Cases: Stroke, Headache, Funny turns
 HW for next lesson on Headaches
o International headache society  international classification of headache
disorders  PDF (diagnostic criteria for headache disorders)  migraine,
tension, cluster, etc
 Bizarre love triangle between
o Stroke
o Migraine (white matter hyperdensities)
o Patent foramen ovale (PFO)
Headache
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History
o Time
 Single or repeated
 New or persistent?
 Onset
 When did they first get the headache?
 Frequency
 Once a day, week, month or year?
 Episodic vs Chronic
o Episodic < 15 per month
o Chronic > 15 per month
 Duration
 Few minutes, hours or days?
o Character
 Throbbing, stabbing, burning, shock-like, dull
o Location
 Front, back, ipsilateral?
o Trigger
o Accompanying sx
 n/v
 photophobia
 neurological sx
o Migraine with aura vs stroke
 Migraine  sx resolves then new sx resolves then …
 Stroke  all sx occur simultaneously
o Family hx
o Medications
Physical Exam
o BP
o Neuro exam
o Fundoscopy (check papilledema)
o CVS, RESP, ABDO check
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Red Flags
o SNOOP
 Systemic sx (fever, signs of meningitis, myalgia, malaise)
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Neurological deficits/dysfunction (AMS, seizures)
Onset of headache is sudden or abrupt
Older age at onset > 50yo
Papilledema and other signs of increased ICP
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Progressive headache
 A new or progressive headache in >50yo pt  high risk
headache for tumour or haemorrhage
1. Thunderclap headache (SAH)  new and worst headache ever
2. Space-occupying lesion  progressively worsening, change in pattern
Primary Headaches
o Tension Headache – most common
 30 minutes to 7 days
 Occasionally to daily (usually end of day)
 Holocephalic (entire head)
 Dull and constant
 Photophobia or phonophobia, no nausea/vomiting/aura
 Mx:
 acute  NSAIDs
 chronic  amitriptyline (prophylactic)
o Migraine Headache
 Cause: OCP, food, stress, menstruation, drugs e.g. SSRI, nitrates,
 4-72 hours
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Unilateral
Pulsating (throbbing, pounding)
Photophobia (light), phonophobia (sounds), osmophobia (smells),
aura, n/v
Disabling with moderate to severe pain. Feel washed out for the next
few days.
Mx:
 Acute
o Antiemetic (ondansetron > metoclopramide)
o NSAID (ibuprofen) or acetaminophen (aspirin) or
paracetamol
 Needs to be taken early
o Severe headache  triptan
 Prophylaxis
o Beta blockers  Atenolol (avoid in asthmatics and
athletes, because it causes bronchoconstriction)
o ARB  Candesartan
o Antidepressants  TCA (anticholinergic AE’s)
o Anticonvulsants  (Tepriomate > Valproate)
o CGRP inhibitors (calcitonin gene-related peptide) 
blocks pain pathway in head
o Ca blockers  Verapamil [works better for cluster
headaches]
o Botox  repeat every 3-4 months
o mAB
ED  Status Migranosus
 Migraine > 72 hours
 Intense pain
 Mx
o IV fluids to correct dehydration
o Chlorpromazine (antipsychotic)  has antiemetic +
sedative properties
o Triptan
o Avoid narcotics
o Steroids (dexamethasone)
o Cluster Headache
 Cause: alcohol
 15-180 minutes  short recurring attacks
 Usually occur in cyclical pattern
 Exclusively unilateral + localised to periorbital +/- temporal region
 Severe agonising pain!! + restlessness
 Autonomic sx: conjunctival injection +/- lacrimation, rhinorrhoea,
nasal congestion
 Partial Horner Syndrome: ptosis + miosis – anhidrosis
 Mx:
 Oxygen therapy 100%
 Triptans
o TAC  cluster or paroxysmal or SUNCT
 Cluster  clustered throughout the year 1 or 2 a day that may last an
hr, mainly men
 Paroxysmal  mainly women, more frequent up to 20 attacks a day
that may last 20 minutes, tx with indomethacin (nephrotoxic NSAID)
 SUNCT  hundreds in a day and last a few seconds (Short lived,
unilateral neuralgia, conjunctival injection, tearing)
 Brain scan!
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o Mixed Headache
 Hours to days
 Holocephalic, bifrontal or unilateral
 Migraine and tension-like
Investigations
o Head CT without contrast
o May consider LP with CSF analysis for suspected meningitis or SAH
Primary Headache
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Migraine – second most common
o Migraine without aura
 At least 5 attacks + all of the following
 Headaches 4-72 hours (when untreated or unsuccessfully
treated)
 Headache has at least 2 of the 4 characteristics
o Unilateral
o Pulsating
o Moderate to severe pain
o Aggravated by physical activity
 During headache at least 1 of the following
o Nausea and/or vomiting
o Photophobia and phonophobia (sound)
o Migraine with aura
 At least 2 attacks + all of the following
 1 or more of the following fully reversible aura sx.
o Visual
o Sensory
o Speech and/or language
o Motor
o Brainstem
o Retinal
 At least 3 of the following 6 characteristics
o At least one aura > 5 minutes
o 2 or more aura sx occur in succession
o Each individual aura sx lasts 5-60 minutes
o At least one aura is unilateral
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o At least one aura is positive
o Aura is accompanied or followed within 1 hour, by
headache
Migraine with typical aura
 The above +
o Aura with both of the following
 Fully reversible visual, sensory and/or
speech/language sx
 No motor, brainstem or retinal sx
Typical aura with headache
Typical aura without headache
Migraine with brainstem aura
 Aura with both of the following
o At least 2 of the following reversible brainstem sx
 Dysarthria
 Vertigo
 Tinnitus
 Diplopia
 Ataxia
 GCS < 13 (decreased level of consciousness)
o No motor or retinal sx
Hemiplegic migraine
 Fully reversible motor weakness +
o Fully reversible visual, sensory and/or speech/language
sx
Familial hemiplegic migraine
 At least one first or second degree relative has had attacks
fulfilling criteria
Chronic migraine
 Headache > 15 days per month for > 3 months
 At least 5 attacks
Tension-type Headache (TTH) – most common
o Infrequent episodic TTH
 At least 10 episodes of headache on < 1 day/month on average (<12
days per year)
 Lasts from 30mins to 7days
 At least 2 of the following
 Bilateral location
 Pressing or tightening
 Mild to moderate intensity
 Not aggravated by routine physical activity such as walking or
climbing stairs
 Both of the following
 No nausea/vomiting
 No more than one of photophobia or phonophobia
o Frequent episodic TTH
 At least 10 episodes of headache on 1-14days/month
o Chronic TTH
 >14 days/month
 Lasting hours to days
 No more than one of photophobia, phonophobia or mild nausea
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Cluster Headache (Trigeminal)
o At least 5 attacks
o Severe or very severe unilateral orbital, supraorbital and/or temporal pain
lasting 15-180 minutes (when untreated)
o Either or both of the following
 At least one of the following, ipsilateral to headache
 Conjunctival injection and/or lacrimation
 Nasal congestion and/or rhinorrhoea
 Eyelid oedema
 Forehead and facial sweating
 Miosis and/or ptosis
 Restlessness or agitation
o Occurring every other day up to 8 episodes per day
Secondary Headache
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Headache attributed to
o Trauma or injury to head and/or neck. Persistent headache due to:
 traumatic injury to the head
 whiplash
o Cranial and/or cervical vascular disorder (non-traumatic intracranial
haemorrhage). Acute headache due to:
 Subarachnoid haemorrhage
 Giant Cell arteritis
o Cervical carotid or vertebral artery disorder. Acute headache
 Cervical artery dissection
 or facial or neck pain
Secondary Headache
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Meningitis
Intracerebral Haemorrhage
Subarachnoid Haemorrhage
Subdural hematoma
Epidural hematoma
Giant Cell Arteritis
Ischemic Stroke
Intracranial space-occupying lesion (brain tumour)
Acute angle-closure
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Trigeminal neuralgia
Anatomically
o Skin (cancer)
o Bone (periosteum – Paget disease)
o Meninges
o Brain (tumours, abscess, hydrocephalus)
 Morning headache (postural)
 Lying down increased ICP
o Blood vessels (stroke, vasculitis e.g., temporal arteritis)
o Eye (glaucoma, uveitis, iritis, strain)
o Ear (otitis media)
o Nose (sinusitis)
o Throat
o Teeth (TMJ)
o Neck (cervicogenic, tumours)
o Homeostasis
 Low BSL
 Low Oxygen, high CO2  sleep apnoeic pts
 Dehydration
 Altitude
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