Headache

Question 1

Red flags for headache.

Answer 1

New onset headache >55

Early morning headache

Headache worsened by Valsalva

Immunosuppression

History of malignancy

Question 2

What is migraine?

Answer 2

Recurrent episodes of headache with photophobia associated with a trigger (e.g. sunlight, stress)

Question 3

Presentation of migraine.

Answer 3

Recurrent attacks of throbbing headache

• with photophobia
• worsened by movement
• N+V

Question 4

What is migraine with aura and what is the significance of this?

Answer 4

Migraine with visual aura around the onset of headache.

Increases risk of ischaemic stroke

Question 5

Girl on contraceptive pill presents with migraine. What is the most important thing to establish and why?

Answer 5

Is there aura around the onset of headache?

Contraceptive pill contraindicated in migraine with aura (due to ischaemic stoke risk)

Question 6

Management of migraine.

Answer 6

Avoid triggers

Oral triptan + NSAID

Prophylactic propranolol/topiramate if severe

Question 7

What is tension type headache? How does it present?

Answer 7

Tight band like headache caused by facial musculature stiffening. Strong association with depression.

Band like pain radiating to the neck without N+V/photophobia

Question 8

How can you distinguish tension type headache from migraine?

Answer 8

Tension type headache doesn’t have photophobia/N+V

Question 9

What are trigeminal autonomic cephalgias (TAC)?

Answer 9

Group of headaches attacking several times a day characterised by unilateral trigeminal pain and autonomic symptoms (ptosis, lacrimation, nasal congestion)

Question 10

List the trigeminal autonomic cephalgias from “short and frequent” to “long and infrequent”.

Answer 10

“Short and frequent”

SUNCT (3-200 times a day, last up to 2 mins)

Paroxysmal hemicrania (1-40 times a day, last up to 30mins)

Cluster headache (1-8 a day, last up to 3 hours)

“Long and infrequent”

Question 11

How do you treat cluster headache?

Answer 11

Acute: high flow oxygen and sumitriptan

Prophylactic: verapamil

Question 12

How do you treat paroxysmal menicranias?

Answer 12

Indomethacin

Question 13

How do you treat SUNCT syndrome?

Answer 13

Lamotrigine or gabapentin

Question 14

What are the features of SUNCT syndrome?

Answer 14

Short lived headache
Unilateral headache
Neuralgiform (stabbing)
Conjuntival injection
Conjunctival tearing

Question 15

What is trigeminal neuralgia? How does it present?

Answer 15

Unilateral trigeminal pain caused by CNV dysfunction

Shooting pain lasting up to 90 seconds exacerbated by cold, touch (shaving)

Question 16

Man presents with jaw pain worst when he shaves. What investigation do you order? What treatment?

Answer 16

Brain MRI (trigeminal neuralgia can be caused by neoplasm)

Carbamazepine

Question 17

What causes trigeminal neuralgia?

Answer 17

CNV dysfunction from

• demyelinating disease
• neoplasm
• vascular disturbance

Question 18

What investigations do you order in a patient with trigeminal autonomic cephalgia?

Answer 18

MRI

MR angiogram

Question 19

Obese woman presents with throbbing headache and N+V.
What would you expect to see on MRI?
Diagnosis?

Answer 19

Slit like ventricles

Idiopathic intracranial hypertension

Question 20

What is idiopathic intracranial hypertension?

How do you treat it?

Answer 20

Chronically raised CSF pressure without known cause. Causes headache, papilloedema and N+V.

Weight loss
Acetalozamide
Shunt

Question 21

Acute thunderclap headache.

Diagnosis?

Answer 21

Subarachnoid haemorrhage

Question 22

Headache after neck hyperextension injury.

Diagnosis?

Answer 22

Carotid dissection.

Question 23

Headache with jaw claudication.

Diagnosis?

Answer 23

Giant cell arteritis