HeadacheCatriona Gribbin

Classification

Primary: 90%• No structural abnormality• Migraine• Tension-type• Cluster

Secondary: 10%• Underlying cause• Subarachnoid haemorrhage• Infection• Raised ICP• Temporal arteritis• Medication overuse

History

• Site• Onset• Character• Radiation• Associations• Timing• Exacerbating/relieving • Severity

RED FLAGS• Systemic• Neurological

signs/symptoms• Onset sudden• Older: > 50 years• Previous history

Migraine

• Most common• Without aura: 80%• With aura: 20%– Visual, sensory, motor

Features• Last 4-72 hours• Throbbing, pulsating, unilateral• Nausea/vomiting• Photophobia

Management• Identify + avoid triggers• Simple analgesia• Anti-emetic• Triptans• Prophylaxis

http://shakeuptheheavens.blogspot.co.uk/2011/12/seeing-thingsmigraine-aura.html

Tension-Type Headache• “Featureless” headache• Bilateral, dull• Mild-moderate• Last hours-days

Management• Identify triggers• Simple analgesia• Beware medication overuse

http://uvahealth.com/services/neurosciences/conditions-and-treatments/11515

Cluster Headaches• Excruciating unilateral pain• Around eye• Lacrimation, rhinorrhoea• Transient Horner’s syndrome• 15 minutes – 3 hours

– Up to 8 attacks a day– For several months

Management• Acute

– Sumatriptan SC– High-flow oxygen

• Prophylaxis– Prednisolone– Verapamil

http://www.nlm.nih.gov/medlineplus/ency/imagepages/19241.htm

Medication Overuse Headache• Analgesics 10-15 days each month• Especially codeine and triptans

Management• Explanation• Abrupt withdrawal from analgesics• Consider prophylaxis – Propanalol or topiramate

Subarachnoid Haemorrhage• 5% of strokesPresentation• Thunderclap headache• Vomiting• Seizures• Meningeal signs

Diagnosis• Non-contrast CT head• Lumbar puncture if negative

– 12 hours after onset– Xanthochromia

• CT angiographyhttp://upload.wikimedia.org/wikipedia/commons/thumb/c/c1/SubarachnoidP.png/230px-SubarachnoidP.png

Management• Nimodipine• Discuss with neurosurgery

MeningitisFeatures• Headache• Neck stiffness• Photophobia• Vomiting• Fever• Drowsiness• Purpuric rash

Diagnosis• Treat first!• Usually clinical• Blood cultures + PCR• Lumbar puncture• CSF analysis and culture

http://www.meningitis-trust.org/meningitis-info/signs-and-symptoms/glass-test/

Management• IV antibiotics immediately• Supportive treatment• Notify public health

Temporal/Giant Cell ArteritisConsider in all patients > 50 yrs with new headache

Features• Pain over temporal arteries• Thickened, tortous artery• Jaw claudication• Visual loss

Diagnosis– ESR > 50– Temporal artery biopsy

Management• High dose prednisolone

http://1.bp.blogspot.com/_3Mcl4mmoypE/SX7hfVXPMMI/AAAAAAAAARc/x-cttE6Vpp0/s400/temporalartery.jpg

Raised Intracranial PressureFeatures• Worse in the morning• Worse on coughing, sneezing• Vomiting• Visual obscurations• Papilloedema• Cranial nerve VI palsy

Causes• Space-occupying lesion• Idiopathic intracranial

hypertension• Venous sinus thrombosis

http://felipebeach.files.wordpress.com/2008/08/brain2.jpg

Imaging• Pressure features• Neurological signs on

examination• MRI

Idiopathic Intracranial Hypertension• When other causes excluded• Young, overweight females• Lumbar puncture

• Diagnostic and therapeutic• Opening pressure > 25cmH2O

Management• Weight loss• Acetazolamide• Shunting

Hickman SJ; Neuro-ophthalmology – The bare essentials; Pract Neurol 2011;11:191-200

A 20 year old student presents with dull generalised headaches. She has been suffering with them for several weeks and they are not responding to over-the-counter analgesics. She is worried as they are distracting her from her study for her exams.

A 20 year old student presents with dull generalised headaches. She has been suffering with them for several weeks and they are not responding to over-the-counter analgesics. She is worried as they are distracting her from her study for her exams.

Tension-type headache

A 50 year old female presents with a severe headache associated with nausea and vomiting. She has had a mastectomy followed by radiotherapy for breast cancer. On examination of the fundus, there is papilloedema.

A 50 year old female presents with a severe headache associated with nausea and vomiting. She has had a mastectomy followed by radiotherapy for breast cancer. On examination of the fundus, there is papilloedema.

Raised intracranial pressure due to cerebral metastases

A 76 year old female presents with headache, tenderness in the scalp when combing her hair and a transient episode of loss of vision affecting the left eye.

A 76 year old female presents with headache, tenderness in the scalp when combing her hair and a transient episode of loss of vision affecting the left eye.

Temporal arteritis

A 45 year old female presents with sudden onset headache. She is drowsy and has neck stiffness.

A 45 year old female presents with sudden onset headache. She is drowsy and has neck stiffness.

Subarachnoid haemorrhage

References• Davies MB; How do I diagnose headache?; J R Coll Physicians Edinb;

2006: 36:336-342• Scottish Intercollegiate Guidelines Network 2008; Diagnosis and

management of headache in adults; 107• National Institute for Clinical Excellence 2012; Diagnosis and

management of headache in young people and adults; 150; London.