Headache

Question 1

Secondary headaches causes

Answer 1

Meningitis
Subarachnoid haemorrhage
Intracranial pressure
Giant cell arteritis
Venous sinus thrombosis
Pituitary apoplexy
Carotid dissection

Question 2

Primary headache causes

Answer 2

Tension headache
Migraine
Cluster headaches
Trigeminal neuralgia

Question 3

Headaches red flags

Answer 3

new
worst ever
thunderclap onset
systemically unwell
symptoms of raised ICP
symptoms of cancer (B symptoms)
meningism
focal signs

Question 4

Does your brain hurt?

Answer 4

no
brain has no sensory neurons
pain from secondary headaches comes from outside the brain

Question 5

When is a headache from raised ICP worse?

Answer 5

lying down
when doing valsalva manoeuvres (eg. straining)

Question 6

What sign on ophthalmoscopy rules out raised ICP?

Answer 6

flickering of veins
rules out raised ICP but not seeing them does not mean there is raised ICP

Question 7

When can a swollen optic disc be called papilloedema?

Answer 7

when you know disc swelling is caused by raised ICP

Question 8

Describe the head CT of a subarachnoid haemorrhage

Answer 8

subarachnoid hyperdensity (blood) (blood in sylvian fissures)
blood obstructed normal CSF flow, causes obstructive hydrocephalus
diffuse swelling

Question 9

What does thunderclap onset mean?

Answer 9

peak intensity straight away

Question 10

Subarachnoid haemorrhage symptoms

Answer 10

thunderclap onset worst ever headache
memingitic

Question 11

Subarachnoid haemorrhage investigations

Answer 11

CT - fantastic early, rubbish late
Lumbar puncture - fantastic within 2 weeks, useless afterwards (looking for xanthrochromia)

look for cause (aneurysms) = CT angiogram or digital subtraction angiography

Question 12

Subarachnoid haemorrhage treatment

Answer 12

bedrest
fluids (normal saline, 3L over 24h)
nimodipine (decreases risk of vasospasm in Berry aneurysms)
look for and secure aneurysms

Question 13

What can cause angiogram negative subarachnoid haemorrhage?

Answer 13

generally less dangerous
eg. RCVS (reversible cranial vasoconstriction syndrome), amyloid angiopathy

Question 14

What cause of headache is notifiable?

Answer 14

meningitis (esp neisseria meningitidis)

Question 15

How does meningitis headache differ from subarachnoid haemorrhage?

Answer 15

meningitis = same headache but slower start

Question 16

Meningitis treatment

Answer 16

antibiotics
elderly/immunocompromised = cover listeria
steroids for pneumococcus

Question 17

GCA symptoms

Answer 17

jaw claudication
amaurosis fugax
scalp tenderness
palpable pulseless temporal arteries

Question 18

What can virtually exclude GCA in a patient?

Answer 18

normal ESR/CRP/Platelets

Question 19

How is GCA confirmed?

Answer 19

temporal artery biopsy
can have skip lesions though

Question 20

GCA treatment

Answer 20

steroids

Question 21

What can cause neck pain and headache in a rollercoaster enthusiast?

Answer 21

carotid artery dissection

can present as Horner’s syndrome
traumatic injury to sympathetic chain
can cause acute, sudden onset headache

Question 22

Carotid artery dissection treatment

Answer 22

aspirin

due to high risk of stroke because of thrombi

Question 23

Thunderclap headache and history of galactorrhea condition

Answer 23

pituitary adenoma, presses on optic chiasm
causing pituitary apoplexy
presents also with bitemporal hemianopia
risk of Addisonian crisis

Question 24

How is pituitary apoplexy treated?

Answer 24

steroids
risk of Addisonian crisis due to pituitary failure

Question 25

Headache in woman on the pill with headache and haemorrhage cause?

Answer 25

venous sinus thrombosis

Question 26

Venous sinus thrombosis treatment

Answer 26

heparin

Question 27

Describe a tension headache

Answer 27

commonest headache
end of the day, not severe, like a band
no signs on examination

Question 28

Describe a migraine headache

Answer 28

very common
genetic predisposition
recurrent unilateral throbbing gradual onset (hours), nausea, vomiting, photo and motion sensitivity
painkillers do not work

Question 29

Migraine treatment options

Answer 29

Holistic
Acute/abortive
Preventative
Keep a diary
Sleep hygiene
Neck stretching
Supplements = Riboflavin 400mg OD, magnesium >600mg OD

Question 30

What abortive medicines can be used for migraines?

Answer 30

at start of attack, with or without anti-emetic

Triptan (PO, SC, Nasal)
2nd dose 1-2 hours later
NSAID (aspirin 600-900mg dispersible)
then ride it out

Question 31

What constitutes medication overuse in migraines?

Answer 31

10 days/month for opiates/triptans
15 days/month any other analgesic

most guidelines suggest withdrawal before starting preventatives
can feel worse before better

Question 32

Preventative medicines used for chronic migraines

Answer 32

Supplements (riboflavin 400mg OD, magnesium)
Tricyclics (amitriptyline)
SNRIs (duloxetine, venlafaxine, mirtazepine)
Beta blockers (propranolol, metoprolol)
Serotonergic modulators (pizotifen)
Neuromodulators (topiramate, valproate)
Calcium channel antagonists (verapamil)
ACE-I/ARB (lisinopril, candesartan)
GON-B/MCNBs
Botox

Question 33

Chronic cluster headache treatment

Answer 33

verapamil - main drug used
lithium
topiramate
gabapentin/pregabalin
sodium valproate
baclofen/tizanidine
levetiracetam
corticosteroids
GON-B
Gammacore

Question 34

Trigeminal neuralgia treatment

Answer 34

Carbamazepine/Oxcarbazepine
gabapentin/pregabalin
baclofen
tizanidine
lamotrigine
topiramate
duloxetine
lacosamide