Headaches

Headache - Medication Overuse Headache ✅

✅💊 Medication Overuse Headache (MOH) – chronic daily headache caused by frequent or excessive use of analgesics or migraine-specific drugs. ⚠️ Typically occurs in patients with pre-existing migraine or tension-type headache who escalate medication use → creating a cycle of dependency and worsening pain.

• 🔑 Primary Cause: Overuse of headache medications (analgesics, triptans, ergotamines, opioids).
• 👩‍⚕️ Commonly Affected: Patients with chronic migraine or tension-type headaches.

📋 Clinical Presentation

Key features of MOH:

• 📆 Headaches ≥15 days/month.
• 😣 Persistent, dull, daily headache (often present on waking).
• 💊 Temporary relief with analgesics → rapid recurrence → cycle of overuse.
• 🌀 Progression from episodic to chronic headache pattern.
• ⚡ Associated symptoms: mild nausea, photophobia, irritability, sleep disturbance.

🤔 Suspect MOH If:

• ✅ Headache ≥15 days/month in a patient with known migraine/chronic headache disorder.
• ✅ Regular overuse of acute headache drugs for >3 months:
  • 💉 Ergotamines
  • 💊 Triptans
  • 🩹 Simple analgesics (paracetamol, ibuprofen, NSAIDs)
  • 💊 Opioids or combination analgesics

🔎 Investigations

🖥️ Imaging (MRI/CT) is usually normal. Its main role is to exclude secondary causes of chronic headache. No specific biomarker exists for MOH → diagnosis is clinical.

• Imaging: Normal (rule out tumour, raised ICP).
• Blood tests: Only to exclude secondary causes if clinical suspicion (e.g., thyroid, renal, liver function).

🧾 Differential Diagnosis

• 🌩️ Migraine progression: Episodic → chronic without medication link.
• 🧠 Brain tumour: If neurological deficits, seizures, abnormal imaging.
• 👁️ Benign Intracranial Hypertension (BIH): Daily headache + papilloedema/visual symptoms.
• 💊 Other drug-induced headaches: e.g., nitrates, caffeine withdrawal.

🛠️ Management

Breaking the cycle of overuse and treating the underlying headache disorder is key.

🎓 Patient Education & Follow-Up

• Explain MOH cycle: overuse → rebound → chronic headache.
• Stress long-term medication reduction, sleep hygiene, hydration, exercise, and stress management.
• Regular follow-up essential to prevent relapse; consider behavioural therapy or specialist headache clinic referral.

💡 Exam Pearl: Think MOH when: “Daily headaches + analgesic overuse + normal imaging”. ✅ NICE-aligned guidance: NICE CG150 – Headaches in adults

Headache - Cluster

🔥 Cluster Headaches are among the most painful primary headache disorders. They often earn the nickname "suicide headaches" due to their intensity. ⏰ They typically follow circadian rhythms, often waking patients at night, and occur in clusters lasting weeks to months.

🧾 About

• Definition: Severe, unilateral, episodic headaches occurring in "clusters" over several weeks, separated by headache-free periods.
• Pattern: Attacks occur daily (sometimes multiple times per day), then remit for months before recurring.

🧬 Aetiology

• Pathophysiology: Thought to involve hypothalamic dysfunction with abnormal circadian regulation and trigeminal autonomic reflex activation.
• May be triggered by alcohol, nitroglycerin, or strong odours during an active cluster phase 🍷.

🩺 Clinical Presentation

• Headache Characteristics: Excruciating unilateral pain, typically orbital, supraorbital, or temporal. Duration: 15–180 minutes.
• Population: 3–4 times more common in men, usually starting between ages 20–50.
• Autonomic Features (ipsilateral):
  • Conjunctival injection, lacrimation 😢
  • Nasal congestion or rhinorrhoea 🤧
  • Eyelid oedema, ptosis, miosis 😵
  • Facial sweating, flushing
• Behavioural clue: Patients are restless or agitated (unlike migraine where patients lie still).

📋 Diagnostic Criteria (ICHD-3)

• At least 5 attacks fulfilling the following:
• Severe unilateral orbital/supraorbital/temporal pain lasting 15–180 min.
• At least 1 ipsilateral autonomic feature (lacrimation, rhinorrhoea, eyelid oedema, facial sweating, miosis, ptosis).
• Frequency: 1 every other day up to 8 per day.

🔍 Investigations

• Clinical diagnosis: No specific test required.
• MRI/CT: Performed if atypical features or secondary pathology (e.g. pituitary lesion, carotid dissection) suspected.

⚖️ Differential Diagnosis

• Migraine: Longer, throbbing, often with photophobia/phonophobia.
• Orbital pathology: e.g. glaucoma, orbital cellulitis, cavernous sinus thrombosis.
• Carotid dissection: Headache + Horner’s syndrome ⚠️.
• Subarachnoid haemorrhage: Sudden thunderclap onset.
• Trigeminal neuralgia: Short electric-shock pains, triggered by touch.

🚑 Acute Management

• High-flow Oxygen: 100% O₂ via non-rebreather at 12–15 L/min for 15–20 min (first-line; rapid relief in many).
• Triptans (non-oral only):
  • Sumatriptan SC injection (6 mg) – gold standard 💉.
  • Sumatriptan intranasal (10–20 mg) or Zolmitriptan nasal spray (5 mg).
• Avoid oral triptans: Onset too slow for cluster attacks.

🛡️ Prevention

• Verapamil: First-line. Start at 80 mg TDS, titrate every 2 weeks up to 960 mg/day. Requires ECG monitoring for PR prolongation ❤️.
• Lithium: Alternative if verapamil contraindicated. Monitor renal + thyroid function.
• Steroids: Prednisolone 60 mg tapered over 2–3 weeks as a bridging option.
• Melatonin: 9–12 mg nocte may reduce nocturnal attacks 🌙.
• Greater Occipital Nerve Block: Local anaesthetic ± steroid injection, effective bridge until oral prophylaxis works.
• Neuromodulation: gammaCore® (vagus nerve stimulator) approved by NICE in refractory cases.

📌 Exam Pearls

✅ Middle-aged man, recurrent unilateral orbital pain with tearing + agitation = think cluster headache.
✅ Responds dramatically to O₂ and subcutaneous sumatriptan.
✅ Restlessness differentiates from migraine (migraineurs prefer lying still).

📚 References

• NICE CKS – Cluster headache
• Hull NHS Headache Guidelines

Cases - Cluster Headache

• Case 1 - Nocturnal Attacks: A 36-year-old man describes severe unilateral periorbital pain waking him at night, lasting 45 minutes. Attacks occur daily for 2 weeks, then remit. Exam during attack: conjunctival injection, lacrimation, ptosis on the painful side. Diagnosis: Cluster headache (episodic). Management: Acute: high-flow O₂, subcutaneous sumatriptan. Preventive: verapamil.
• Case 2 - Alcohol Trigger: A 42-year-old man develops excruciating stabbing pain behind his left eye 20 minutes after drinking beer. He is agitated, paces around, and has ipsilateral rhinorrhoea. Attacks have recurred at the same time each evening for the past month. Diagnosis: Cluster headache precipitated by alcohol. Management: Avoid alcohol during cluster period; acute therapy with 100% O₂; preventive verapamil with ECG monitoring.
• Case 3 - Chronic Cluster Headache: A 50-year-old man reports continuous cycles of daily unilateral orbital headaches for the past year, with no remission >3 months. Attacks last 60–90 minutes, associated with lacrimation and nasal congestion. Diagnosis: Chronic cluster headache. Management: Acute: subcutaneous or intranasal triptan; O₂. Preventive: high-dose verapamil (with ECG), lithium if refractory. Neurology referral.

Teaching Commentary 💥

Cluster headache is a trigeminal autonomic cephalalgia, characterised by: - Excruciating, strictly unilateral orbital/temporal pain, - Short duration (15–180 min), - Occurs in “clusters” (weeks–months), often nocturnal, - Associated with ipsilateral autonomic features (lacrimation, rhinorrhoea, ptosis, conjunctival injection). Typical patient = middle-aged man, smoker, restless during attacks. Acute treatment: high-flow oxygen, subcutaneous or intranasal triptans. Preventive: verapamil (first-line), lithium, topiramate. Alcohol is a classic trigger during active clusters.

Thunderclap Headache ✅

⚡ Thunderclap headache (TCH) is a sudden, severe headache that reaches maximal intensity within seconds to minutes. ❗ Always consider subarachnoid haemorrhage (SAH) until proven otherwise. Rapid recognition and early management save lives.

📖 Definition

• Severe headache reaching maximum intensity within 1 minute.
• Often described as "worst headache of life" by patients.
• May be associated with nausea, vomiting, photophobia, neck stiffness, or collapse.

🧠 Pathophysiology

• Sudden arterial rupture (aneurysm) → bleeding into subarachnoid space → meningeal irritation, raised ICP.
• Other causes: sudden vascular events (dissection, RCVS), venous congestion (sinus thrombosis), pituitary apoplexy, hypertensive crises.

⚡ Red Flags

• Onset to maximal intensity <1 minute.
• Neurological deficit (focal signs, seizures, altered consciousness).
• Signs of raised ICP (vomiting, papilloedema).
• History of trauma, anticoagulation, illicit drug use (cocaine, amphetamines).
• Previous SAH or known aneurysm.

🚑 Initial Assessment & Immediate Actions

• ABCDE: Ensure airway, breathing, circulation; oxygen if hypoxic; monitor vitals and GCS.
• Insert IV access and monitor fluid balance.
• Assess for neurological deficits, meningism, seizure activity.
• Check medications (anticoagulants, antiplatelets) and coagulation status.
• Urgent senior/neurology/neurosurgery review.

🔍 Investigations

• Non-contrast CT head: First-line; ~95% sensitive within 6 hours for SAH.
• CT angiography (CTA): Localises aneurysm; plan for endovascular repair.
• Lumbar puncture: If CT negative and suspicion remains; look for xanthochromia ≥6 hours post-onset.
• MRI/MRA: Consider for RCVS, venous sinus thrombosis, pituitary apoplexy.
• Blood tests: FBC, U&E, coagulation, troponin if ACS suspected.
• Other: ECG, vital signs, blood pressure monitoring.

📊 Differential Diagnosis

⚡ Thunderclap Headache – Causes, Investigation, and Management

🧠 Thunderclap headache is a severe headache that reaches maximum intensity within 1 minute. It is a medical emergency until serious causes are ruled out, particularly subarachnoid haemorrhage (SAH). Early recognition, prompt imaging, and specialist referral are crucial.

📊 Thunderclap Headache – Causes, Features & Investigations

💡 Student Tip: Always consider SAH first in thunderclap headache. Use clinical red flags, imaging, and timing of headache to triage. Know that sexual headache is usually benign but always rule out vascular causes first.

📊 Thunderclap Headache – Urgency Table

💡 Tip for Students: Always treat thunderclap headache as SAH until proven otherwise. Use red/urgent/benign coding in exams or clinical decision-making to prioritise investigations and referral.

🔎 Key Points for Students

• Always assume SAH until proven otherwise with thunderclap headache.
• CT head is first-line; sensitivity highest within first 6 hours.
• If CT negative but suspicion remains, perform LP ≥6h after onset to look for xanthochromia.
• Sex-related primary headache is diagnosis of exclusion; rule out vascular emergencies first.
• RCVS can mimic SAH but typically recurrent; triggers include postpartum, vasoactive drugs.
• CVT and pituitary apoplexy may present similarly but have distinguishing neurological or systemic features.
• Prompt neurosurgical or neurointerventional input is essential for aneurysmal SAH.
• Monitor for complications: re-bleeding, vasospasm, hydrocephalus, seizures, hyponatraemia.

🧪 Suggested Investigations

• Non-contrast CT head immediately for suspected SAH/ICH
• CTA/MRA for aneurysm localization or arterial dissection
• MRV/CTV if CVT suspected
• LP if CT negative but high suspicion of SAH
• Hormonal panel + MRI pituitary if apoplexy suspected
• Bloods: FBC, U&E, coagulation, liver function, inflammatory markers as indicated

📚 References (UK Guidance)

• NICE: Headaches in over 12s – diagnosis and management (NG128)
• RCP: Acute Subarachnoid Haemorrhage Guidance
• RCS Neurosurgery: SAH Guidelines
• Cerebral Venous Thrombosis: Diagnosis and Management

💊 Acute Management (UK Guidance)

• Airway, breathing, circulation; transfer to high-dependency/neuro-ICU if unstable.
• Blood pressure control: SBP 140–160 mmHg before aneurysm secured (IV labetalol or nicardipine).
• Analgesia: Paracetamol ± opioids; avoid NSAIDs pre-repair.
• Anticoagulants/antiplatelets: Reverse if on therapy.
• Nimodipine 60 mg PO/NG every 4 hours for 21 days (vasospasm prevention, per NICE and national guidance).
• Definitive aneurysm repair: Early coiling or clipping (<72 hours), ideally in a tertiary neuroscience centre.
• Monitor for complications: Rebleeding, hydrocephalus, vasospasm, hyponatraemia, seizures.

🩺 Supportive & Ongoing Management

• Maintain euvolaemia; monitor electrolytes closely.
• Neurocritical care: daily assessment, imaging for vasospasm (TCD, CTA).
• Hydrocephalus: External ventricular drain (EVD) acutely, VP shunt for chronic cases.
• Seizures: Treat if occur; routine prophylaxis not recommended.
• Early physiotherapy, occupational therapy, and multidisciplinary team input.

📌 Teaching Points for Students

• All thunderclap headaches are SAH until proven otherwise.
• CT sensitivity declines after 6 hours; consider LP if negative.
• Early neurosurgical involvement critical for outcome.
• Nimodipine prevents vasospasm, not rebleeding.
• High index of suspicion for secondary causes: RCVS, dissection, venous thrombosis.
• Documentation of onset, severity, associated neurological symptoms is vital for triage.

📚 References & Guidance

• NICE NG42: Headaches in over 12s – diagnosis and management
• RCP: Subarachnoid haemorrhage guideline
• BMA: SAH Clinical Guideline
• Makindo: Saccular aneurysms
• van Gijn J, Rinkel GJ. Subarachnoid haemorrhage. Brain. 2001;124:249–278.
• Connolly ES et al. Guidelines for the management of aneurysmal subarachnoid haemorrhage: Stroke. 2012;43:1711–1737.

🖼 Suggested Images for Students

• CT head: SAH – blood in basal cisterns, fissures, ventricles
• CTA brain: saccular aneurysm at anterior communicating artery
• Diagram: Circle of Willis aneurysm locations and percentages
• Flowchart: Acute management pathway – airway, BP, nimodipine, aneurysm repair
• CT/MRI: Complications – hydrocephalus, infarction from vasospasm