Understanding Headache Disorders for PLAB 1
Headache disorders are common neurological conditions that can significantly impact quality of life. For the PLAB 1 exam, a thorough understanding of their classification, diagnosis, and management, particularly within the UK context, is crucial. This module will cover the most prevalent types of headaches, diagnostic approaches, and evidence-based treatment strategies.
Classification of Headache Disorders
Headache disorders are broadly categorized into primary and secondary headaches. Primary headaches are not caused by another underlying medical condition, while secondary headaches are symptoms of another disorder.
| Category | Examples | Key Characteristics |
|---|---|---|
| Primary Headaches | Migraine, Tension-type headache, Cluster headache | No identifiable underlying cause; the headache itself is the primary problem. |
| Secondary Headaches | Headache due to head injury, infection (e.g., meningitis), vascular disorders (e.g., subarachnoid haemorrhage), substance withdrawal | Symptom of an underlying condition that requires diagnosis and treatment of the cause. |
Migraine: A Common Primary Headache
Migraine is a complex neurological disorder characterized by recurrent headaches, often unilateral, pulsating, and moderate to severe in intensity. It is frequently associated with nausea, vomiting, and sensitivity to light and sound.
Tension-Type Headache (TTH)
Tension-type headache is the most common type of primary headache. It is typically bilateral, pressing or tightening in quality, mild to moderate in intensity, and not aggravated by routine physical activity. It is not usually associated with nausea or vomiting.
Tension-type headache is typically bilateral and pressing/tightening in quality, whereas migraine is often unilateral and pulsating. TTH is not aggravated by physical activity, unlike migraine.
Cluster Headache
Cluster headache is a severe, unilateral headache that occurs in cyclical patterns or 'clusters'. It is characterized by excruciating pain, typically around one eye, and is associated with autonomic symptoms on the same side of the face.
Cluster headaches are known for their extreme severity and distinct pattern. The pain is often described as boring or stabbing and is strictly unilateral, usually centered around the eye or temple. Attacks are short-lived (15-180 minutes) but occur frequently (1-8 times per day) during cluster periods, which can last weeks to months. Autonomic symptoms on the affected side are hallmark features and include conjunctival injection (redness of the eye), lacrimation (tearing), nasal congestion, rhinorrhoea (runny nose), forehead and facial sweating, miosis (pupil constriction), ptosis (drooping eyelid), and eyelid oedema (swelling). Patients often become restless or agitated during an attack. Acute treatment involves high-flow oxygen and subcutaneous sumatriptan. Prophylactic treatments include verapamil and lithium.
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Red Flags for Secondary Headaches
It is crucial to identify 'red flags' that suggest a secondary cause for the headache, requiring urgent investigation and management. These signs and symptoms warrant immediate medical attention.
Red Flags for Secondary Headaches:
- Sudden onset, severe headache ('thunderclap' headache)
- New onset headache in patients over 50 years old
- Headache associated with fever, stiff neck, or rash
- Neurological deficits (weakness, numbness, visual changes, confusion)
- Headache that worsens with coughing, straining, or lying down
- History of cancer or immunocompromise
- Papilloedema (swelling of the optic disc)
Diagnostic Approach to Headache
A thorough history is paramount in diagnosing headache disorders. Key elements include the character, location, severity, duration, frequency, associated symptoms, triggers, and relieving factors of the headache. A physical and neurological examination is also essential.
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Management Principles (UK Guidelines)
Management strategies for headache disorders in the UK follow NICE (National Institute for Health and Care Excellence) guidelines, emphasizing a stepwise approach.
Key Takeaways for PLAB 1
Focus on differentiating primary from secondary headaches, recognizing the red flags for urgent referral, and understanding the first-line management options for common headache types like migraine and tension-type headache, as per UK guidelines.
Learning Resources
The official NICE guideline providing comprehensive recommendations on the diagnosis and management of headaches in adults and children, crucial for UK practice.
An informative resource from The Migraine Trust explaining the complexities of migraine, including aura and different types of attacks.
The official classification system for headache disorders, providing diagnostic criteria for various headache types.
A patient-friendly overview of common headache causes and when to seek medical advice from the National Health Service.
A clinical learning module from BMJ covering the diagnosis and management of headaches, suitable for healthcare professionals.
A detailed explanation of cluster headaches, their symptoms, and management from a dedicated support organization.
Clinical guidance and resources for GPs on managing headache disorders, reflecting UK primary care practice.
A comprehensive medical overview of headache disorders, including differential diagnosis and treatment options, from a reputable medical resource.
A patient-focused resource explaining different types of headaches, their causes, and treatment options, useful for understanding patient perspectives.
A review article from a leading neurology journal discussing the latest approaches to migraine diagnosis and management.