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
Acephalgic migraine
Triptans: 5-HT antagonists e.g. sumatriptan

5. Tension-Type Headache
“Featureless” headache
Bilateral, dull
Mild-moderate
Last hours-days
Management
Identify triggers
Simple analgesia
Beware medication overuse
Band/pressure

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
Trigeminal autonomic cephalal
gias
Lifelong condition

7. Medication Overuse Headache
Analgesics 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
5% of strokes
Most due to rupture of berry aneurysm
Management
Nimodipine
Discuss with neurosurgery

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
CSF: + opening pressure, low glucose, high protein, high WCC: neutrophils
Management
IV antibiotics immediately
Supportive treatment
Notify public health

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

11. 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:

12. 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:

13. 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.

14. 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

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
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
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:
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.