This document provides an overview of headaches, including their classifications, types, management, and case examples. It begins with aims to define headaches and review their classifications, types, and management. It then discusses the commonality of headaches and the importance of history. Primary headaches include tension, migraine, and cluster headaches, while secondary headaches can be due to conditions like meningitis or subarachnoid hemorrhage. Tips are provided for answering multiple choice questions, along with two case examples and their answers. The document then reviews specific headache types in more detail, including their characteristics, associated features, and management. It also includes a brief anatomy review and discussions of conditions like trigeminal neuralgia, shingles,

1. Headaches for the AMK
By Sanaa Butt

2. Aims
• Define headaches / their classifications
• Review different types and their management
• Review MCQ’s and approach how to answer
them
• Throw in some AMK gold!

3. Why?
Headaches are COMMON!
Almost everyone has suffered from a tension
headache at some point!
The key is in the history….

4. Definition
‘pain in the head which can arise from many
disorders or may be a disorder in and of
itself ’

5. Classifications
Primary
Secondary
• Tension
• Migraine
• Cluster
• Subarachnoid
haemorrhage
• Temporal Arteritis
(Giant Cell
Arteritis)
• Meningitis

6. Tips on the AMK approach
1.FIRST READ THE QUESTION!!!
2. Cover up the answers.
3. Read the vignette if need be. See if you know
the answer.
4. Uncover the options.
If you can eliminate 2 answers try and guess.
Work through all the answers you know and return
to the tricky questions. (applies to 2nd years)
Follow your gut instincts!

7. Case 1
A 38 year old male attends the A&E complaining of an episode
of right sided peri-orbital pain earlier that evening. He described
it as 10/10 on the pain scale and ‘boring’ in nature. He
mentioned it was weepy and the pain did not relent for 50
minutes. He described a similar episode occurring 6 weeks ago.
On examination his eye is red and the pupil is constricted.
What is the most likely diagnosis?
A. Tension headache
B. Conjunctivitis
C. Migraine
D. Cluster headache
E. Subarachnoid Haemorrhage
F. Don’t know

8. Case 1
A 38 year old male attends the A&E complaining of an episode
of right sided peri-orbital pain earlier that evening. He described
it as 10/10 on the pain scale and ‘boring’ in nature. He
mentioned it was weepy and the pain did not relent for 50
minutes. He described a similar episode occurring 6 weeks ago.
On examination his eye is red and the pupil is constricted.
What is the most likely diagnosis?
A. Tension headache
B. Conjunctivitis
C. Migraine
D. Cluster headache
E. Subarachnoid Haemorrhage
F. Don’t know

9. Case 1
A 38 year old male attends the A&E complaining of an episode
of right sided peri-orbital pain earlier that evening. He described
it as 10/10 on the pain scale and ‘boring’ in nature. He
mentioned it was weepy and the pain did not relent for 50
minutes. He described a similar episode occurring 6 weeks ago.
On examination his eye is red and the pupil is constricted.
What is the most likely diagnosis?
A. Tension headache
B. Conjunctivitis
C. Migraine
D. Cluster headache
E. Subarachnoid Haemorrhage
F. Don’t know

10. Primary Headaches: Character
Tension
Migraine
Cluster
Bilateral
Unilateral or Bilateral
Unilateral
Tight/ band like
Non tender
Pulsating & throbbing
Periorbital
‘like an ice-pick in my
eye’. So painful sufferers
may bang their head
against the wall/with an
object
Pain +
Pain ++
Pain +++

11. Primary Headaches: Associated
Features
AURA
Tension
Migraine
Cluster
Non tender forehead
Photo/phono-phobia
Aura - Classical migraine approx
Weepy/Red eye
Rhinorrhoea
Constricted pupil
Unilateral sweating
Ptosis
20% cases
Visual:
Scintillating scotoma
fortification spectra
Tactile: Numbness
Speech: Speech disturbance

12. Primary Headaches: Extras
Tension
Migraine
Cluster
Stress
Anxiety
Fatigue
Poor posture
Women>Men 2:1
Neuro/Vasodilation theory
Men >Women 5:1
Precipitants:
Pneumonic CHOCOLATE
CHeese/CHocolate
OCP
Caffeine
OL (alcohOL)
Anxiety
Travel
Exercise
Nocturnal
Often regular cycle:
up to 160 mins
1-2/day
4-12 week cycles before
remission

13. Primary Headaches: Management
Tension
Migraine
Cluster
Conservative:
Control sleep, exercise &
diet.
Acute
NSAIDs
Triptans –
sumitriptan/rizatriptan
Acute
O2 15 mins
Triptans
Medical:
Paracetamol
NSAIDs
S.E. Paracetamol/NSAID chronic
use may induce headaches!!
Prophylactic:
B-blockers
Amitriptyline
Prophylactic:
Medical
Verapamil
Surgical:
Occipital nerve block

16. Case 2
A 45 year old female is brought in to the A&E by paramedics
after collapsing in a supermarket. A primary survey is carried
out ABC are clear however her GCS is noted to be 8/15 and she
has marked neck stiffness. She vomited twice since her arrival.
You look at her past notes and see she has a known history of
Polycystic Kidney Disease and is on ACEi's for her high blood
pressure.
What is the most likely cause of her collapse?
A. Temporal Arteritis
B. Vasovagal syncope
C. Subarachnoid Haemorrhage
D. Migraine
E. Meningitis
F. Don’t know

17. Case 2
A 45 year old female is brought in to the A&E by paramedics
after collapsing in a supermarket. A primary survey is carried
out ABC are clear however her GCS is noted to be 8/15 and she
has marked neck stiffness. She vomited twice since her arrival.
You look at her past notes and see she has a known history of
Polycystic Kidney Disease and is on ACEi's for her high blood
pressure.
What is the most likely cause of her collapse?
A. Temporal Arteritis
B. Vasovagal syncope
C. Subarachnoid Haemorrhage
D. Migraine
E. Meningitis
F. Don’t know

18. Case 2
A 45 year old female is brought in to the A&E by paramedics
after collapsing in a supermarket. A primary survey is carried
out ABC are clear however her GCS is noted to be 8/15 and she
has marked neck stiffness. She vomited twice since her arrival.
You look at her past notes and see she has a known history of
Polycystic Kidney Disease and is on ACEi's for her high blood
pressure.
What is the most likely cause of her collapse?
A. Temporal Arteritis
B. Vasovagal syncope
C. Subarachnoid Haemorrhage
D. Migraine
E. Meningitis
F. Don’t know

19. Brief Anatomy

20. Brief Anatomy

21. Brief Anatomy

22. Brief Anatomy

23. Brief Anatomy

24. Brief Anatomy

25. Subarachnoid Haemorrhage
Aetiology:
Berry aneurysm
AV malformation

26. Subarachnoid Haemorrhage:
Associations

27. Subarachnoid Haemorrhage
‘Hit round the head with a
baseball bat’
‘Worst headache of my life’
THUNDERCLAP
HEADACHE
Collapse
Vomiting
Neck stiffness
Photophobia
Sentinel headache – prior leak

28. Subarachnoid Haemorrhage:
Management
ABC
CT
Lumbar Puncture > 12 hr
Xanthocromia - billirubin
REFER TO NEURO
CT cerebral angiogram

29. Subarachnoid Haemorrhage:
Management
Medical: Oral hydration/ IV if
unconscious
Nimodipine – reduce vasospasm
Systolic >160mmHg
Surgical:
Endovascular
coiling/Surgical
clips/Stenting
Why do people die?
1. Re-bleeding
2. Cerebral Ischemia
3. Hydrocephalus
4. Hyponatremia

30. Meningitis
Inflammation of the meninges
• Headache!!
• Neck stiffness
• Malaise
• Nausea & Vomiting
• Joint pain
• Altered consciousness
Cold hands and feet
• NON BLANCHING
PETICHIAL RASH

31. Meningitis: Children
http://www.kidsgrowth.com/images/fp_image
s/meningitis_symptoms_baby.jpg

32. Meningitis: Aetiology
Bacterial
Babies
Group B Strep, E coli, Listeria monocytogenes
Kids
Neisseria Meningitides(meningiococcus), Streptococcus
pneumonia(streptococcus), Haemophillus influenza B
Adults
Meningiococcus, Streptococcus, Listeria monocytogenes. TB.
Viral – Enterovirus, Herpes SV2, Varicella zoster CMV
Fungal – Cryptococcal meningitis in immunosuppressed/HIV/ elderly pts.
Parasitic - Schistoma
Non infectious - Ca

33. Meningitis: Management
ABC
O2 + IV
fluids
High Suspicion: 2 GRAMS IV cefotaxime

34. Meningitis: Management
FBC, U&E
Blood cultures,
swab throat &
rectum
Lumbar puncture

35. Meningitis: LP results
Bacterial
TB
Viral
Appearance
(clear)
Turbid
Fibrin webs
Clear
Bacteria
(none)
Present in
smear/culture
Often not found on
smear
-
Glucose
(80% blood)
<1/2 plasma
<1/2 plasma
>1/2 plasma
Protein
(0.2-0.4)
>1.5
1-5
<1
WCC/mm3
(<5)
>1000
Neutrophil
predominant
10-1000
lymphocyte
predominant.
50-1000
Lymphocyte
predominant.

36. Meningitis: LP results
Bacterial
TB
Viral
Appearance
(clear)
Turbid
Fibrin webs
Clear
Bacteria
(none)
Present in
smear/culture
Often not found on
smear
-
Glucose
(80% blood)
<1/2 plasma
<1/2 plasma
>1/2 plasma
Protein
(0.2-0.4)
>1.5
1-5
<1
WCC/mm3
(<5)
>1000
Neutrophil
predominant
10-1000
lymphocyte
predominant.
50-1000
Lymphocyte
predominant.

37. Case 3
A 66 year old enters your practice complaining of grumbling
aches and pains in her shoulders and hips for the past 6 weeks.
You look at her bloods from last week and see a CRP of 84
(normal = <10) and ESR 117 (normal approx 38). A diagnosis
of Polymyalgia Rheumatica is made. Before she leaves you
examine her temples and feel for any tenderness and ask if she
has noticed any change in vision.
What are you concerned about?
A. Hemiplegic Migraines
B. Giant Cell Arteritis
C. Multiple Sclerosis
D. Skull fracture
E. Shingles
F. Don’t know

38. Case 3
A 66 year old enters your practice complaining of grumbling
aches and pains in her shoulders and hips for the past 6 weeks.
You look at her bloods from last week and see a CRP of 84
(normal = <10) and ESR 117 (normal approx 38). A diagnosis
of Polymyalgia Rheumatica is made. Before she leaves you
examine her temples and feel for any tenderness and ask if she
has noticed any change in vision.
What are you concerned about?
A. Hemiplegic Migraines
B. Giant Cell Arteritis
C. Multiple Sclerosis
D. Skull fracture
E. Shingles
F. Don’t know

39. Case 3
A 66 year old enters your practice complaining of grumbling
aches and pains in her shoulders and hips for the past 6 weeks.
You look at her bloods from last week and see a CRP of 84
(normal = <10) and ESR 117 (normal approx 38). A diagnosis
of Polymyalgia Rheumatica is made. Before she leaves you
examine her temples and feel for any tenderness and ask if she
has noticed any change in vision.
What are you concerned about?
A. Hemiplegic Migraines
B. Giant Cell Arteritis
C. Multiple Sclerosis
D. Skull fracture
E. Shingles
F. Don’t know

40. Temporal Arteritis
AKA Giant Cell Arteritis
50% association with PMR
RED FLAGS:
Abnormal superficial temporal artery:
– tender, thickened or beaded
–reduced or absent pulsation.
Scalp tenderness
Transient or permanent visual loss
Jaw Claudication

41. Temporal Arteritis
ABC
Temporal A. Biopsy
Bloods – CRP, ESR, Plasma viscosity
High Suspicion: Start high dose steroids
Duplex ultrasonogrophy

42. Brief Anatomy
CN (I) Olfactory
CN(II) Optic
CN (III) Occulomotor
CN (IV) Trochlear
CN (V) Trigeminal
CN (VI) Abducens
CN (VII) Facial
CN (VIII) Vestibulocochlear
CN (IX) Glossopharyngeal
CN (X) Vagus
CN (XI) Accessory
CN (XII) Hypoglossal

43. Brief Anatomy
Trigeminal

44. Brief Anatomy
Facial Nerve
Chorda tympani – branches off earlier
1. Special Sensory - Taste
Ant 2/3 of tongue
2. General sensory of ear canal

45. Trigeminal Neuralgia

46. Trigeminal Neuralgia
•
•
•
•
Paroxysmal stabbing pain
Lasts seconds / minutes
Unilateral
Triggers:
washing the
area/Shaving/Eating/ talking
MRI: Be concerned about
secondary causes like
tumours, aneurysms or MS!
Management
Medical:
Carbamezapine
Surgical:
Rhizotomy

48. Shingles
Reactivated herpes zoster
(chicken pox)
Immunosuppressed/old
Dormant: Dorsal Root Ganglia
General: malaise/pyrexia/fever
Specific:
Burning pain
Itch (pruritus)
Vesicular rash --> Blister

50. Shingles : Ramzay Hunt Syndrome
Type 2
Reactivation of Herpes zoster of the
facial nerve
Facial nerve paralysis
Blisters on anterior 2/3 of the tongue
Loss of taste
Otalgia

51. NB: PT45
Coital cephalagia
AKA primary sexual headache
AKA benign exertional headache
Diagnosis by exclusion
BEWARE: Similar precipitant/presentation as a
subarachnoid.
MUST RULE OUT SUBARACHNOID FIRST!!

52. NICE. Headaches. Diagnosis and management of headaches in young people and adults. www.guidance.nice.org.uk/cg150
Sept 2012
Date accessed 14/11/2013.
Murray Longmore, Ian Wilkinson, Edward Davidson, Alexander Foulkes, and Ahmad Mafi. Oxford Handbook of Clinical
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Accessed 17/11/2013
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