Headache

Question 1

Tension

Answer 1

Weeks, months, years
Tightness/pressure
Constant or worse towards evening
Rarely with nausea

Reassurance, explain muscles around head, reduce analgesia, relaxation techniques, low dose amitrip, won’t go away overnight

Question 2

Migraine

Answer 2

With nausea
With/without aura, spreads over minutes
Unilateral or bilateral
Usuallyhours-days
Photophobia, photophobia, gut symptoms
Pulsating, sharp
More common in women, esp mid-cycle at period and menopause (oestrogen)
Look for triggers
Maybe exacerbated by physical activity

Question 3

Trigeminal autonomic cephalagia (TAC)

Answer 3

Rare
Recurrent pain in trigeminal distribution with autonomic features (eye watering, nasal congestion, redness eye)
Commonest of these is cluster headaches - unilateral (striking circadian rhythm, same time of day, clustering in periods of usually a few weeks)
Paroxysmal hemicranias (more common in women), shorter, more freq attacks, response to indomethacin

Question 4

Med overuse headache

Answer 4

> 15days/month
Worsened during analgesia
10days/month for other acute e.g. triptans
Uncertain whether abrupt cessation or gradual stopping is better for tx

Question 5

Thunderclap

Answer 5

Instant or rapidly appearing (<60s)
Must consider SAH but can be exertion (coital cephalgia)
Requires urgent investigation,CT head, LP after 12 hours, look for bilirubin and oxyhemoglobin

Question 6

Raised ICP

Answer 6

Headache usually mild
Diurnal variation - worse in morning, often gone by lunch
Often mild nausea
Neuro features
Look for papilloedema
Tumours, abscess, CSF blockage
Urgent referral and scan

Question 7

Meningitis

Answer 7

Fever
Photophobia
Neck stiffness
Altered consciousness
Petechial rash
Most is viral but cannot distinguish clinically so tx with ceftriaxone/cefotaxime or ben pen

Question 8

Temporal arteritis

Answer 8

Never <50y/o
maybe features of polymyalgia
jaw claudication
Tender temporal arteries
Raised ESR
Can use USS or temporal artery biopsy (sample error)
Danger of blindness, use steroids early

Question 9

Cerebral venous sinus thrombosis

Answer 9

Often female on OCP
Headache, often severe
Often seizures
Maybe bilateral, haem
MRI/MRV

Question 10

Low ICP

Answer 10

After LP
Headache on standing, eased with lying
Can occur spontaneously
Blood patch for post-LP headache

Question 11

Early morning headaches

Answer 11

Obese
History snoring
Maybe COPD
Headache in morning
Diagnosis sleep apnoea with co2 retention