Headache Catriona 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 Acephalgic migraine Triptans: 5-HT antagonists e.g. sumatriptan 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 Band/pressure 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 Trigeminal autonomic cephalal gias Lifelong condition 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 strokes Presentation Thunderclap headache Vomiting Seizures Meningeal signs Diagnosis Non-contrast CT head Lumbar puncture if negative 12 hours after onset Xanthochromia CT angiography 5% of strokes Most due to rupture of berry aneurysm Management Nimodipine Discuss with neurosurgery http://upload.wikimedia.org/wikipedia/commons/thumb/c/c1/SubarachnoidP.png/230px-SubarachnoidP.png

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 CSF: + opening pressure, low glucose, high protein, high WCC: neutrophils Management IV antibiotics immediately Supportive treatment Notify public health http://www.meningitis-trust.org/meningitis-info/signs-and-symptoms/glass-test/

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

Raised Intracranial Pressure 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 Imaging Pressure features Neurological signs on examination MRI Indications for imaging: http://felipebeach.files.wordpress.com/2008/08/brain2.jpg

Idiopathic Intracranial Hypertension When other causes excluded Young, overweight females Lumbar puncture Diagnostic and therapeutic Opening pressure > 25cmH2O Management Weight loss Acetazolamide Shunting Normal opening pressure 12-20cm (approx) Hickman SJ; Neuro-ophthalmology – The bare essentials; Pract Neurol 2011;11:191-200

A 20 year old student presents with dull generalised headaches 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 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 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 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.