Head & Face

Question 1

Which 6 serious conditions need to be considered in a presentation of head or face pain?

Answer 1

CAD
Stroke / haemorrhage
Myocardial ischaemia
Hypertensive crisis
Intra-cerebral tumour
Meningitis

Question 2

Which signs indicate meningitis?

Answer 2

Severe throbbing headache with nuchal rigidity and photophobia, underlying fever and malaise

• may have a rash
• may have nausea / vomiting / anorexia
• may have joint pain

Question 3

What are the signs of a CAD?

Answer 3

• acute onset unilateral head and neck pain
• dizziness
• asymmetrical CN findings
• speech / vision changes
• tinnitus
• ataxia / decreased co-ordination
• unilateral neuro deficit in limbs

Question 4

What are the 3 types of primary headaches?

Answer 4

Migraine
Tension type
Trigeminal Autonomic Cephalgias (cluster)

Question 5

What are the features of a migraine

Answer 5

• moderate to severe pulsating pain
• unilateral
• one or more of photophobia, phonophobia, nausea
• may have aura
• episodes last 4-72 hours

Question 6

What are the features of a cervicogenic headache

Answer 6

• unilateral ‘rams horn’ pain pattern
• pain can begin in neck and is aggravated by neck movements
• moderate to severe non-pulsating pain
• episodes last one hour to one week

Question 7

What are the features of a tension type headache

Answer 7

• bilateral
• mild to moderate pain (tight / pressing / tension quality)
• pain radiates from neck, upper back or eyes
• pain not agg. by movement
• lasts minutes to days

Question 8

What is the pathology of cervicogenic headaches?

Answer 8

Referred pain from the trigeminocervical nucleus (sensory afferents from C1-3 spinal nerves) refer pain to areas of head and neck innervated by trigeminal nerve

Question 9

What are the features of trigeminal autonomic cephalgias (cluster) headaches?

Answer 9

• severe unilateral pain
• episodes of 15-180 minutes in clusters (from every second day to 8 daily)
• one or more of: lacrimation, rhinorrhea, oedema of eyelid, forehead or face, miosis / ptosis, restlessness

Question 10

What is the pathology of trigeminal autonomic cephalgias (cluster) headaches?

Answer 10

• dysfunction of hypothalamus / biological clock

Question 11

What is the proposed pathophysiology of migraine?

Answer 11

• pathology not fully understood
• increased activity of trigeminocervical nucleus
• increased SNS activity
• increased blood floow to head and face

Question 12

What is the pharmacological treatment of migraines?

Answer 12

First line - triptans with one of NSAIDs and/or paracetemol; can use anti-emetic if nausea present

• aim of pharma is to constrict dilated arteries and reduce blood flow to head and face

Question 13

What is the pharmacological treatment of tension type headaches?

Answer 13

analgesics

Question 14

What are the diagnostic criteria for a tension type headache?

Answer 14

10 or more attacks

consisting of 2 or more of: bilateral, pressure, mild to moderate pain, not aggravated by movement

no nausea

0-1 of photophobia or phonophobia

Question 15

What is the pharmacological management of trigeminal autonomic cephalgias (cluster) headaches?

Answer 15

• during attack: 02
• preventive: triptans, corticosteroid

Other management:

• regular sleep cycles
• avoid triggers during cluster periods (anything that causes vasodilation ie: alcohol, heat, strenuous activity, stress)

Question 16

What can act as a trigger for trigeminal autonomic cephalgias (cluster) headaches?

Answer 16

Anything that increases vasodilation:

• alcohol
• heat
• strenuous activity
• stress
• nitroglycerines (in CVD medication)

Also: disruption to sleep cycle

Question 17

What are some common PROMs to use for headaches?

Answer 17

HIT-6 (Headache Impact Test)
HDI (Headache Disability Index)
MIDAS (Migraine Disability Assessment Test)

Question 18

What are 4 common triggers for headaches?

Answer 18

Stress
Depression
Exertion
Posture

Question 19

What are 8 common causes of iatrogenic headaches?

Answer 19

Alcohol
Caffeine
Nicotine
Analgesics (aspirin, codeine, paracetemol)
Antibiotics
Combined COCP
Vasodilators
Substance use or withdrawal

Question 20

What are 6 common causes of secondary headache?

Answer 20

URTI / sinusitis
TMJ / dental disorder
Eye disorder
Trigeminal neuralgia
Anaemia
Metabolic disorders (thyroid / diabetes)

Question 21

What are the 4 major types of unilateral headache?

Answer 21

CAD
migraine
cervicogenic
cluster

Question 22

What are the 4 major types of bilateral headache?

Answer 22

Meningitis
Sinusitis
Hypertensive crisis
Tension type

Question 23

Describe the presentation of a hypertensive crisis

Answer 23

• headache caused by a sudden severe increase in BP (180/120 or above)
• emergency: can cause a stroke
• bilateral severe pulsating pain
• SOB / dyspnoea
• blurred vision
• nausea / vomiting
• anxiety / confusion
• dizziness / vertigo
• seizures / loss of consciousness
• may have chest pain

Risk factors:

• CV disease or risk factors
• forgetting to take BP medication
• use of cocaine / amphetamines / stimulants
• kidney disease

Findings:
BP 180/120 or above

Question 24

Describe the presentation of sinusitis

Answer 24

• tightness / pressure / throbbing pain over the frontal, orbital and maxillary regions
• accompanied by rhinorrhea, nasal congestion
• may be accompanied by fever, fatigue, unwellness
• typically occurs after a viral URTI / cold

Findings:

• pain aggravated by bending forward or lying down
• tenderness on palpation of paranasal sinuses

Question 25

Which nerves supply sensory innervation to the face?

Answer 25

Trigeminal nerve branches V1, V2 & V3