Headaches

By no means an exhaustive list of headaches- more to come- but definitely more than I knew last year. I used to call every single twinge a migraine. Now I just proclaim to the world that I have a tension headache.


Headaches

Definition:

Tension headache most chronic and daily headaches, rarely disabling and usually self-treated without seeking medical care

Cluster headache- considered to be the most painful primary headache condition, associated with autonomic phenomena, often occurring in episodic clusters

Migraine– severe episodic headache that may have a prodrome of focal neurological symptoms (aura) and is associated with systemic disturbance. Can be subclassified as migraine with aura (classical migraine) or without aura (common migraine) and migraine variants (familiar hemiplegic, opthalmoplegic and basilar)

Trigeminal neuralgia- facial pain syndrome in the distribution of ≥1 divisions of the trigeminal nerve

Giant cell arteritis– a.k.a temporal arteritis, a granulomatous inflammation of large arteries (a vasculitis), particularly branches of the external carotid artery, most commonly the temporal artery

Aetiology/ risk factors:

Tension headache associated with psychological stress, lack of sleep, missing meals

Cluster headache– unknown cause

Migrainethought to be a primary brain disorder resulting from altered modulation of normal sensory stimuli and trigeminal nerve dysfunction.

-Associations: obesity, patent foramen ovale

-Familial hemiplegic migraine: rare, hereditary

Trigeminal neuralgia secondary causes include: compression of nerve root by intracranial aneurysms or tumour, chronic meningeal inflammation, multiple sclerosis, Herpes Zoster Virus, skull base malformation, systemic sclerosis.

Giant cell arteritis Unknown Aetiology. Associated with polymyalgia rheumatic in 50%. Associated with HLA-DR4 and HLA-DRB1.

Epidemiology:

Tension headache most common cause of headache, extremely common. Mean global prevalence in adults is 42%. Onset generally between 20-30 years. Only slightly more common in females (2:3, M:F).

Cluster headache– ≥5x more common in males, onset at any age, commoner in smokers.

Migraine 8% prevalence, 2x more common in females. Usual onset in adolescence or early adulthood but can occur in middle age.

Trigeminal neuralgia generally more common in males but 2x more common in females if Asian, > 50 years old.

Giant cell arteritis- Annual incidence is 18 in 100,000. 2-4x more common in females. Common in the elderly. Peak age onset 65-70 years.

Symptoms:

Tension headache– bilateral, non-pulsatile (dull) headache +/- scalp muscle tenderness

pain generalised throughout head, often frontal & occipital regions

“tight band around my head” (constricting pain)

may have tenderness of the muscles of the neck

Cluster headache disabling

-rapid onset of excruciating pain around one eye

                             -pain is strictly unilateral and almost always affects same side

                             -pain lasts 15-160 min, occurs 1-2x day, often nocturnal

-clusters last 4-12 weeks and are followed by pain-free periods of months or even 1-2 years before next cluster

                            -sometimes chronic, not episodic

Migraine disabling

-classically presents as visual or other aura lasting 15-30 minutes, followed within 1h by unilateral, throbbing headache

-may also present as isolated aura without headache, or as episodic severe headache without aura (common migraine):

-often premenstrual

-usually unilateral (but may be bilateral)

-nausea, vomiting

-photophobia, phonophobia (lie in a dark quiet room

-may have allodynia = all stimuli produce pain e.g. brushing hair, wearing earrings, shaving

Criteria if no aura: -≥5 headaches lasting 4-72h + nausea/vomiting (or photo/phonophobia) + any 2 of: unilateral, pulsating, impairs or worsened by routine activity

-most migraine attacks are episodic rather than a chronic daily headache lasting many weeks

Prodrome: precedes headache by hours/days e.g. yawning, cravings, mood/sleep change

Aura: precedes headache by minutes and may persist during it

Visual– flashing lights, ‘melting’ and jumbling of lines, dots, or zigzags, scotomata (blindspots) or hemianopia

Somatosensory– paresthesia (tingling)

Motor– dysarthria and ataxia (basilar migraine), ophthalmoplegia, hemiparesis

Speech– dysphasia, paraphasia

Image result for cadbury chocolate

What’s with the random Cadbury?

-Partial triggers: CHOCOLATE = Chocolate, Hangovers, Orgasms, Cheese, Oral contraceptives, Lie-ins, Alcohol, Tumult (stress), Exercise

 

Trigeminal neuralgia– paroxysms of intense, stabbing pain, lasting seconds

-pain is unilateral, in the trigeminal nerve distribution

-typically affecting mandibular or maxillary divisions

Image result for trigeminal nerve dermatomes

-triggers include: washing affected area, shaving, eating, dental prostheses

Giant cell arteritis headache over a few weeks (subacute onset)

-jaw claudication (facial pain)

-scalp & temporal tenderness e.g. pain when brushing hair

-blurred vision, amaurosis fugax/ sudden blindness, typically one eye

Systemic features = malaise, low-grade fever, lethargy, weight loss, depression

Symptoms of polymyalgia rheumatic = early morning pain and stiffness of the muscles of the shoulder and pelvic girdle

Signs:

Tension headache– no specific signs

Cluster headache autonomic dysfunction

-pain may be associated with eye becoming watery and bloodshot with lid swelling, lacrimation, facial flushing, rhinorrhea, miosis (contracted pupil) +/- ptosis (drooping upper eyelid) = Horner’s syndrome

Image result for cluster headache eye

Migraine no specific signs

Trigeminal neuralgia– face screws up with pain

Giant cell arteritis tender, thickened, pulseless temporal arteries and scalp tenderness

erythema and swelling overlying temporal artery

decreased visual acuity

Extra-cranial symptoms = unequal or weak pulses

Investigations:

Tension headache, Cluster headache, Migraine­- no specific investigations needed if typical history. May do investigations to exclude other diagnoses.

e.g. FBC, ESR, CT/MRI, Lumbar puncture

Trigeminal neuralgia

MRI– exclude secondary cause (~14% cases) e.g. tumors or aneurysms

Giant cell arteritis

    –ESR > 40mm/h, CRP raised

-Platelets raised

-Alkaline phosphatase raised, Hb low (normocytic anaemia of chronic disease

Temporal artery biopsy within 7 days of starting steroids

-skip lesions occur so biopsy may be negative

Image result for giant cell arteritis

Management:

Tension headache

Acute attack = simple analgesics e.g. paracetamol, aspirin, ibuprofen, naproxen

Chronic =

-Stress relief e.g. massage, relaxation training, CBT, or anti-depressants (e.g. amitriptyline or doxepin), may be helpful

-Recommendations for regular exercise and improved sleep to prevent tension headaches

Cluster headache

Acute attack = 100% oxygen for ∼ 15 minutes via non-rebreathable mask (unless COPD)

SUMATRIPTAN (SC 6mg) at onset (or zolmitriptan spray 5mg)

Prevention = varying degrees of evidence for suboccipital steroid injections, intranasal civamide (cis-isomer of capsaicin), verapamil, lithium, melatonin, methysergide

Migraine

NSAIDS e.g. ketoprofen (100mg), dispersible aspirin (900mg/6h). As effective and less likely to cause medication overuse headache than triptans and ergots (both 5HT agonists).

TRIPTANS– e.g. Sumatriptan, rizatriptan

ERGOTS– E.G. Ergotamine, Cafergot suppository (ergotamine + caffeine)

Botulinum toxin type A injections-12 weekly, last resort in chronic migraine (> 14 days/month)

Non-pharmacological therapy:

-warm or cold packs to head or rebreathing into paper bag may help abort attacks

-spinal manipulation

-riboflavin, magnesium

Prevention:

-Remove triggers- regular sleep, caffeine restriction, reduce stress, symptom diary

-ensure medication overuse headache does not complicate matters

1st line = propranolol (40-120mg/12h), amitriptyline (10-75mg), topiramate (anti-convulsant) (25-50mg/12h), or calcium channel blockers

2nd line = valproate, pizotifen, gabapentin, pregabalin, ACE inhibitors, or NSAIDs

If one drug does not work after 3 months, try another.

Trigeminal neuralgiaCARBAMAZEPINE, LAMATROGINE, PHENYTOIN or GABAPENTIN (anti-convulsants)

-Surgery may be needed if drugs fail. Surgery may be directed at the peripheral nerve, the trigeminal ganglion or the nerve root.

e.g. Microvascular decompression– anomalous vessels are separated from the trigeminal root.

Giant cell arteritis– if suspected, ESR should be measured and high dose prednisolone (60mg/d PO) started immediately to prevent visual loss. Reduce prednisolone gradually as symptoms and ESR decrease, to a maintenance dose (7.5-10mg/d) that may be needed for 1-2 years.

-Low dose aspirin to decrease risk of visual loss, TIA or stroke.

-Give PPI and bisphosphonates for steroid/NSAIDs side effects.

-GCA + visual symptoms- IV Methylprednisolone for 3 days (advocated by some).

 

Complications:

-pain, reduced quality of life

-disruption of daily activities

-progress onto analgesia-overuse headache

-GI bleeds from use of NSAIDs

-depression

Migraine– status migrainosus (> 72h), migrainous infarction, migraine-triggered seizures, chronic migraine

Trigeminal neuralgiapost-op: hearing loss, facial hypaesthesia (reduced sensibility to touch), corneal hypaesthesia, trigeminal motor weakness, keratitis, cranial nerve palsies etc.

Giant cell arteritis– irreversible bilateral visual loss can occur suddenly if not treated, carotid artery or aortic aneurysms, side effects of steroids

Prognosis:

Tension headache- most cases are intermittent and do not interfere with work or normal life span, but they may become chronic if life stressors are not changed. Self-treatment with simple analgesics is usually effective.

Cluster headache- symptoms tend to improve with increasing age.

Migraineusually chronic, but majority of cases can be managed well by preventative/ early treatment measures.

Trigeminal neuralgia- chronic affliction, may have variable periods of remission and relapse.

Giant cell arteritis– typically a 2 year course, then complete remission.

References: Cheese & Onion, Rapid Medicine, BMJ Best Practice
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