18. Headaches

Question 1

What’s a tension headache?

Answer 1

Normal, everyday headaches. Usually when neck and scalp contract.

This headache is generalised, dull, pressure-like. Worsened by eye strain and better with analgesics.

Question 2

How would we manage a tension headache?

Answer 2

Headache diaries - avoid triggers
Relaxation techniques - remedy stress
Analgesia - paracetamol or ibuprofen

Question 3

What are we cautious of when prescribing analgesics in headaches?

Answer 3

Medication-overuse headaches/rebound headaches.

Withdraw all analgesic medication to stop this.

Question 4

How would a cluster headache present?

Answer 4

Lacrimation
Rhinorrhoea
Partial horner's (ptosis, miosis)
Red, swollen eyes
Sweating

Unilateral behind the eye, acute and sudden onset often at night. Sharp, piercing, burning worst pain ever. N&V.
Same time each day for weeks, cyclical.

Question 5

How do we manage cluster headaches?

Answer 5

Subcutaneous sumatriptan
High-dose, high-flow oxygen

Verapamil prophylactically (CCB)

Question 6

What’s a migraine?

Answer 6

Chronic episodic, neurological disorder that causes headaches.

Question 7

How do migraines present?

Answer 7

Unilateral
Paroxysmal, comes on gradually and is pulsating/throbbing
Exacerbated by light and sound, activity or stress.

Associated with aura - flashing light/tingling. N&V, visual changes, numbness. ADL affected.

Question 8

How would we investigate a migraine?

Answer 8

Investigations for most headaches are to exclude more sinister causes e.g.
ESR - giant cell arteritis
LP - haemorrhage/meningitis
MRI - exclude anything more sinister

Question 9

Management of a migraine?

Answer 9

Conservative - diary, avoiding triggers, relaxation techniques
Acute - simple analgesia, triptans
Preventative - propanolol or topimarate. Amitryptiline

NO OPIATES - cause progression, comorbidity etc.

Question 10

What is trigeminal neuralgia?

Answer 10

A facial pain syndrome in the distribution of the trigeminal nerve. (often mixed up with temporal ateritis)

Question 11

How does trigeminal neuralgia present?

Answer 11

Unilateral along trigeminal division. Paroxysmal with stabbing, shooting or electric shock pain and numbness. Worse on brushing teeth, speaking, shaving, talking.

MS is risk factor

Question 12

How would we manage trigeminal neuralgia?

Answer 12

Acute anticonvulsants

Long-term - microvascular decompression or ablation surgery

Question 13

What can cause a raised intracranial pressure?

Answer 13

Space-occupying lesion (tumour, haemorrhage, abscess)
Hydrocephalus
Meningitis/encephalitis

Question 14

Risk factors for raised ICP?

Answer 14

Female sex
Obesity and weight gain
Endocrine conditions

Question 15

How does a raised ICP present?

Answer 15

Focal neurological symptoms
Papilloedema
Cheyne-strokes respiration
Cushing’s triad - increased SBP, irregular breathing, bradycardia

Bilateral headache that’s throbbing, vomiting, altered GCS, seizures, vision problems. Worsen in mornings, coughing/sneezing and lay down.

Question 16

How do we investigate a raised ICP?

Answer 16

Urgent CT head

No LP - can cause brainstem herniation

Question 17

How do we treat raised ICP?

Answer 17

Manage risk factors e.g. weight loss
Analgesia
Identify and treat cause

Question 18

How might meningitis present?

Answer 18

Meningism - neck stiffness, photophobia and headache
Fever
N&V
Seizures
Malaise
Altered mental state

Question 19

What are kernig’s and brudzinski’s signs?

Answer 19

Kernig’s Sign - with the hips flexed, there is pain/resistance on passive knee extension - this is due to severe stiffness in the hamstrings
Brudzinski’s Sign - flexion of the hips and knees when the neck is flexed - this is due to severe neck stiffness

A petechial or purpuric rash can be typical with meningitis too.

Question 20

How would we investigate meningitis?

Answer 20

Obs, vbg
2 sets of blood cultures, ideally before treatment but never delay
Lumbar puncture (most important)
CT head before LP if signs of raised ICP

Question 21

How would bacterial CSF appear?

Answer 21

Turbid, increased neutrophils with low glucose and high protein

Question 22

How would viral CSF appear?

Answer 22

Clear with increased lymphocytes

Question 23

How would TB CSF appear?

Answer 23

Fibrin web with increased lymphocytes, decreased glucose and high protein

Question 24

How would we manage meningitis?

Answer 24

At GP - benzylpenicillin IM and urgent hospital referral
At A&E - broad spectrum antibiotics (ceftriaxone IV, benzylpenicillin IM (or acyclovir if viral))

Targeted ABx
Consider IV dexamethasone

Question 25

How does

encephalitis differ to meningitis?

Answer 25

Meningitis is of meninges.
Encephalitis is of brain parenchyma.

Encephalitis often has viral prodrome with an altered mental state.
Treat with acyclovir immediately.