Assessment

• Episodic headaches (tension, migraine, cluster): frequency <15 /month. Migraine or tension headaches are described as chronic if they occur on ≥15 days/month, for >3 months. Headache assessment (CKS), Headaches in over 12s: diagnosis and management. (NICE, 2012)

​Cluster headache

• Cluster headache (CKS)

Medication overuse headache

• Medication overuse headache (CKS)​

Migraine

• Acute migraine: paracetamol, NSAIDS (ibuprofen), aspirin 900mg, triptans (sumatripatan 50-100mg, nausea/vomiting: metoclopramide 10mg/prochlorperazine 10mg

• Prevention: propanolol, topiramate, amitriptyline, riboflavin, non-pharma

• Menstrual migraine: usually affects women between 2D before and 3D after the start of menstruation and is due to the drop in oestrogen level. Options: frovatriptan (first-line), zolmitriptan, COCP, topiramate and propranolol are used as preventative measures taken around the time of menstruation. Aspirin is used in the acute treatment of migraines.

• 5HT1-receptor agonists (e.g. sumatriptan) contra-indicated with PMH of myocardial infarction

• Migraine (NHS Choices) / Migraine (CKS)

Subarachnoid haemorrhage (SAH)

• Usually Berry aneurysm in Circle of Willis

• Can happen during physical effort or straining e.g. coughing, going to toilet, lifting, having sex

• Severe (thunderclap), occipital, nause/vomiting, photophobia, other visual/neuro sx

• Herald/sentinal bleed: small leaks with characteristics of SAH that resolve

• CT (95-98% sensitivity) and LP to exclude (in the 2% that are CT negative), ECG changes (long QT, Q waves, dysrhythmias, ST elevation)

• Subarachnoid haemorrhage (Patient.info)

Tension headache

• Tension headache (CKS) / Chronic tension-type headache (patient.info)

Benign intracranial hypertension

• Typically presents with headache and insidious-onset visual field defect in young obese women.

Temporal / giant cell arteritis

• Inflammatory condition primarily affecting the aorta and its extracranial branches. Age >50Y. Significant overlap with PMR

• Frontal headache, unilateral transient loss of vision, tender over her temples, feeling 'out of sorts'.

• Sudden loss of vision can occur due to ischaemic optic neuropathy - caused by occlusion of the short posterior ciliary arteries. Less commonly, central retinal artery occlusion can occur.

• ESR & high dose prednisolone 60mg immediately. Steroids do not interfere with temporal artery biopsy (if done) for a few days. This single intervention may be sight saving. This also needs a same day ophthalmology opinion given the eye involvement

Resources:

• RCGP. Curriculum Topic Guides: eyes and vision. 2019.

• RCGP. Curriculum Topic Guides: musculoskeletal health. 2019.

• British Society for Rheumatology, British Health Professionals in Rheumatology. Guidelines for the Management of Giant Cell Arteritis. 2010