What are the two main categories of headaches?
- Primary or Secondary
- Secondary are usually the life/sight threatening ones
- Primary often have normal clinical exam but secondary abnormal exam like a rash or neurological deficits
What are some examples of primary and secondary headache disorders?
- Secondary are mainly acute but on this list they are chronic from drug side effects down
- Ones in red need immediate referral to a and e
- Medication overuse can also cause secondary headache
What are some drugs that have a headache as a side effect?
- Vasodilators
- Caffeine withdrawal
- Analgesics
How do we take a history from a patient for a presenting complaint of a headache?
- HPC: using SQUITARS
- PMH: have they had headaches before and how does this compare, do they have any conditions that predispose to headaches
DH: analgesic use, medication over use
FH: anyone in family have migraines
SH: stress? sleep? alcohol and coffee consumption? any diet triggers? hydrated?
ENQUIRE ABOUT RED FLAGS
What are some red flags when a patient has a headache?
SNOOP
- Systemic signs and disorders (e.g of meningitis or hypertension)
- Neurological symptoms (SOL, Glaucoma)
- Onset new or changed and patient over 50 (could be brain mets)
- Onset in thunderclap presentation (haemorraghe)
- Papilloedema, pulsatile tinnitius, positional provocation, precipitated by exercise (raised ICP)
What clinical examinations should you do when a patient presents with a complaint of a headache?
- Vital signs e.g BP, PR, temp (bradycardia and hypotension can be raised ICP whilst hypertension can be the cause of the headache)
- Full peripheral and cranial nerve examination
- Other relevant systems (e.g CVS if feeling dizzy)
What are some associated symptoms with a headache are we interested in knowing?
- N+V?
- Photophobia?
- Neck stiffness?
- Rash?
- Weight loss?
- Sleep disturbance?
How would a tension type headache present?
S: Usually bilateral frontal (sometimes occipital) and radiates into neck
Q: squeezing/band like, non pulsatile
I: mild to moderate (can still do everything)
T: worse at end of day, can be recurrent. >15 a month is chronic, less is episodic
A: stress, poor posture (e.g at computer), lack of sleep
R: simple analgesia
S: possible slight nausea
NORMAL CLINICAL EXAMINATION
What is the most common primary headache disorder?
What is the pathophysiology of a tension type headache?
- May be due to tension in muscles of head and neck, e.g occipitofrontalis
- More common in females, especially young 20-39
- Would be unusual for >50 to have first onset
How would a migraine type headache present?
S: unilateral temportal or frontal
Q: throbbing or pulsating with sudden or gradual onset
I: moderate-severe (often disabling)
T: lasts between 4-72 hours with cycling character
A: photo and phonophobia, menstrual cycle, stress, lack of sleep, certain food like cheese and chocolate
R: sleep and analgesia like triptans
S: aura before attack, nausea and vomiting
NORMAL EXAMINATION
What is the pathophysiology and epidemiology of migraine type headaches?
- Unclear but some theories suggest vasodilation of meningeal blood vessels across the cortex
- Clear family history
- 2% of the general population have them and it is twice as common in females than males
- Most have first attack before 30 and severity decreases with age
What is the pathophysiology and epidemiology of a medication over use headache?
- 3rd most common type of headache in the UK and mainly in 30-40s and females
- Due to upregulation of pain receptors in the meninges when patient takes regular analgesics (more than 10 days a month) for an existing headache disorder
- Headache on headache
What are the clinical features of a medication overuse headache?
- Headache present on at least 15 days of the month
- No improvement with OTC medication
- Patient using regular analgesics over 10 days in a month for pre-exisiting headache disorder (particularly co-codomol)
- Coexists with depression and sleep distrubance
How do we treat medication over use headaches?
- Discontinue medication and should be fully resolved by 2 months
- Headache will worsen before it improves
What is the pathophysiology and epidemiology of a cluster headache?
- More common in males than females and usually starts about 30-40 years
- Pathophysiology unknown but triggers are:
- Alcohol
- Histamine (hayfever)
- GTN
- Heat
- Solvent inhalation
- Exercise
- Lack of sleep
How would a cluster headache present?
S: unilateral around/behind eye with no radiation
Q: sharp, stabbing and penetrating
I: very severe, constant intensity with no relief
T: rapid onset and attacks last from 15mins-3hours 1-2 times a day, usually at night. clusters of attacks can occur for 2-12 weeks with 3month to 3 years remission
A: head injury, alcohol, smoking
R: simple analgesics not effective but tryptans and oxygen in acute phase are
S: ipsilateral decrease sympathetic activity symptoms like red watery eye, ptosis, nasal congestion
AUTONOMIC FEATURES ON CLINICAL EXAM
How may a headache due to a space occupying lesion present?
- Gradual onset that is progressive and often dull
- Worse in the morning/on waking
- Worsened with posture (leaning forward), cough and valsalva manoeuvre due to raised ICP
- Nausea and vomiting
- Focal neurological symptoms or behaviour/personality changes
- Possible papilloedema or vision changes
Headache due to SOL rarely occurs without abnormal exam findings!!!
What is the pathophysiology of trigeminal neuralgia and how does it cause a headache?
- Compression of the trigeminal nerve due to a vascular malformation
- Can also be compressed by tumours, skull base abnormalities or MS
- More common in females 50-60 years and those with history of chronic pain
- Increasing incidence with age
How would a headache due to trigeminal neuralgia present?
- *S:** unilateral (usually over one eye) and can radiate to eyes, lips, nose scalp (CN V distribution)
- *Q:** sharp, stabbing, electric shock like and sometimes burning
I: severe
T: sudden onset lasting seconds to two minutes
A: light touch to face, cold wind, eating, vibrations
R: difficult to alleviate as nerve type pain
S: may have numbness and tingling before attack
CLINICAL EXAM NORMAL
What is temporal arteritis (giant cell arteritis) and how does it present?
- Vasculitis involving small and medium sized arteries of the head
- More common in females and over 50s (mainly over 75s)
- Involves superficial temporal artery and sight threatening due to ischaemia of CNI
CONSIDER IN ANY >50 YEAR OLD WITH ABRUPT ONSET HEADACHE WITH VISUAL DISTURBANCE OR JAW CLAUDICATION
How do we treat temporal arteritis?
Immediate steroids whilst awaiting biopsy result
What are the range of management plans that a GP carries out for a headache?
- Simple analgesics
- Triptans
- High flow oxygen (cluster)
- Urgent referral for further investigation
- Ask patient to keep headache diary
A psychologist carries out an experiment and finds that a patient when shown an object in their left visual field they are unable to verbally name it but they can if it is in their right visual field, which part of the brain is damaged?
Corpus Callosum damage (e.g joe and epilepsy surgery)
- Left visual field goes to right hemisphere where the language centre is not so cannot verbalise but can draw them out in left hand if shown image on left and then speak it from looking at their picture
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1 - Topography of the Nervous System30
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2 - Embryology of the Nervous System18
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3 - Glia36
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4 - Somatosensory System32
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5 - The Eye43
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6 - Arterial Supply to the Brain17
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7 - The Motor System40
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8 - Movement Disorders46
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9 - Higher Cortical Function22
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10 - Reticular Formation and Consciousness24
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11 - Neuropathology35
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12 - Confusion in the Elderly36
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13 - Headaches40
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14 - Stroke27
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15 - Raised ICP27
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16 - Meningitis and Subarachnoid Haemorraghe34
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17 - Anxiety Disorders24
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18 - Mood Disorders28
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19 - Psychosis31
