MEDICINE - Headache I

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Headache

Chronic

Medication misuse

Withdraw culpritPrescribe preventer (TCA, valproate, gabapentin)

Episodic --> daily headache

Chronic use of:- mixed analgesia (i.e. with codeine)- opiates- ergotamines- triptans

Chronic raised ICP

VomitingPapilloedemaEpilepsyProgressive focal neurologyMental or behavioural change

Don't lumbar puncture

Present on waking/causes wakingWorse lying down

Occurs in 50% of RICPSOL (neoplasm, abscess, subdural)Benign intracranial hypertension

Tension headache

Tight band around headBilateral, non-pulsatileStress & depression

Very common, any demographicEsp. middle-aged women

Acute single episode

Head injury

DrowsinessFocal neurology

Subdural haematomaExtradural haematoma

Pain local to trauma or generalisedLasts ~2/52, may resist analgesia

Common following minor head trauma

Tropical infection

E.g. malaria, typhoid, Dengue feverSEE INFECTIOUS DISEASE NOTES

Sinusitis

Usually self limitingAnalgesia and steam inhalationDiscourage smoking and alcohol excessAntiobiotics (e.g. amox/doxy) may work

Dull, constant ache over affected frontal/maxillary sinusTender overlying skin ± post-nasal dripEthmoid/sphenoid pain is felt deep in midlinePain worse bending over, may have associated coryza

Often 2° bacterial infection after viralSometimes 2° to tooth root infection

Sub-arachnoid

Encephalitis

EXPERT HELP! ITUAciclovir for HSVEmpirical Abx: ceftriaxone, benpen

CSF microscopy, serology, throat swabs, stool culture

Wernicke's encephalopathy

MeningismDecreased consciousnessConvulsions ± focal CNSΨ: temporal lobe fits, amnesia, odd behaviour

Inflammation of brain parenchyma > meningesViral (HSV, Japanese B, HIV, coxsackie, echo, rabies, West Nile)Measles: subacute sclerosing panecephalitisRubella: progressive rubella panencephalitisS. aureus and other pyogenic bacteria from e.g. sinus, SBE/IE

Meningitis

Acute recurrent

Trigeminal neuralgia

CarbamazepineLamotriginePhenytoinGabapentinSurgery: peripheral nerve, trigeminal ganglion, root

Unilateral paroxysms of intense, stabbing pain, lasting secondsMost commonly in mandibular and maxillary divisionsMay recur frequently through day and nightMay be triggered by touching the area, shaving etc.

Trigeminal nerve distributionAnomalous intracranial vessels compressing trigeminal rootTypically male > 50y

Glaucoma

EXPERT HELP!Acetazolamide

Red, congested eye, cloudy corneaDilated, fixed, oval pupil

Rapid onset of constant aching around 1 eyeRadiation to foreheadGreatly decreased visionNausea & vomiting

Elderley and hypermetropic

Cluster headache

Acute: 100% Oxygen, sumatriptan; Prevention: verapamil, lithium, steroids

Rapid onset of STRICTLY unilateral (and always same side)Pain around 1 eye, watery & bloodshotEpidsodes last 15-160 mins, 1-2 episodes/dayClusters last 4-12/52 then pain free for months

Autosomal dominantM > F, smokersSuperficial tempral artery hypersensitivty to 5HT

Migraine

SEE HEADACHES II

Subacute

Giant cell arteritis

Exclude in any > 50y with persistent headache > 2/52

Prompt steroids (saves vision)

Tender, thickened, pulseless temporal arteriesESR > 40 mm/h

Jaw claudication whilst eating