Headache

1. Headache Catriona Gribbin

2. Classification Primary: 90% • No structural abnormality • Migraine • Tension-type • Cluster Secondary: 10% • Underlying cause • Subarachnoid haemorrhage • Infection • Raised ICP • Temporal arteritis • Medication overuse

3. History • Site • Onset • Character • Radiation • Associations • Timing • Exacerbating/relieving • Severity RED FLAGS • Systemic • Neurological signs/symptoms • Onset sudden • Older: > 50 years • Previous history

4. 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

5. 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

6. 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

7. Medication Overuse Headache • Analgesics 10-15 days each month • Especially codeine and triptans Management • Explanation • Abrupt withdrawal from analgesics • Consider prophylaxis • Propanalol or topiramate

8. Subarachnoid Haemorrhage • 5% of strokes Presentation • Thunderclap headache • Vomiting • Seizures • Meningeal signs Diagnosis • Non-contrast CT head • Lumbar puncture if negative • 12 hours after onset • Xanthochromia • CT angiography • Management • Nimodipine • Discuss with neurosurgery http://upload.wikimedia.org/wikipedia/commons/thumb/c/c1/SubarachnoidP.png/230px-SubarachnoidP.png

9. Meningitis Features • Headache • Neck stiffness • Photophobia • Vomiting • Fever • Drowsiness • Purpuric rash Diagnosis • Treat first! • Usually clinical • Blood cultures + PCR • Lumbar puncture • CSF analysis and culture • Management • IV antibiotics immediately • Supportive treatment • Notify public health http://www.meningitis-trust.org/meningitis-info/signs-and-symptoms/glass-test/

10. Temporal/Giant Cell Arteritis Consider 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

11. Raised Intracranial Pressure • Imaging • Pressure features • Neurological signs on examination • MRI Features • 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

12. 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; PractNeurol 2011;11:191-200

13. 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.

14. A 20 year old student presents with dull generalisedheadaches. 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

15. 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.

16. 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

17. 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.

18. 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

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

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

21. 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.