Headache

Question 1

What is important to ask in a headache history in terms of onset?

Answer 1

Onset:
Acute (seconds to minutes)	
SAH/Intra-cerebral haemorrhage/coital/thunderclap
Evolving (hours to days) 
Infection/inflammatory/↑ICP
Chronic (weeks to months)
Chronic daily headache/ ↑ICP

Question 2

What are sinister symptoms of headaches/along with headaches?

Answer 2

Cognitive effects
Seizures
Fever
Visual disturbance
Vomiting
Weight loss

Question 3

During examination of a patient with a headache, what would you look out for?

Answer 3

Fever/rash/neck stiffness/↑BP/organomegaly
Fundal changes (papilloedema)
Cranial nerve signs/Horners Syndrome
Focal abnormalities 
Long tract signs

Question 4

What are the characteristic features of sub-arachnoid haemorrhage?

Answer 4

Awoken with severe, sudden onset (seconds) head pains
Back of head, severity 10/10
Vomiting and confused
Clinically apyrexial, refusing fundoscopy and globally hyper-reflexic
Ocular movements appear impaired

Question 5

What drugs can cause drug induced migraine?

Answer 5

mn

Question 6

What is important to ask in a headache history in terms of periodicity?

Answer 6

Periodicity
Episodic (at least a few days free between attacks)
Migraine /Cluster headache
Chronic (headache most days)
Medication overuse/chronic migraine/hemicrania continua

Question 7

What is important to ask in a headache history in terms of Associated features?

Answer 7

Associated features:
Diurnal variation/postural element
Nausea and vomiting
Photophobia/ phonophobia
Autonomic features (lacrimation/Horners/red eye)

Question 8

What is important to ask in a headache history in terms of behaviour, family history, medication, concerns?

Answer 8

Behaviour
Lies down in dark room (Migraine)
Agitation/pacing (Cluster)

Family History
Migraine is often familial

Medication/ self medication
Analgesia (what? And how often?)

What is the patient concerned about?

Question 9

What are the signs and symptoms of Raised Intracranial pressure?

Answer 9

Headache (worse on lying or awakening)
Vomiting
Seizures
Papilloedema
lateralising signs

Question 10

What causes Raised Intracranial pressure?

Answer 10

Mass Effect (brain tumour, abscess)
Brain swelling (Hypertensive encephalopathy)
Increased venous pressure
CSF outflow obstruction (hydrocephalus)
Increased CSF production (meningitis/SAH)

Question 11

What is the treatment of brain abscesses?

Answer 11

Resuscitation
Broad spectrum IV antibiotics (cefotaxime)
Steroids (dexamethasone) in patients with streptococcus pneumoniae meningitis
Neurosurgical consultation (craniotomy and drainage)

Question 12

What are the signs and symptoms of temporal arteritis?

Answer 12

Signs/symptoms
Weight loss
Myalgia
Transient loss of vision
Jaw claudication
Tender non-pulsatile temporal artery

Question 13

What is the treatment of temporal arteritis?

Answer 13

Commence immediate high dose steroids
Prednisolone 60mg od for 1st week
Slow taper over 6 weeks to 15-20mg od
Arrange temporal artery biopsy

Question 14

What are associated features with a migraine headache?

Answer 14

Nausea
photophobia
dizziness
Focal migraine:
Cranial
neuropathies/cerebellar signs (basilar arteries involved)
Hemiplegic (frontal lobe)
Visual aura: black and white flashes/straight lines
occipital seizure: coloured dots

Question 15

How does migraines arise?

Answer 15

Neurovascular headache
Brain waves slow down
Cortical depression from occipital lobes = visual defects
then may spread to the parietal/frontal lobe = sensory loss/hemiparesis

Question 16

What are triggers for migraines?

Answer 16

sleep deprivation
hunger
stress
oestrogens

Question 17

What is the management for migraines?

Answer 17

Brain imaging:
Focal symptoms/signs lasting 24 hours or more
New onset daily migraine

Conservative measures:
Avoid caffeine/ increase water intake
Avoid tyramine foods (cheese/chocolate/red wine)
Sleep hygiene and regular meals

Analgesia:
Triptans/naproxen/paracetomol

Preventative treatment:
Propranolol/pizotifen/topiramate/valproate/amitriptiline/botox

Question 18

What are the characteristics of Trigeminal autonomic cephalgias?

Answer 18

gradual onset unilateral right orbital pain
short-lasting headaches
variable autonomic features - red eye, eyelid droop

Question 19

What is the management of Trigeminal autonomic cephalgias?

Answer 19

Pain relief
Sumatriptan (Class A)
High flow 100% oxygen

Prevention (start at beginning of cluster):
Prednisolone
Verapamil
Indomethacin

Question 20

What are the characteristics of tension headache?

Answer 20

Intermittent BILATERAL headache
Described as tight band around head lasting several hours
normally just headache and no other symptoms

Question 21

What is the management of tension headache?

Answer 21

Relaxation and massage
amitriptyline (if frequent)
Acupuncture
Ensure patient has recently had optician check - eye strain

Question 22

Low intercranial pressure can be caused by what procedure causing a headache?

Answer 22

Lumber punture

Question 23

Who commonly suffers with Idiopathic Intracranial Hypertension with what symptoms?

Answer 23

woman of child bearing age

Visual problems - papilledema

Question 24

What is the definition of a chronic daily headache?

Answer 24

headache lasting over 4 hours on over 15 days per month for over 3 months

Question 25

What are the treatment options for a chronic daily headache?

Answer 25

Withdraw analgesia if history of overuse

Consider amitriptyline/topiramate for transformed migraine