Headache

Nota:

• Aura - negative - hemianopia, hemiplegia, scotoma or positive e.g. fortification spectra
• Genetic predisposition
• often triggered by lack of sleep, stress oe foods or related to OCP or mensruation

1. Migraine

   Nota:

   • Uncommon forms; familial, hemiplegic, basilar-type and periodic syndromes e.g. abdominal migraine and BPV
   1. Management
      1. Preventers
         1. Beta-blockers

            Nota:

            • Contraindicated in asthma!
            1. AE; fatigue, cold limbs, postural hypotension, vivid dreams
            2. CI; peripheral vascular disease, pregnancy, asthma
         2. Anti-epileptic medications - sodium channel blockers
            1. Sodium valproate

               Nota:

               • Not child bearing age!
               1. AE; liver dysfunction, weight gain, alopecia, tremor, PCOS, pancreatitis
               2. CI; pregnancy, liver disease, juvenile onset myoclonic epilepsy?
            2. Topiramate
               1. Weight loss, memory and concentration, acute glaucoma
               2. CI; pregnancy
         3. 5-HT antagonists e.g. pizotifen
            1. AE; weight gain
            2. CI; pregnancy
      2. Relievers
         1. Aspirin 600-900mg
         2. Triptans
            1. Sumitriptan - 5HT1 agonist
               1. AE - chronic daily headache

1. Cluster headache

   Nota:

   • more common in middle aged men, can be triggered by alcohol
   1. triptans - injection?

1. Tension headache
   1. Management
      1. Relivers
         1. triptans
      2. Psychological support and stress reduction
      3. Preventers
         1. Amytriptaline

1. SOL
   1. Other possible features
      1. Visual field defects - lesion in optic pathway
      2. CN abnormalities
      3. Abnormal gait
      4. torticollis
      5. headache wakes up
      6. Growth failure
2. Idiopathic intracranial hypertension
   1. Clinical features
      1. Overweight females or pregnant
      2. Blindess on stooping
      3. Tinnitus
   2. Management
      1. Monitor vision e.g. blind spot to prevent permanent damage
      2. Weight loss
      3. Investigations; exclude other causes, LP therapeutic and diagnostic - raised opening pressure
      4. Diuretics - acetazolamide, furosemide
      5. intra-ventricular shunt

1. Sudden collapse after lucid period following head injury
   1. Extra dural haematoma

      Nota:

      • Middle meningeal artery tear
      1. CT; lenticular / biconvex, midline shift
      2. Pupillary changes - depending on severity (see notes)
2. confusion, fluctuating consciousness, possible raised ICP, focal; seizure, hemiplegia, aphasia. following head injury
   1. chronic or acute subdural haematoma

      Nota:

      • elderly and alcoholics particularly at risk due to brain atrophy, coagulation problems (liver, drugs etc) and risk of falls.
3. head and neck pain - spontaneous or secondary to deceleration or rotational injury
   1. Arterial dissection

1. Sudden onset, worst headache ever, cant sleep, meningism - neck stiff, photophobia (blood irritates meninges)
   1. Urgent CT scan
      1. White haemorrhage
         1. Subarachnoid haemorrhage
            1. management
               1. calcium channel blocker
               2. saline fluids
      2. LP - once raised ICP ruled out - check for meningitis
2. nausea, vomiting, drowsy, seizures, focal signs, usually female, pregnant
   1. Venous sinus thrombosis
      1. Management
         1. CT
         2. IV unfractionated heparin +/- thrombolysis
         3. Control seizures and raised ICP

Nota:

• Check sinus tenderness

Nota:

• Check vision esp in children

1. Giant cell arteritis

   Nota:

   • In over 60s only
   • Associated with polymyalgia rheumatica
   1. Management
      1. TA biopsy
      2. Raised ESR and CRP
      3. Immediate corticosteroids e.g. prednisolone 60-80mg / day