Headache

Question 1

Red flag head ache features

Answer 1

New or unexpected headache
New headache in over 50
New headache in under 10
Thunderclap headache
Atypical aura (over an hour) with headache
Aura occurring for first time during use of COCP
Persistent morning headache with nausea
Progressive headache over weeks
Headache with postural change
New headache in pt with cancer history
New headache in pt with HIV history

Question 2

What is a migraine

Answer 2

Neurological disorder characterised by recurrent, unilateral, throbbing headaches preceded by aura

Question 3

Symptoms and clinical signs of migraine

Answer 3

Aura (visual or sensory) prior to migraine
Photophobia / phonophobia
Unilateral throbbing / pulsating headache - lasts hours (4-72hrs)
Nausea / vomitting
Worsened by activity

Question 4

Ix for migraines

Answer 4

Clinical diagnosis

Rule out secondary cause first (even with prev migraine history)
Neuro exam - for raised intracranial pressure
MRI
Blood tests - ESR/CRP for giant cell arteritis

Question 5

How to differentiate between migraine and tension headache

Answer 5

Migraine - unilateral, aggravated by activity, nausea / vomiting, aura

Tension headache - bilateral, not worsened by activity, no nausea or vomiting

Question 6

How to differentiate between migraine and cluster headaches

Answer 6

Migraine - unilateral, pain lasts hours to days

Cluster headache - unilateral, pain lasts 15-180 mins, up to 8 times a day, autonomic symptoms e.g. lacrimation, ptosis, miosis

Question 7

Migraine treatment outline

Answer 7

Acute management

Prophylactic management

Avoid triggers
Don’t take COCP
Headache diary
Refer if management fails in primary care

Question 8

Migraine acute management

Answer 8

Analgesia (aspirin, paracetamol, ibuprofen) with an antiemetic (metaclopramide - helps absorb painkiller) and a triptan (sumatriptan)

Take above all together at once at start of migraine

Question 9

Prophylactic migraine treatment and when is it given

Answer 9

If more than 8 episodes within a month or if acute treatment is contraindicated / ineffective, risk of frequent use of acute treatment

Depends on contraindications
Amitriptyline
Propranolol
Candesartan
Topiramate
Pizotifen
Sodium valproate

Question 10

Signs and symptoms of tension type headache

Answer 10

Bilateral non pulsatile headache with no neurological symptoms - no aura or photophobia

“Tight band like pressure” headache

Question 11

Tension headache investigations

Answer 11

Clinical diagnosis from history

Question 12

Tension headache management

Answer 12

Analgesia acutely

Amitriptyline is effective only if debilitating

Question 13

How does cluster headaches present

Answer 13

Episodic, severe unilateral headaches in periorbital area around eye
Side locked
Autonomic symptoms on one side same as headache side e.g. lacrimation, blood shot eye, nasal discharge, conjunctival infection, periorbital oedema, ptosis, miosis

Question 14

Cluster headache investigation

Answer 14

Angiogram if pt has cluster headache symptoms and Horner’s syndrome and pulsatile tinnitus - to rule out carotid dissection

Imaging to rule out secondary causes

Question 15

Cluster headache acute management

Answer 15

100% Oxygen
Sub cut sumatriptan

Question 16

Cluster headache preventive management

Answer 16

Veramapil
Steroids - prednisolone

Topiramate / sodium valproate - sometimes
Lithium - rare

Question 17

SUNCT / SUNA - presentation

Answer 17

Short lasting unilateral headache - rare

Autonomic symptoms with sharp shooting pains
Side locked
Lasts minutes to seconds

Question 18

Trigeminal neuralgia symptoms and treatment

Answer 18

May have autonomic features
Sharp shooting pain lasting seconds
Always triggered

Carbamazepine - 1st line
Neurosurgical vascular decompression - definitive

Question 19

Paroxysmal hemicrania presentation

Answer 19

Side locked headache
Resolves with indomethacin

Rare

Question 20

Hemicrania continua presentation

Answer 20

Side locked headache - resolves with indomethacin
Non remitting , continuous headache until treatment

Question 21

Causes of vascular headaches

Answer 21

Cerebral venous sinus thrombosis (VST)
Haemorrhage
Temporal arteritis / GCA

Question 22

Vascular headache caused by Cerebral venous sinus thrombosis presentation and investigation

Answer 22

Headache
Seizures
Reduced consciousness
Pro ptosis
Facial oedema

Computed tomography head or magnetic resonance venography

Question 23

Vascular headache caused by Haemorrhage presentation and investigation

Answer 23

Vomiting
Thunder clap headache
Reduced level of consciousness
Pre retinal haemorrhage
Meningism

Computed tomography head and lumbar puncture

Question 24

Vascular headache caused by Temporal arteritis presentation and investigations

Answer 24

Jaw claudication, temporal headache, vision loss, hard non pulsating temporal artery

USS and biopsy

Question 25

Cerebral venous sinus thrombosis treatment

Answer 25

Warfarin / heparin
Neurosurgical / ENT intervention

Question 26

Vascular headache caused by Haemorrhage treatment

Answer 26

Neurosurgical
Blood pressure management

Question 27

Temporal arteritis management

Answer 27

Steroids

Question 28

Presentation of headache secondary to intracranial neoplasm

Answer 28

Progressive
Worse in morning or when lying down
Nausea or vomiting
Certain movements aggravate it

Question 29

Headache due to intracranial neoplasm Ix and management

Answer 29

Genetic testing of tumour
MRI brain

Neurosurgical intervention
Steroid / immunosuppression
Chemo / radiotherapy