=====Headache===== {{ :wiki:neurology:headacheclassification.png?400|}} Red flags warranting further Ix or referral: *worsening headache with fever *sudden‑onset headache reaching maximum intensity within 5 minutes *new‑onset neurological deficit or cognitive dysfunction *change in personality *impaired level of consciousness *recent head trauma (typically within the past 3/12) suggestive of [[wiki:trauma:headinjury#subdural_haematoma|Subdural Haematoma]] *headache triggered by cough, valsalva, sneezing or exercise *orthostatic headache *symptoms suggestive of giant cell arteritis *symptoms and signs of acute narrow angle glaucoma *a substantial change in the characteristics of their headache. ^ Common primary headaches || ^Migraine without aura ^ criteria | | |• Headache lasting 4 hours to 3 days\\ • Nausea/vomiting and/or light and noise sensitivity\\ • **2 of the following:**\\ 1. Unilateral pain\\ 2. Moderate or severe intensity pain\\ 3. Aggravation by simple physical activity\\ 4. Pulsating pain | ^Migraine with aura ^ criteria | | |• **At least 3 of the following:**\\ 1. Reversible focal brainstem or cortical dysfunction\\ 2. Aura develops over >4 minutes, or 2 auras in succession\\ 3. Each aura <60 mins\\ 4. Headache <60 mins following aura | ^Episodic tension-type headache ^ criteria | | |• Duration 30 minutes to 7 days\\ • No nausea/vomiting; may have light or noise sensitivity (not both)\\ • **At least 2 of the following:**\\ 1. Mild or moderate intensity pain\\ 2. Bilateral pain\\ 3. No aggravation by simple physical activity\\ 4. Pressing or tight (non-pulsating) pain | ^Chronic tension-type headache ^ criteria | | |• >15 days pain per month, for >6 months\\ • No vomiting; one only of nausea, light sensitivity, noise sensitivity\\ • **At least 2 of the following:** \\ 1. Mild or moderate intensity pain\\ 2. Bilateral pain\\ 3. No aggravation by simple physical activity\\ 4. Pressing or tight (non-pulsating) pain | ^Cluster headache ^ criteria | | |• unilateral, esp around/behind the eye\\ • almost always stay the same side for life\\ • variable types of pain, but severe, from sharp to throbbing\\ • accompanying eye redness or watering or other eye changes\\ • facial sweating\\ • usually lasts 15/60 - 3/24 | ^Secondary Headaches || | |• Intracranial bleeds\\ • infection eg Meningitis/encephalitis\\ • medication overuse headache\\ • post-traumatic\\ • intracranial hypertension\\ • toxic eg alcohol, CO\\ • neoplastic | ====Migraine==== *Current opinion favours a primarily neural cause involving feedback loops through innervation of cranial arteries in the trigeminovascular system *Theories include: relative deficiency of 5-hydroxytriptamine (5-HT), Ca channel abnormalities and calcitonin gene related peptide *usually infrequent compared with tension type headache which is a frequent occurrence in sufferers Differentiating Migraine from [[wiki:neurology:Stroke_TIA|TIA/Stroke]] in the ED is difficult: *gradual onset of CNS symptoms in Migraine vs sudden for Stroke/TIA *Stroke can develop in patient during migraine *some rare genetic links to both, the most common of which is **CADASIL** (Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leuko-encephalopathy) *90% patients suffer Migraine with aura *present with stroke at a young age, with median age at onset of 48y *The risk of stroke is twice as high in migraine with aura patients, both between (migraine related stroke) and during attacks (migraine infarction) *stroke risk is increased in women, smokers, oral contraceptive use, those with recent onset of migraine, and age <45yr ====Migraine with brainstem aura (Bickerstaff's) migraine==== The International Classification of headache disorders outlined the following criteria for the diagnosis of basilar migraine. *(A) Symptoms not attributed to another disorder *(B) At least 2 attacks that fulfill criteria C, D, or E *(C) Aura with more than one of the following symptoms: dysarthria, vertigo, tinnitus, hearing impairment, diplopia, ataxia, decreased level of consciousness, bilateral paresthesia, with no motor or retinal symptoms and completely reversible symptoms *(D) At least one of the following: At least 1 aura symptom occurring gradually over 5 minutes or more and/or 2 or more symptoms occurring in succession over 5 minutes or more, each aura symptom lasts more than 5 minutes, but less than 60 minutes, at least 1 aura symptom is unilateral *(E) Migraine without aura begins during the aura or within 1 hour. ====Orgasmic headache==== *Sexual activity is common cause of Primary Headache *also one of numerous triggers of arterial dissection *arterial dissection is a well recognised cause of secondary Orgasmic Headache *arteries most frequently involved are internal carotid or vertebral arteries ====Cavernous Sinus Thrombosis==== *rare, life-threatening disorder of 2 types: 1. septic (usually) secondary to facial infection, sinusitis, orbital cellulitis, pharyngitis, or otitis or 2. aseptic - following traumatic injury or surgery, especially in the setting of a thrombophilic disorder. *acute or sub-acute over several days - fever, headache (50-90%), periorbital swelling and pain, visual disturbance eg. photophobia, diplopia, loss of vision. *Less common - rigors, stiff neck, facial numbness, confusion, seizures, stroke symptoms, or coma. *Eye findings are nearly universal (90%). *periorbital edema (initially unilateral but typically bilateral), lid erythema, chemosis, ptosis, proptosis (due to impaired venous drainage of the orbit) *restricted or painful eye movement, papilledema, retinal hemorrhages, decreased visual acuity (7% to 22%), photophobia, diminished pupillary reflex, and pulsating conjunctiva. *Blindness can result in 8% to 15% of cases. *CN-VI most common single neuropathy, causing partial ophthalmoplegia with reduced abduction. Most cases, progress rapidly to complete external ophthalmoplegia from CN-III, IV, VI involvement. [[https://www.ncbi.nlm.nih.gov/books/NBK448177/|NCBI Cavernous Sinus Thrombosis]]\\ ====Chiari Malformation==== *rare and mostly congenital. Occasionally secondary to trauma/hydrocephalus *often a protrusion of the cerebellum and sometimes part of brainstem through the foramen magnum *highly variable neurological signs and symptoms dependent on degree of herniation *most common - occipital headaches of variable nature - throbbing, pulsating, stabbing, sharp, exacerbated by cough, strain etc *graded: *Chiari type 0 * minimal or no herniation but associated syringomyelia * occipital headaches probably from altered CSF flow *Chiari type I * most common type * >5mm descent of the caudal tip of cerebellar tonsils past the foramen magnum * usually no other neurological abnormality but may get some symptoms *Chiari type II * brainstem, fourth ventricle, and >5 mm descent of the caudal tip of cerebellar tonsils past the foramen magnum with spina bifida. * obvious problem in childhood with brainstem and lower cranial nerve dysfunction *Chiari type III * extremely rare, debilitating condition with life threatening complications * herniation of the cerebellum with or without the brainstem through a posterior encephalocele. *Chiari type IV * Cerebellar hypoplasia or aplasia with normal posterior fossa and no hindbrain herniation. * usually fatal in infancy [[https://rarediseases.org/rare-diseases/chiari-malformations/|Chiari Malformation - raredisease.org]]\\ [[https://emedicine.medscape.com/article/1483583-overview|Emed - Chiari]] ====Investigation strategy==== *Older people with new headache should have an ESR to assess the possibility of giant cell (temporal) arteritis *Imaging is rarely needed acutely *CT scan if emergency presentation suggests intracranial haemorrhage - eg 'thunderclap' presentation or localising CNS signs *MRI is otherwise preferred imaging modality * ====Acute management==== *simple analgesia and anti-emetics - including aspirin, paracetamol & NSAIDs. *Opiates should not be routinely used in part because of worsening of GI symptoms *5HT1-receptor agonists (Triptans) eg sumatriptan, especially in combination with NSAID or paracetamol. Caution with patients at risk of ACS *//**Dose:**// Oral: 50–100 mg and repeat after ≥2/24 hours if needed, S/C: 6mg and repeat after ≥1/24 if needed *metoclopramide and prochlorperazine initially are useful for headache apart from their anti-emetic actions *Ergots, eg. ergotamine - 5HT agonist, ∝agonist etc. *Side effects including N&V and other vascular effects mutually exclusive *less predictable than more effective Triptans *high flow ≥12Lpm Oxygen for cluster headaches ---- ==References include:== [[https://www.nice.org.uk/guidance/CG150|Headache in over 12s NICE 2015]]\\ [[https://jnnp.bmj.com/content/72/suppl_2/ii10|Migraine - Dx & Mx]]\\ [[https://www.aafp.org/afp/2014/0415/p642.html|Chronic Daily Headache - Dx & Mx]]\\ [[https://www.medscape.org/viewarticle/477719|Headache - Dx & Mx]]\\ [[https://www.bash.org.uk/wp-content/uploads/2012/07/10102-BASH-Guidelines-update-2_v5-1-indd.pdf|Brit Assoc Guidelines 2010]]\\ https://touchneurology.com/cluster-headache-diagnosis-and-treatment/\\ [[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2117461/|J Neurol Neurosurg Psych: orgasmic headache and MCA dissection case review]]\\ [[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5346116/|Migraine and stroke - A link?]]\\ [[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5628377/|Migraine and Stroke article 2017]]\\ https://rarediseases.org/rare-diseases/hemiplegic-migraine/\\ [[https://www.ncbi.nlm.nih.gov/books/NBK507878/|Basilar migraine review 2020]]\\ {{ :wiki:neurology:cuh_headache_pathway_july_2016.pdf |}}\\