Neurology >
Primary Headaches

“Headaches not caused by an underlying condition”

  • Tension Headache
    • The most common type of headache, diffuse, feels like a tight band
  • Cluster Headache
    • Recurrent severe headaches on one side of the head (around the eye)
    • Attacks come in “clusters”
  • Migraine
    • Pulsating headaches on one side of the head and can be accompanied by an aura
  • Trigeminal Neuralgia
    • Chromic pain condition that affects the trigeminal nerve which carries sensation from face to brain
Risk Factors
  • Tension Headache
    • Teenagers & Adults
    • Women
  • Cluster Headache
    • Male
    • Smoking
    • Alcohol
    • Family History
  • Migraine
    • Obesity
    • Family History
  • Trigeminal Neuralgia
    • Women
    • Age (>55)
Aetiology
  • Tension Headache
    • Triggers include Stress, squinting and posture
  • Cluster Headache
    • Unclear
  • Migraine
    • Triggers include hormonal, emotional, physical, dietary, environmental, medicinal.
    • Very individual
  • Trigeminal Neuralgia
    • Triggers include talking, smiling, chewing, washing, brushing, shaving and wind.
Pathophysiology
  • Tension Headache – Muscular origin
  • Cluster Headache – unclear
  • Migraine – unclear
  • Trigeminal Neuralgia
    • Compression of the trigeminal nerve
    • Can be secondary to another condition, such as a tumour, cyst, arteriovenous malformation, and MS
Clinical Presentation
  • Tension Headache
    • Bilateral tight band sensation
    • Recurrent
    • Occurs late in the day
  • Cluster Headache
    • Short painful attacks around 1 eye
    • 30-180 mins
    • Once/twice a day for 1-3 months
    • + lacrimation or flushing
  • Migraine
    • Unilateral
    • Pulsating
    • Trigeminal nerve distribution
    • For a few hours – days
    • May have aura before
    • Worse on movement
    • Photo/phonophobia
  • Trigeminal Neuralgia
    • Unilateral
    • Paroxysms of intense stabbing pain lasting seconds
    • Trigeminal nerve distribution (jaw/teeth/cheeks…)
    • Face screws up with pain
Investigations
  • Tension Headache – Diagnose based on history
  • Cluster Headache – Diagnose based on history
  • Migraine – Diagnose based on history
  • Trigeminal Neuralgia
    • Diagnose based on history
    • MRI to exclude secondary cause
Management
  • Tension Headache
    • Lifestyle changes
      • exercise, yoga, improve posture, break from screens, avoid identified triggers
    • Painkillers
      • Paracetamol or ibuprofen
  • Cluster Headache
    • Acute attack
      • Give 100% oxygen in non-rebreathable mask
      • Sumariptan
    • Prevention
      • Avoid triggers (alcohol)
      • Medication: CS/verapamil
  • Migraine
    • Avoid identified triggers
    • Prophylactic treatment
      • Propranolol/topiramate
      • Botulinum toxin type A injections (every 12w, last resort
    • During attack
      • Oral/nasal triptan with NSAID/paracetamol
      • Antiemetics
    • Non-pharmacological
      • Warm/cold packs to head
      • Rebreathing into a paper bag
      • Acupuncture
  • Trigeminal Neuralgia
    • Avoid identified triggers
    • Medicine
      • Carbamezapine
      • Other anticonvulsant e.g. phenytoin, gabapentin
    • Surgery (if drugs fail)
      • Percutaneous procedures (glycerol, radiofrequency injections, balloon compression) – x-ray directed, damages TN at Gasserian ganglion
      • Stereotactic radiosurgery
      • Microvascular decompression
Complications
  • Tension Headache
    • Painkiller headache
  • Cluster Headache
    • Prone to injuring themselves during an attack
    • Substance abuse
    • Depression
  • Migraine
    • Increased risk of ischaemic stroke (especially with aura).
      • Risk increased by using the combined contraceptive pill
  • Trigeminal Neuralgia
    • The emotional strain of repeated episodes – depression
  • Avoidance of necessary and social activities
Quick Revision Sheet

Access an overview table of the Primary and Secondary headaches here (pdf)

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