Managing Headaches

Question 1

How many people are affected by headaches in their lifetime?

Answer 1

95%.

Question 2

What normally causes acute onset headaches (secs-mins)? (4)

Answer 2

• SAH
• Intra-cerebral haemorrhage
• Coital
• Thunderclap

Question 3

What normally causes evolving onset headaches (hours-days)? (3)

Answer 3

• Infection
• Inflammation
• Increased ICP

Question 4

What normally causes chronic onset headaches (weeks-months)? (2)

Answer 4

• Chronic daily headache

- Increased ICP

Question 5

What types of headache are episodic? (2)

Answer 5

• Migraine

- Cluster headache

Question 6

What types of headache are chronic? (3)

Answer 6

• Medication overuse
• Chronic migraine
• Hemicrania continua

Question 7

What are autonomic associated features of headaches? (3)

Answer 7

• Lacrimation
• Horners
• Red eye

Question 8

What are red flag symptoms?

Answer 8

• Cognitive effects
• Seizures
• Fever
• Visual disturbance
• Weight loss (systemic)

Question 9

What sort of behaviour does a migraine normally cause?

Answer 9

Patient lies down in dark room.

Question 10

What sort of behaviour does a cluster headache normally cause?

Answer 10

Patient in agitated/pacing.

Question 11

What sort of headache often has a family history (60%)?

Answer 11

Migraine.

Question 12

Give some examples of 1* headache syndromes.

Answer 12

Migraine
Tension headache
Cluster headache
Coital headache

Question 13

What is a secondary headache syndrome?

Answer 13

A headache that is caused by another condition.

Question 14

Give some examples of secondary headache syndromes.

Answer 14

SAH
Stroke
Meningoencephalitis

Question 15

CASE 1:

• woke with severe sudden onset head pains
• vomiting & confused
• hyper-reflexive
• ocular movements impaired (R eye down & dilated)

Answer 15

DIAGNOSIS: occulomotor (III) nerve palsy & migraine
MANAGEMENT: pain relief & refer to neurology

Question 16

CASE 2:

• diabetic
• 72 hours evolving headache & nausea
• hyper-reflexia in right arm & leg

Answer 16

TEST: S. pneumoniae in blood culture
DIAGNOSIS: infection/abscess
MANAGEMENT: -broad spectrum antibiotics (cefotaxime)
-steroids
-Neurosurgical consultation

Question 17

What causes raised intra-cranial pressure? (4)

Answer 17

• Mass effect (e.g. tumour)
• Brain swelling
• Increased venous pressure
• CSF build up

Question 18

What are the symptoms of raised intra-cranial pressure? (3)

Answer 18

• Headache (worse when lying)
• Vomiting
• Seizures

Question 19

What are the signs of raised intra-cranial pressure? (2)

Answer 19

• Papilloedema

- Lateralising signs

Question 20

CASE 3:

• Left temporal headache for 2 weeks (» jaw)
• Visual disturbance this morning
• Fees nauseated

Answer 20

DIAGNOSIS: temporal arteritis
MANAGEMENT: -high dose steroids (prednisolone)
-temporal artery biopsy

Question 21

What is temporal arteritis?

Answer 21

Condition where medium/large arteries in the head and neck become inflamed.

Question 22

What are the signs & symptoms of temporal arteritis?

Answer 22

• Weight loss
• Myalgia
• Transient vision loss
• Jaw claudication
• Non-pulsatile temporal artery

Question 23

CASE 4:

• 3 month episodic headache (R temporal/occipital)
• Nausea & dizziness
• Black dots in vision
• Left hemi-sensory disturbance

Answer 23

DIAGNOSIS: migraine
MANAGEMENT: -brain imaging
-analgesics (e.g. triptans)
-Preventative treatment (e.g. propanolol)

Question 24

What are the triggers for migraines?

Answer 24

• Sleep deprivation
• Hunger
• Stress
• Oestrogen

Question 25

What is the pathophysiology of migraines?

Answer 25

Cortical spreading depression (brain waves slow down).

Question 26

What are coloured dots in the visual field likely to be due to?

Answer 26

Occipital seizures.

Question 27

What are black and white dots in the visual field likely to be due to?

Answer 27

Likely to be due to migraines.

Question 28

CASE 5: - severe gradual onset unilateral right orbital pain - agitated & tachycardia - streaming red eye with eyelid droop - smoker

Answer 28

DIAGNOSIS: trigeminal autonomic cephalgias CHARACTERISTICS: short-lasting headaches & autonomic features (e.g. eyelid droop) MANAGEMENT: -pain relief (sumatriptan) -prevention (prednisolone)

Question 29

What is trigeminal autonomic cephalgias?

Answer 29

Pain on one side of head. | -activation of trigeminal systems.

Question 30

What are the 3 types of trigeminal autonomic cephalgias?

Answer 30

- Cluster headache - Paroxysmal hemicrania - SUNCT

Question 31

``` CASE 6: -intermittent bilateral headache for few months ('tight band around head') -hypertension -IBS ```

Answer 31

DIAGNOSIS: tension headache (mild migraine) MANAGEMENT: -relaxation -consider amitriptyline

Question 32

What is new daily persistent headache?

Answer 32

- Similar to tension headache - No previous headache history - Rarely sinister

Question 33

What are the causes of new daily persistent headache?

Answer 33

- Raised ICP - Low ICP - Chronic meningitis - Head injury

Question 34

What is idiopathic intracranial hypertension?

Answer 34

Increased intracranial pressure in the absence of tumour/disease.

Question 35

Who is idiopathic intracranial hypertension common in?

Answer 35

Women of child bearing age. | -too much CSF >> headache

Question 36

What is chronic daily headache?

Answer 36

Headache lasting >4 hours on >15 days per month, for >3 months.

Question 37

What causes chronic daily headache?

Answer 37

- De novo | - Previous episodic headache (transformed migraine, etc.)

Question 38

What are treatment options for chronic daily headache?

Answer 38

Limited - withdraw overused analgesia - consider amitriptyline/topiramate for transformed migraine