Headache

Question 1

6 weeks, unilateral headache
Pulsating in nature
Lasting a day at a time, then no headache for a few days
Associated with nausea
Wants to lie down in a darkened room
Triggered by alcohol
Diagnosis?

Answer 1

Migraine

Question 2

Characteristics of migraine - adults

Answer 2

Headache attack 4-72 hours
With/without preceding aura (focal neurological symptoms)
Unilateral
Pulsating
Mod-severe pain
Aggravation by or causing avoidance of routine physical activity
During - N+V, photophobia, phonophobia

Question 3

Treating migraine

Answer 3

Diary, avoiding trigger, Triptan/NSAIDs

Question 4

Chronic vs episodic migraine

Answer 4

Chronic migraine: headache on more than 15 days of each month, 8 of which have features of migraine.
Episodic migraine: less frequency than described in the above definition.

Question 5

Red flags to watch out for in headaches (with aura)

Answer 5

Motor weakness
Double vision
Visual symptoms affecting only one eye
Poor balance
Decreased level of consciousness

All can indicate TIA/Stroke

Question 6

Aura without migraine - concerned about?

Answer 6

TIA/Stroke

Question 7

Severe, sudden onset headache

Answer 7

SAH, venous sinus thrombosis, vertebral artery dissection

Question 8

Progressive or persistent, acute change during headache

Answer 8

Consider space occupying lesions, subdural haematoma

Question 9

Tension-type headache characteristics

Answer 9

30 mins to 7 days, bilateral
Pressing or tightening - non-pulsating
Mild-moderate pain intensity
Not aggravated by physical activity

Question 10

Managing tension headaches

Answer 10

Lifestyle modifications, pain relief

Question 11

Headache triggered by Valsalva manoeuvre

Answer 11

Consider posterior fossa lesion or chiari 1 malformation

Question 12

Headache worse on standing?

Answer 12

Consider CSF leak

Question 13

Headache worse on lying?

Answer 13

Consider causes of raised ICP - space occupying lesions, venous sinus thrombosis

Question 14

Fever, photophobia and neck stiffness … think

Answer 14

Meningitis, encephalitis

Question 15

Headache with papilloedema ?

Answer 15

Consider BIH, venous sinus thrombosis, space occupying lesions

Question 16

Medication overuse headache

Answer 16

Overusing medication can cause chronic headache

Headache occurring on 15 or more days/month in a patient with a pre-existing primary headache and developing as a consequence of regular overuse of acute or symptomatic headache medication (on 10 or more or 15 or more days/month, depending on the medication) for more than 3 months. It usually, but not invariably, resolves after the overuse is stopped’.

Question 17

Menstrual related migraine - what treatment can be given off-label?

Answer 17

Frovatriptan
Zolmitriptan

These can be taken daily on days migraine is anticipated or from two days before until three days after bleeding starts. All patients should be followed up to review efficacy of treatment.

Question 18

As discussed elsewhere migraine with aura is a contraindication to the use of the combined oral contraceptive pill due to the increased risk of …

Answer 18

As discussed elsewhere migraine with aura is a contraindication to the use of the combined oral contraceptive pill due to the increased risk of ischaemic stroke. The combined pill should be used with caution in those with migraine without aura, particularly if there are additional risk factors present for vascular events.

Question 19

Status migrainosus: a debilitating migraine that persists for longer than…

Answer 19

Status migrainosus: a debilitating migraine that persists for longer than 72 hours.

Question 20

Cluster headaches

Answer 20

Very severe unilateral orbital, supraorbital and/or temporal pain lasting 15-180 mins
Very short and very severe

Question 21

Cluster headaches

Answer 21

Recurrent unilateral headaches centred on the eye or temporal region
They occur in short attacks (15-180 minutes) and are associated with ipsilateral autonomic signs (e.g. conjunctival injection, nasal congestion). It may be episodic (80-90%) with periods of remission or chronic (no periods of remission > 3 months). The severity of the pain should not be underestimated. It is often described as one of the most painful conditions and it can be enormously disruptive to normal life.

Question 22

SNOOP
Red flags for headache

Answer 22

Question 23

Cluster headaches - acute episodes are treated with …, and further attacks may be prevented with …

Answer 23

Cluster headaches - acute episodes are treated with triptans/ oxygen therapy and further attacks may be prevented with verapamil

Question 24

Short burst oxygen therapy in management of acute cluster headaches

Answer 24

Short burst oxygen therapy: in the absence of contraindications 100% oxygen (12-15L/min) can be administered via a non-rebreather face mask for 15-20 minutes. It is possible to set up oxygen at home.