Good Hope, Heartlands, and Solihull Eye Clinics

Headache from the ophthalmologists view for professionals

David Kinshuck, from lectures


4 simple features in the patient's history can accurately diagnose migraine, and therefore neuro-imaging is not needed. Migraine causes a POUNDING headache:


  • pulsating, ache throbbing, pressure
  • duration 4-72 hours (96 hours)
  • Unilateral, occasionally bilateral
  • Nausea
  • Disabling
  • Accompanying symptoms, sit still, draw curtain, feels ill then gets better
  • Aura... One third, recurring, evolves, during attack; versus Tia...full onset at start
  • Migraine..visual change evolves 
  • Premonitory symptoms may last days
  • Chronic migraine ..pattern changes,
  • Neck pain...facial pain...autonomic symptoms 

CNS lesion a possibility

MRI needed

  • cluster type headache
  • abnormal CNS examination
  • ill-defined headache
  • headache with aura
  • headache aggravated by valsalva-like manoeuvre
  • headache with vomiting


  • Right, scotoma, spreads across vision, 20 minutes, more frequent, followed by headache lasting hours = episodic migraine with aura, confirm normal ocular examination 

Case 34

  • 10 y once a week now twice last all day nausea Episodic migraine


  • Premonitory
    Triptan nsai or paracetamol and antiemetic Sumitriptan oral or subcutaneous Ibuprofen 600-800 high dose anti antiemetic eg metachlorpropamide 10 mg
  • Prevention Beta locker topiramate then second line Amitriptyline
  • Botox etc
  • Use preventative dose Aura Vision sensory speech fully reversible unilateral, headache follows Spreads
  • Tia sudden aura positive
  • Moh medication overuse headache
    Severe pain sharp spike s red eye many times a day Autonomic Cluster paroxysmal hemicrania sunct Cluster 15-180m, rapid, restless.. migraine want rest...
  • Hemicrania.. indomethacin
  • Cluster tryptan subcutaneous oxygen steroids Gon block, preventative verapramil etc


  • 4-72 h, freq vary, uni, bilateral, throbbing, n,v, aggravated by activity, photphonophobia
  • Aura: Before peak pain...not always progressive over minutes, positive or negative phenomenon, aura visual most speech hemiplegia
  • Tension featureless,30. -120 m, any freq, pressure heavy, tightening pain
  • Chronic migraine, 15 d a month  , 8 d a month migraine features
  • Crystal clear normal days
    How many days severe
  • Headache diary
    Headache overuse..analgesics > 3m
    15 d a month, less with tryptans
    Increase headache 50%
  • Patient concern, long history, family history, ineffective treatment etc...NOT worrying
  • Red flags:  Fever, posture, personality change, 

Medication overuse headache

DTB 2010 Suspect this if the headache

  • occurs >15 days/month
  • after 3 months of anti-migraine drugs, analgesics, caffeine
  • they is often a primary headache such as migraine or tension headache
  • after use of these drugs for> 9 days/month
  • after 37 doses/month (ergots), 114 (analgesics)
  • days medication taken is more indicative than the actual number of doses
  • after months of use (ergots), more than a year (analgesics)
  • gets better after stopping the drugs after 1-4/weeks in 50% of patients
  • if the headache continues after stopping for 4 weeks then investigations are required
  • paracetamol more than 15 days a month
  • caused by paracetamol or ibuprofen


  • thunderclap headache
  • particularly age>40
  • neck pain or stiffness
  • raised blood pressure
  • loss of consciousness
  • vomiting
  • BMJ 2010   editorial    article

Other thunderclap headaches

  • Lots of causes or thunderclap headache, including no identifiable problem.
  • Ct within 3 hours, if possible,
  • if normal scan within 6 hours not subarachnoid
  • ?reversible vasoconstriction syndrome 
  • Thunderclap headache takes 1 minute to max, migraine.. 5 minutes 


  • City Hospital...headache nurse Julie Edwards
  • IIH...Miss Susie Mollan, QE


Chronic ha

  • > 3months
  • headache: 1/2000 neoplasms 

Cluster headaches

Tac trigeminal autonomic cephalgia

  • Restless, rocking, (migraine rest)
  • Mild ptosis, miosis
  • Sunct...tearing : 30m -4 h worst pain ever, responds to oxygen and sumitrapn

Trigeminal neuralgia 

  • Triggers, spontaneous remission, trigger, period without, 


Frequent headaches longer than 3 hours

  • >3 hours may be migraine, no autonomic features (these are cluster)
  • want to lie still ...migraine.


  • does not need to lie down, unlike migraine (dark room, lies down)

A case

  • Case 76y, tender temporal artery, high crp 17, treated
  • But pain was like an electric shock..hundreds  of times a day, and pain came with red eye and watering...autonomic headaches..
  • Cause in this case Superior cerebellar artery loop, lamotrigine treatment

Aute headache and ptosis

Acute headache and ptosis: carotid artery discection , 3rd, gca, etc


Treatment can be complicated

  • Expert help may be needed, from a headache nurse/specialist/neurologist
  • As an example of how complicated treatment may be: A 30y lady presented with many headaches, worse at times, and was told
    • The headache itself is a chronic migraine with medication overuse headache and it does have a vertiginous element to it.
    • To improve this initially we need to exclude the medication overuse headache.  Therefore reduce your painkillers to no more than 2 days a week and when you develop a bad headache. ( Most painkillers are only effective if used 2 days a week or less)
    • To treat a severe episode,
      • use Sumatriptan at 100 mg with
      • two Paracetamol
      • and the anti sickness tablet.  The goal is to consistently shut the headache down in 2-4 hours. If necessary your anti sickness tablet could be used particularly during the  first few months when you are cutting your painkillers down but to no more than 2 days a week.
    • In terms of prevention
      • I suggest we stop the Amitriptyline and Pizotifen.  The doses are too low and are not reducing the headache. (These can be used but were not ideal for this patient at this stage.)
      • Start Topiramate (NOT IF PREGNANT or trying to get pregnant), starting at 25 mg at tea time, increasing every 2 weeks aiming for 100 mg for next 4-6 months with a goal to reduce headaches overall by 50%.
    • I will then review your progress again in 4-5 

Rarely multiple problems

  • Case 75y cauc, Abrupt headache lasting seconds left sided ha
  • but later
  • Then got visual disturbances, unilateral tranient monocular visual loss, complete, lasts 5 minutes, full recovery, one cws...gca

Headache and loss of sight

  • Case 37y
  • 10s bilateral loss episodic, built up  over 1 week headache increasing over -a week.
  • Visit 2....blurred vision 2d
  • Acute neuromyelitis optica, Plasma exchange 

Headache and worse bending

  • Case 25y
  • Vision worse when bends, reduced vision, reduced colour, swollen discs, severe anaemia...., icp very very high

Headache and diplopia

  • Case 76y
  • 2 w headache, unwell, diplopia, vertical, 
  • Esr a little up,  Got worse sight, left 3rd, 
  • Swollen temporary arteries, gca

Types of headache

  • Migraine, tension,tac,secondary,
  • Primary .. Tension migraine tac
  • Secondary 
  • Chronic >15 d month
  • Ichd3 bible open in clinic