Good Hope, Heartlands, and Solihull Eye Clinics

Headache from the ophthalmologists view for professionals

David Kinshuck, from lectures


See    See.

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
  • duration 4-72 hours
  • Unilateral
  • Nausea
  • Disabling

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

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


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


Chronic ha

  • > 3months

Cluster headaches

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

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