Headache

Migraine

Pathology:                    The pathogenesis of migraine remains unknown,though it has been suggested that it is a sequence of phases including prodromal,aura, headache and post-drome.

Classical migraine: Migraine with visual aura

Common migraine: Migraine without visual aura

Hemiplegic migraine: Sporadic or familial migraine, associated with mutations in calcium/sodium channels

Aetiology:                    The mechanism of migraine is still yet to be determined, although genetics may play a role as it is more common in individuals with a family history.

Triggers: food such as chocolate, cheese, exercise, menses, hunger, lack of sleep, stress, combined oral contraceptive pill.

Symptoms:

• Prodromal Phase: Non specific symptoms such as difficulty concentrating, irritability, hunger, excessive yawning, tiredness
• Aura phase: Visual symptoms such as scintillations, zigzag lines, scotomas; somatosensory symptoms such as paraesthesia and dysphasia
• Headache Phase: Unilateral throbbing or pulsating and nausea.

Signs:                              

• Prodromal Phase: Nil
• AuraPhase: Weakness, paraesthesia and hemiparesis
• HeadachePhase: Photophobia, phonophobia

Investigations:          No investigations are required to make a clinical diagnosis, although brain imaging may be indicated if the migraine is atypical or if there are any red flags.

Treatment:                  Acute treatment includes Aspirin, Paracetamol, NSAIDs, Anti-emetics, Triptans.

Prophylactic treatment may include Beta blockers, Pizotifen, Antiepileptic drugs such as Topiramate and Sodium Valproate, Amitriptyline and Methysergide.

 Idiopathic Intracranial Hypertension

Pathology:                    Idiopathic intracranial hypertension is characterised by an increase in intracranial pressure with no evidence of an underlying structural brain pathology, though it is theorised to be due to inadequate absorption of cerebrospinal fluid in the arachnoid villi.

Aetiology:                    Idiopathic intracranial hypertension is commonly encountered in obese women of child bearing age.

Symptoms:                  Headache which is worse with coughing, sneezing, bending down, visual obscurations which may worsen when bending down, pulsatile tinnitus.

Signs                              Papilloedema and 6^th nerve palsy may also be present [false localising sign]

Investigations:          Investigations should include:

• Bloods: FBC, ESR, haematinics, coagulation and ANA
• Imaging: CT/MRI to exclude structural brain lesions
• Special Tests: Lumbar puncture which will show an elevated CSF opening pressure, and Humphrey’s visual fields should be performed to assess for defects.

Treatment

Conservative: Weightloss is the primary treatment method for this condition.

Medical: Lumbar puncture to reduce cerebrospinal fluid pressure, or the administration of Acetazolamide, may be recommended.

Surgical: Optic nerve fenestration or lumbo-peritoneal shunt procedure may also be recommended.

Complications

Visual loss is the chief complication of this condition.

Prognosis

10% of those affected by this condition may suffer from a progressive visual loss or optic atrophy.