Headache

Question 1

• Recurrent, severe headache which is usually unilateral and throbbing in nature
• May be be associated with aura, nausea and photosensitivity
• Aggravated by, or causes avoidance of, routine activities of daily living. Patients often describe ‘going to bed’.
• In women may be associated with menstruation

Answer 1

Migraine

Question 2

• Recurrent, non-disabling, bilateral headache, often described as a ‘tight-band’
• Not aggravated by routine activities of daily living

Answer 2

Tension headache

Question 3

• Pain typical occurs once or twice a day, each episode lasting 15 mins - 2 hours with clusters typically lasting 4-12 weeks
• Intense pain around one eye (recurrent attacks ‘always’ affect same side)
• Patient is restless during an attack
• Accompanied by redness, lacrimation, lid swelling
• More common in men and smokers

Answer 3

Cluster headache

Question 4

• Typically patient > 60 years old
• Usually rapid onset (e.g. < 1 month) of unilateral headache
• Jaw claudication (65%)
• Tender, palpable temporal artery
• Raised ESR

Answer 4

Temporal Arteritis

Question 5

• Present for 15 days or more per month
• Developed or worsened whilst taking regular symptomatic medication
• May be psychiatric co-morbidity

Answer 5

Medication Overuse Headache

Question 6

What medciations put a patient at most risk of medication overuse headache?

Answer 6

Opioids and Triptans

Question 7

What is the management of medication overuse headache?

Answer 7

Abruptly withdraw - triptans and simple analgesics

Gradually withdraw - opiod analgesics.

Question 8

Describe the 15 RED FLAGS of headache.

Answer 8

1. Compromised immunity, caused, for example, by HIV or immunosuppressive drugs
2. Age under 20 years and a history of malignancy
3. A history of malignancy known to metastasis to the brain
4. Vomiting without other obvious cause
5. Worsening headache with fever
6. Sudden-onset headache reaching maximum intensity within 5 minutes
7. New-onset neurological deficit
8. New-onset cognitive dysfunction
9. Change in personality
10. Impaired level of consciousness
11. Recent (typically within the past 3 months) head trauma
12. Headache triggered by cough, valsalva (trying to breathe out with nose and mouth blocked), sneeze or exercise
13. Orthostatic headache (headache that changes with posture)
14. Symptoms suggestive of giant cell arteritis or acute narrow-angle glaucoma
15. A substantial change in the characteristics of their headache

Question 9

What are some other causes of headache?

Answer 9

• Meningitis
• Encephalitis
• Subarachnoid haemorrhage
• Head injury
• Sinusitis
• Glaucoma (acute closed-angle)
• Tropical illness e.g. Malaria
• Chronic headache - raised ICP, Paget’s disease and psychological.

Question 10

What is the definition of chronic-type headache?

Answer 10

A tension headache occuring on 15 or more days per month.

Question 11

What are the NICE guidelines on the management of tension-type headache?

Answer 11

Acute: Asprin, paracetamol, NSAIDs.

Prophylais - 10 sessions of acupuncture over 5-8 weeks.

Question 12

What drug is widely used for prophylaxis for headache and what does NICE recommend regarding it?

Answer 12

Amitriptyline

2012 NICE guidelines do not support it.

Question 13

• A 74-year-old lady presents to your surgery with a four month history of headaches. She says that they occur over the right fronto-parietal area and describes them as a constant dull ache, worse at night, occasionally waking her from sleep. She has taken paracetamol which has not really helped.
• She has not experienced any nausea, vomiting, loss of consciousness, seizures, forgetfulness or tinnitus.
• Her medical history includes carcinoma of the breast at the age of 35 necessitating right mastectomy. She has hypertension well-controlled for the last ten years by amlodipine 10 mg daily.
• Clinical examination was unremarkable except for a right-sided mastectomy scar and evidence of mild osteoarthritis in several joints. Neurological examination showed no abnormality and there was no papilloedema.
• What is the next step in the management of this patient?

Answer 13

Refer urgently.

• Any patient with previous cancer & who develops a headache should be urgently referred.
• Also refer if they develop any of the following:
  
  • Recent onset seizure
  • Progressive neurological deficit
  • New neurological signs.
  • New mental or cognitive change