Headache

Question 1

What are the triggers for a migraine?

Answer 1

CHOCOLATE
C: Chocolate
H: Hangovers
O: Orgasm
C: Cheese
O: OCP
L: Lie ins
A: OH-
T: Tumult (loud noises)
E: Exercise

Question 2

What is the criteria for migraine without aura?

Answer 2

A) >5 attacks fulfilling B-D criteria
B) 1-48hours
C) >2: B/L or U/L, pulsating, mod-severe intensity, aggravation/avoiding normal routine
D) During headache: N&V or photo/phonophobia

Question 3

What is the criteria for migraine with aura?

Answer 3

A) Recurring headache lasting 1-48hours
B) >2 attacks fulfilling C
C) >3: Reversible aura, aura developing gradually over >4mins, no longer than 60mins, headache following aura in <60mins

Question 4

What are the prodromal Sx of a migraine?

Answer 4

Yawning
Cravings
Mood & Sleep disturbance

Question 5

How are migraines managed?

Answer 5

Weight loss (linked to oestrogen)

ACUTE: NSAID + PO Triptan + Paracetamol

CHRONIC if >2/month: BB (Propranolol) or Amitriptyline/Topiramate/ Valproate

Question 6

How are migraines treated prophylactically?

Answer 6

Topiramate or Propranolol if severe and >2/month

Question 7

What are the red flags of a headache?

Answer 7

Worsening with fever
Sudden onset reaching max intensity at 5mins
↓conciousness
↓vision
Jaw claudication
Vomiting
↓GCS

Question 8

What are the +ve & -ve phenomena that can be associated with migraine?

Answer 8

\+ve = addition of neuro Sx (tremor)
-ve = loss of normal neuro function (sensation)

Question 9

What are the types of tension headache?

Answer 9

Episodic: <15days/month
Chronic: >15days/month likely due to meds

Question 10

How does a tension headache present?

Answer 10

Tight band/ pressure sensation around head
Symmetrical (B/L)
Gradual onset
Regular + mild intensity
Exacerbated by STRESS
No aura or N&V

Question 11

How is a tension headache managed?

Answer 11

Reassurance
ACUTE: Aspirin, Paracetamol/NSAID
Consider TCA

Question 12

What are the triggers of cluster headache?

Answer 12

Male smoker
Alcohol
Sleep (lack of)

Question 13

How does a cluster headache present?

Answer 13

15mins-2hour duration
Often NOCTURNAL
Intense sharp stabbing pain around EYE
Red, watery eye
Lid swelling
U/L rhinorrhoea (on side of headache)
Restless patient

Question 14

How is a cluster headache managed?

Answer 14

100% O2 15L/min + IV/SC Triptan

Question 15

How is a cluster headache treated prophylactically?

Answer 15

Verapamil

Question 16

What are the causes of sinusitis?

Answer 16

Anatomical: Septal deviation, polyps
Mucosal: Viruses (Rhinovirus), bacterial (Strep Pneumoniae, Haemophilus)
Smoking

Question 17

What are the Sx of sinusitis?

Answer 17

Facial pain + tenderness
Frontal pressure worse bending forward
Rhinorrhoea: Thick & purulent
Mouth breathing (nasal obstruction)
Fever
Post nasal drip= chronic cough

Question 18

How is acute bacterial sinusitis diagnosed?

Answer 18

> 3 Sx:

• Discolouration & purulent discharge w/ U/L predominance
• Fever >38
• Severe local pain w/ U/L predominance
• ↑ESR/CRP
• Double sickening: Deterioration in health after initial mild illness

Question 19

How is sinusitis investigated?

Answer 19

Bloods: ↑ESR/CRP

CT paranasal sinus/ nasal endoscopy: Recurrent sinusitis

Question 20

How is acute sinusitis treated?

Answer 20

Analgesia + nasal saline irrigation
Ephedrine 0.5%
PO Abx: Amoxicillin

Question 21

How is chronic sinusitis treated?

Answer 21

Intranasal corticosteroids

Refer to ENT for functional endoscopic sinus surgery

Question 22

What is hydrocephalus?

Answer 22

↑ in vol of CSF occupying the cerebral ventricles

Question 23

How is hydrocephalus classified?

Answer 23

Non-communicating/obstructing: CSF obstructed in ventricles or between ventricles & SA space
Communicating: Communication between ventricles & SA space, problem outside of ventricular system
Normal pressure
Hydrocephalus ex vacuo: Ventricular expansion secondary to brain atrophy (Alzheimer’s, Pick’s disease) CSF normal

Question 24

What are the causes of hydrocephalus?

Answer 24

Idiopathic: 1/3 adults
Obstructive Congenital: Arnold-Chiari, toxoplasmosis,
Obstructive acquired: Intraventricular haematoma, tumours, aqueduct stenosis
Communicating: SAH, infection
Meningitis
Prematurity

Question 25

What are the Sx of hydrocephalus?

Answer 25

KIDS: Vomiting, irritable, rapid ↑ in head circumference, setting sun sign, ↑limb tone
ADULTS: Headache, vomiting, papilloedema, impaired upwards gaze, unsteady gait (leg spasticity), CN6 palsy, blurred vision

Question 26

How is hydrocephalus investigated?

Answer 26

-CT +/- contrast:
Dilated Lateral + 3rd V w/NORMAL 4th V = Aqueduct stenosis
Dilated Lateral + 3rd V w/ABNORMAL 4th V = Posterior fossa mass
Generalised dilatation = communicating hydrocephalus
-USS IN BABIES: Anterior fontanelle

Question 27

How is hydrocephalus managed?

Answer 27

Depends on severity
Serial LP in acute deterioration
Meds: Furosemide + Acetazolamide
Surgery: External ventricular drain/shunt

Question 28

What are the complications of hydrocephalus?

Answer 28

Fatal in first 4yrs of life if untreated
Epilepsy
Learning & developmental difficulties
Surgery: Infection, shunt obstruction, subdural haematoma

Question 29

What is fibromyalgia?

Answer 29

Syndrome characterised by widespread pain throughout body w/tenderness at specific anatomical sites

Question 30

What are the RFs of fibromyalgia?

Answer 30

Women
30-50yo
Low income
Divorced
Poor education

Question 31

What conditions are associated w/fibromyalgia?

Answer 31

IBS
RA
AS
SLE

Question 32

How does fibromyalgia present?

Answer 32

Chronic, widespread pain >3m
Multiple sites
Absence of inflammation
Multiple tender sites
Lethargy
Sleep disturbance
Headaches

Question 33

How is fibromyalgia diagnosed?

Answer 33

Widespread pain involving BOTH sides of body + ABOVE & BELOW waist + including axial skeleton
Smythe 11/18 tender points

Question 34

How is fibromyalgia managed?

Answer 34

Explain diagnosis
Aerobic exercises
CBT
Low dose: Pregabaline, Amitriptyline, Duloxetine