Headache

Question 1

Describe a headache with meningism

Answer 1

• acute
• severe
• felt over most of head
• neck stiffness

Question 2

What should you exclude if a patient presents with an acute, sever headache felt over most of the head?

Answer 2

1) Meningitis (fever, photophobia, neck stiffness, purpuric rash, coma)
2) Encephalitis (fever, odd behaviour, fits or decreased consciousness)
3) subbarrachnoid haemorrhage (sudden onset, worst ever headache, occipital, stiff neck, decreased consiousness, focal signs)

Question 3

What is your immediate management plan for a patient who presents with acute, sever headache felt over most of the head and neck stiffness?

Answer 3

• Urgent CT head

- if Ct +ve do Lumbar puncture to look for infection or blood products in CSF.

Question 4

What could be the cause of a localised headache that becomes more generalized. Lasts around 2 weeks and is resistant to analgesia

Answer 4

Head Injury

Question 5

Why do we do a CT head in a headache that lasts around 2 weeks and is not helped by analgesia?

Answer 5

The headache could be due to trauma.

Do CT to exclude subdural or extradural haemorrhage if drowsy

Question 6

cause of subacute / sudden headache with papilloedema

Answer 6

venous sinus thrombosis

Question 7

what is papilloedema

Answer 7

swelling of the optic disc

Question 8

what are the symptoms of sinusitis?

Answer 8

dull, constant ache over frontal or maxillary sinuses with tenderness +/- postnasal drip.
- pain worse with bending over

Question 9

where is ethmoid or sphenoid sinusitis pain felt ?

Answer 9

deep in the midline at the root of the nose

Question 10

what could cause a low pressure headache?

what are the symptoms of a low pressure headache?

Answer 10

CSF leak

• a headache that becomes severe when the patient is upright and quickly disappears when the patient is lying flat.
• Thus, the headaches are typically absent first thing in the morning, and start or worsen shortly after getting out of bed.
• The pain is often worse at the back of the head, and may be accompanied by some neck discomfort and nausea.

Question 11

An 80yr old presents with constant , aching pain that develops rapidly around one eye, radiating to forehead. She also has reduced vision, visual haloes, nausea and vomiting.

Answer 11

Acute glaucoma

( could also be cluster headache : pain around one eye , bloodshot + watery, miosis, ptosis, unilateral, affects same side, lasts for 4-12wks then pain free , recurrs)

Question 12

What are the signs and symptoms of acute glaucoma?

Answer 12

signs:

• red, congested eye
• cloudy cornea
• dilated, non responsive pupil
• decreased visual acuity

Symptoms:

• sudden onset pain around one eye , radiated to forehead
• reduced vision
• visual haloes
• nausea/ vomiting

Question 13

A 30 yr old man presents with rapid onset of excruciating pain around one eye that has become watery and bloodshot with lid swelling, lacrimation and facial flushing, as well as a constricted pupil. The pain is only on one side. It lasts 15-60mins and occurs once or twice a day. It is often at night. This has been going on for 4 weeks. He had a similar thing last year/.

Answer 13

Cluster headache

Question 14

What are the symptoms of a cluster headache?

Answer 14

• sudden, severe pain around one eye
• pain is unilateral
• lasts 15 - 60 mins
• occurs once or twice a day
• often nocturnal
• lasts for 4 - 12 weeks
• few months / years main free
• pain recurrs on same side
• Pain debilitating

Question 15

What is the treatment for cluster headaches?

Answer 15

• 100% Oxygen for 15min via non rebreathe mask

- sumatripan 6mg at onset

Question 16

A 55 yr old man presents with:

• intense, stabbing pain that lasts seconds on one side of the face after shaving
• his face screws up with pain

Answer 16

Tigemminal neuralgic

Question 17

What are the triggers of trigemminal neuralgic pain?

Answer 17

Usually affects mandibular or maxillary regions.
Triggers:
- washing face
- shaving
- eating
- talking

Question 18

Visual disturbances followed by unilateral throbbing headache within one hour?

Answer 18

migraine

Question 19

Premenstrual episodic severe unilateral headache, with nausea / vomiting, photophobia

Answer 19

• migraine

Question 20

What is a migrain prodrome?

Answer 20

precedes headache by hours/days :

• yawning,
• cravings
• mood change
• sleep change

Question 21

What is a migraine aura?

Answer 21

• precedes headache by minutes / may persist during headache
• visual disturbances (choatic, distorting, jumbled lines,dots)
• parasthesia (numbness spreading from fingers to face)
• dysarthria (unclear articulation of speech)
• ataxia ( loss of balance)
• opthalmoplegia (eye muscles paralysed)
• Speech - dysphasia (difficulty putting word together)

Question 22

A 56 yr old presents with a headache that has lasted a few weeks. The headache affects the front and side of his head

Answer 22

Exclude giant cell arteritis

ask about jaw pain and visula disturbances

Signs:

• thickened , tender, pulseless temporal arteries
• jaw claudication
• ESR >40mm/h
• prompt diagnosis and steroids to avoid blindness.

Question 23

Describe the symptoms of a Tension headache?

Answer 23

• bilateral
• non pulsatile headache
• scalp muscle tenderness
• no vomiting
• no sensitivity to head movement
• stress relief / massage helps

Question 24

What are the symptoms of a headache with raised intracranial pressure?

Answer 24

• worse on waking, lying, bending forward, coughing
• vomiting
• papilloedema
• seizures
• odd behaviour

Question 25

What tests do you do for a headache that is worse on waking, lying, bending forwards, coughing?

Answer 25

CT head to exclude space occupying lesion (most likely headache caused by raised ICP)

**Only do Lumbar puncture after CT.

Question 26

What is a common reason for episodic headache becoming chronic daily headache?

Answer 26

Medication overuse (painkiller rebound) headache