Headache

Migraine

aura phase (evolves over 30-60mins so can diff w/ TIA)
- visual- flahing lights, zigzag lines, fortification spectra, paracentral scotoma
- hemianopia
- sensory- paraesthesiae, numbness
- hemiparesis
- ophthmaloparesis
headache phase
- severe, throbbing, unilateral, photo/phonophobia, N&V, worse w/ activity
NB common to have no aura, can be bilateral, can last 2-5 days
Mx
- avoid trigger factors
  - dietary: cheese, chocolate, alcohol, coffee, dieting, dehydration
  - non-dietary: stress, menstruation, OCP, exercise, relaxation, travelling, altered sleep
- acute Tx: analgesic (not codeine), anti-emetic, triptan if severe
- prophylaxis: B antagonist (propanolol) or AED (topiramate) or amytriptyline or acupuncture, botox for chronic migraine

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band around head
- "pressure", "going to explode"
may have other features of anxiety
- acute hyperventilation (panic attacks)
- chronic hyperventilation
  - distal and perioral paresthesiae, dizzy spells, palipitations
Mx
- reassurance
- lifestyle changes
- analgesics (aspirin, paracetamol, ibuprofen, never codeine)
- prophylaxis (amitryptaline, ?SSRIs)
- possible psych referral
NB medication overuse headache
- any analgesic, esp codeine, also ergotamine, triptans
- no set dose triggers it
- Dx confirmed 3 months post-w/drawal

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one of the trigeminal autonomic cephalgias (TACs)
clinical features:
- unilateral
- several occular/frontal pain
- eye injected/watering
- unilateral nasal discharge
- agitation
- often at night
- 30-60 mins, may have multiple attacks
- occur in clusters
Ix
- MRI- can be due to pituitary lesions (e.g. pituitary adenoma)
Mx
- acute: sumatriptan, oxygen
- prophylaxis: verapamil, methysergide, lithium, prednisolone

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clinicla features
- headache
- scalp tenderness
- jaw claudication (rare)
- fever, weight loss, anaemia
- raised ALP
- polymyalgia rheumatica
Ix
- ESR
- temporal artery biopsy
Cx
- TIA, stroke, blindness
Tx
- prednisolone 60mg daily for 1 month then reduce (by 5mg every 2 weeks until 10mg then by 1mg per month to 5mg then by 1mg every 2 months)
- continues for 2-3 years (even though sympt pos only for days)

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clinical features
- headache
- visual disturbances
- tinnitus
- blindness
- papilloedema
- CNVI palsies
precipitants: obesity, OCP, pregnancy, steroid therapy, tetracyclines, nitrofuraantoin
Ix
- CT/MRI - cerebral venous sinus thrombosis
- LP
Mx
- monitor visual fields
- remover precipitant- weight loss
- acetazolamide or other diuretic
- lumpo-peritoneal shunt
- optic nerve sheath fenestration

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?tumour
- focal symptoms, headache wakes pt, epilepsy
- physical signs e.g. hemiparesis
?SAH
?temporal arteritis
?cluster headache or other TAC

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