Headache

Question 1

Describe four categories for differentials for acute headaches. (4)
Give at least one example for each. (10)

Answer 1

Vascular - SAH, sinus venous thrombosis, intracranial bleed.
Infective / inflammatory - meningitis, encephalitis, abscess.
Ophthalmic - acute glaucoma
Situational - cough, exertion, sex.

Question 2

Describe eight causes of chronic headaches. (7)

Answer 2

Migraine
Cluster headaches
Tension headaches
Trigeminal neuralgia
Raised ICP (tumour)
Giant cell arteritis 
Drugs (analgesics, caffeine, vasodilator, side effects) 
Hypertension (pre-eclampsia, pheochromocytoma)

Question 3

Describe the differences between primary and secondary headaches. (4)

Answer 3

Primary are caused by the headache condition itself (eg migraines).
Secondary are caused by something else (eg medication overuse/SAH/sinusitis)

Question 4

List the six categories of headache for immediate hospital referral. (12)

Answer 4

Vascular (SAH, haemorrhage, thrombosis)
Infective (meningitis, encephalitis)
Ophthalmic (acute glaucoma) 
Increased ICP (tumour)
Giant cell arteritis 
Hypertension (pheochromocytoma, pre-eclampsia).

Question 5

Describe the red flags of headaches. Give a key cause of each of the red flags. (11)

Answer 5

SNOOP
Systemic signs - meningitis, HTN. 
Neurological signs - SOL, glaucoma
Onset recently and patient over 50 - tumour 
Onset with thunderclap - SAH 
Papilloedema - raised ICP

Question 6

Describe the history of headaches caused by space occupying lesions. (4)

Answer 6

Gradual onset and progressive. 
Associated neurology (often vision changes) 
Features of raised ICP - early morning, N+V, worse on bending/coughing.

Question 7

Describe the history of migraines. (13)

Answer 7

S - unilateral, often frontal 
Q - sudden/gradual onset, pulsating 
I - moderate
T - between 4-72 hours, can be menstrual
A - photo/phonophobia 
R - sleep, OTC medication 
S - Aura, N+V.

Question 8

Describe migraines
Triggers (4)
Epidemiology (5)
Cause (1)

Answer 8

Foods, lack of sleep, stress, hormones.
2% of the population, more females, usually onset by 30, severity decreases with age, often has fHx.
Cause unknown.

Question 9

Describe the history of tension headaches. (11)

Answer 9

S - bilateral, temporal
Q - squeezing, non-pulsatile
I - mild
T - worse at end of day 
A - stress, poor posture, lack of sleep 
R - OTC painkillers 
S - mild nausea

Question 10

Describe tension headaches

Epidemiology (3)

Answer 10

Females > males, young > old. No fHx.

Question 11

Describe medication overuse headaches. (2)

Define medication overuse. (5)

Answer 11

A headache present on at least 15 days of the month that is not relieved by medication.
Overuse is (for longer than 3 months)
Triptans or opioids (inc codeine) for more than 10 days a month
Paracetamol, high dose aspirin, or NSAIDs for more than 15 days a month.

Question 12

Describe medication overuse headaches.
Epidemiology (2)
Treatment (2)
Co-existing conditions. (2)

Answer 12

20% of all headaches, females > males.
Resolves in 2 months without pain killers, but will get worse before it gets better.
Often co-exists with depression or sleep problems.

Question 13

Describe the history of cluster headaches. (14)

Answer 13

S - around or behind one eye
Q - sharp, penetrating
I - very severe and constant
T - rapid onset, attacks last 15mins - 3 hours, 1-2 per day, commonly nocturnal.
A - head injury, alcohol, smoking.
R - high flow oxygen
S - red and watery eye, nasal congestion.

Question 14

Describe cluster headaches.
Pattern of episodic nature (2)
Definition of chronic (2)
Triggers. (7)

Answer 14

Clusters last 2-12 weeks, remission lasts 3mo-3 years
Described as chronic if you have no gap in 12mo or remission of less than 1mo.
Triggers: alcohol, histamine, GTN, heat, exercise, solvents (occupational), lack of sleep.

Question 15

Describe the history of Trigeminal neuralgia. (14)

Answer 15

S - unilateral, over eye. 
Q - stabbing, “electric shock”
I - severe 
T - sudden, lasts less than 2 minutes 
A - light touch, wind, eating, vibration
R - nothing. 
S - preceding tingling or numbness. Can radiate to eyes, lips, nose or scalp.

Question 16

Describe Trigeminal neuralgia.
Causes (5)
Epidemiology (4)

Answer 16

95% caused by compression of CNV by an artery or vein.
5% caused by tumours, MS, skull abnormalities - needs a referral
Occurs at around 55, females > males, increases with age, common with pHx of chronic pain.

Question 17

Describe giant cell arteritis.
Causes (1)
Symptoms (4)
Diagnosis (2)
Treatments (2)

Answer 17

Vasculitis of the temporal artery.
Frequent and severe headaches, jaw problems and vision problems (supplies superior orbital artery).
Diagnosed with USS and biopsy.
Treatment is immediate high dose corticosteriods eg prednisolone. Ensure these are withdrawn slowly to avoid Addisonian crisis.