1. Headache

Question 1

What are the sinister causes of a headache?

Answer 1

VIVID

• Vascular
• infection
• vision-threatening
• raised intracranial pressure
• dissection

Question 2

What are the vascular causes of a headache?

Answer 2

• Subarachnoid haemorrhage
• hematoma
• cerebral venous sinus thrombosis
• cerebellar infarct

Question 3

What are the infective causes of a headache?

Answer 3

• Meningitis
• encephalitis

Question 4

What are the vision-threatening causes of a headache?

Answer 4

• Temporal arteritis
• acute glaucoma
• cavernous sinus thrombosis
• pituitary apoplexy
• posterior leukoencephalopathy

Question 5

What are the causes of a raised intracranial pressure?

Answer 5

• Space occupying lesion
• cerebral oedema
• hydrocephalus
• malignant hypertension
• idiopathic intracranial hypertension

Question 6

What are the red flags to look out for in someone with a headache?

Answer 6

• Decreased level of consciousness
• sudden onset worst headache ever
• seizure
• no previous episodes
• headaches worse when lying down along with morning vomitting
• progressive persistent headache
• constitutional symptoms
• reduced visual acuity
• past medical history

Question 7

What might a decreased level of consciousness suggest in someone with a headache?

Answer 7

• subdural haematoma- fluctuating consciousness
• extradural haematoma- altered consciousness following a lucid interval
• subarachnoid haemorrhage (SAH)

Question 8

What does a persistent headache, worse when lying down with early morning nausea suggest?

Answer 8

Raised intracranial pressure

• intracranial pressures rise when we lie down

Question 9

What might a progressive persistent headache suggest?

Answer 9

Expanding space occupying lesion

eg. tumour, abscess, cyst or hematoma

Question 10

What are constitutional symptoms?

Answer 10

• weight loss
• night sweats
• fever

might suggest malignancy, chronic infection or inflammation

Question 11

what does sudden onset worst headache ever suggest?

Answer 11

• this is inline with SAH
• as blood in the CSF irritates the meninges
• very severe headache with instantaneous onset is inline with SAH

Question 12

what basic observations to look out for?

Answer 12

• altered consciousness (GCS score)
• blood pressure and pulse (malignant hypertension)
• Temperature (fever and headache suggests intracranial infection )

Question 13

what focal neurological signs to look out for?

Answer 13

• focal limb deficit
• third nerve palsy
• sixth nerve palsy
• twelfth nerve palsy
• horners syndrome

Question 14

What might a focal limb deficit suggest with a headache?

Answer 14

• Intracranial pathology is more likely
• (migrainous aura)

Question 15

What signs are seen in a third nerve palsy?

Answer 15

• Ptosis (drooping eyelid)
• mydriasis (dilated pupil)
• eye deviated down and out

Question 16

What signs are seen in a sixth nerve palsy?

Answer 16

• Convergent squint and/ or failure to abduct the eye laterally

Question 17

what signs are seen in twelfth nerve palsy?

Answer 17

• tongue deviation

Question 18

What are signs of horner’s syndrome?

Answer 18

• Partial ptosis (drooping eyelid)
• anydrosis (lack of sweating)
• miosis ( pinpoint pupil)

Question 19

features to look at in eye inspection?

Answer 19

• exophthalmos - cavernous sinus thrombosis
• cloudy cornea - acute glaucoma
• optic disc appearance on fundoscopy - raised ICP

Question 20

What does scalp tenderness suggest?

Answer 20

Classically seen in temporal arteritis

Question 21

what might stiff neck or photophobia suggest?

Question 22

management of temporal arteritis?

Answer 22

• elevated erythrocyte sedimentation rate
• C-reactive protein

management is to reduce the immune regulated inflammation to prevent more visual loss

• high dose corticosteroids

temporal artery biopsy could be done later on to confirm

Question 23

criteria to diagnose temporal arteritis?

Answer 23

• age of onset of symptoms is greater than 50
• new headache
• ESR>50
• clinically abnormal temporal artery (tender/non pulsatile)
• biopsy of temporal artery shows mononuclear infiltration

Question 24

What are the causes of non sinister headache?

Answer 24

• tension type headache
• migraine
• cluster headache
• sinusitis (secondary)
• medication overuse headache (secondary)
• TMJ dysfunction syndrome (secondary)
• trigeminal neuralgia (secondary)

Question 25

questions to categorise non-sinister headaches?

Answer 25

• different types of headaches or just one type?
• are there any triggers?
• how disabling are the headaches?
• does the patient get an aura before headaches?

Question 26

What are the characteristics of a migraine?

Answer 26

• Unilateral
• aura
• more common in women
• sensitive to light and nausea
• pulsatile pain
• last between 4-72 hours

Question 27

What are the characteristics of a tension-type headache?

Answer 27

• very common
• It is bifrontal like a band
• more common in women
• few hours and not disabling
• no other features

Question 28

What are the characteristics of trigeminal neuralgia?

Answer 28

• More common over 60s
• unilateral sharp facial pain
• lasts seconds
• triggered by eating, laughing, talking

Question 29

What are the features of sinusitis?

Answer 29

• Constitutional symptoms and facial pain
• worse with movements
• lasts several days with infection

Question 30

features of medication overuse headache?

Answer 30

• seen with migraine medication and analgesics
• resemble migraine/tension-type headaches
• treatment is withdrawal from analgesic use

Question 31

What are the features of a cluster headache?

Answer 31

• Unilateral pain over one ey
• more common in men
• causes patients to wake up at night
• occurs in clusters every few weeks
• headaches are very disabling

Question 32

characteristics of TMJ syndrome headache?

Answer 32

• most common in individuals 20-40 years old
• headache and dull ache in muscles of mastication
• click or grinding noise when they move their jaw