 42

Vascular compression, multiple sclerosis, tumour

Question 43

How is trigeminal neuralgia treated?

Answer 43

Carbamazepine, oxcarbazepine; surgery if refractory

Question 44

What are features of cluster headache (a TAC)?

Answer 44

Severe unilateral pain + autonomic signs; circadian pattern; patient is restless

Question 45

What are features of paroxysmal hemicrania?

Answer 45

Short attacks (2–30 min), frequent (up to 40/day), absolute response to indometacin

Question 46

What are features of SUNCT/SUNA?

Answer 46

Very short attacks (5–240 sec), stabbing pain, conjunctival injection, tearing

Question 47

How is SUNCT/SUNA treated?

Answer 47

Lamotrigine, topiramate, greater occipital nerve block, deep brain stimulation in refractory cases