Headache

Question 1

Sinister causes of a headache

Answer 1

V - vascular 
I - infectious
V - vision-threatening
I - intracranial pressure
D - dissection

Question 2

Vascular diagnoses?

Answer 2

SAH
Sub/extradural haematoma
cerebral venous sinus thrombosis
cerebellar infarct

Question 3

Infectious diagnoses?

Answer 3

Meningitis

Encephalitis

Question 4

Vision-threatening diagnoses?

Answer 4

temporal arteritis
acute glaucoma
cavernous sinus thrombosis
pituitary apoplexy
posterior leucoencephalopathy

Question 5

Intracranial pressure diagnoses?

Answer 5

SOL
idiopathic intracranial HTN
hydrocephalus
malignant HTN
cerebral oedema

Question 6

Dissection diagnoses?

Answer 6

carotid dissection

Question 7

Red flag symptoms

Answer 7

decreased consciousness 
sudden onset
worst headache ever
seizure (or focal neurological deficit)
lack of previous episodes
reduced visual acuity
persistent
worse when lying down/in the morning
FLAWSV symptoms
history of malignancy

Question 8

Why would you check temperature?

Answer 8

check for fever to indicate intracranial infection

Question 9

Why would you check BP

Answer 9

malignant HTN

Question 10

Focal neurological signs

Answer 10

limb deficit
third nerve palsy
sixth nerve palsy
twelfth nerve palsy
Horners sydrome

Question 11

What is the horners syndrome triad?

Answer 11

partial ptosis
anhydrosis
miosis

Question 12

what does exophthalmos suggest?

Answer 12

cavernous sinus thrombosis

Question 13

what does a cloudy cornea or fixed dilated or oval pupil?

Answer 13

acute glaucoma

Question 14

what does optic disc appearance on a fundoscopy suggest?

Answer 14

raised ICP

Question 15

what does scalp tenderness suggest?

Answer 15

temporal arteritis

Question 16

symptoms of temporal arteritis

Answer 16

jaw claudication
headache
scalp tenderness
visual disturbances

Question 17

pathophysiology of temporal arteritis

Answer 17

formation of immune inflammatory granulomas in the tunica media of medium/large arteries

Question 18

management of temporal arteritis

Answer 18

blood test for raised ESR and CRP
high dose corticosteroids
temporal artery biopsy

Question 19

diagnosis criteria of temporal arteritis

Answer 19

3 of the following:
onset of symptoms above 50 years old
new headache
ESR elevated >55mm/hr
clinically abnormal temporal artery - tender or non-pulsatile
biopsy reveals mononuclear cell infiltration or granuloma

Question 20

differentials of non-sinister headaches

Answer 20

tension-type
migraine
sinusitis 
medication-overuse
temporomandibular joint dysfunction 
trigeminal neuralgia
cluster

Question 21

tension-type

Answer 21

often bi-frontal
no other symptoms
usually lasts no more than a few hours

Question 22

migraine

Answer 22

usually unilateral
associated with aura - sensitivity to sound/light/smell
can last between 4-72 hours
differential for epilepsy and TIAs

Question 23

treatment for migraines

Answer 23

Triptans - sumatriptan

5HT receptor agonists - cerebral vasoconstriction and inhibition of trigeminal nerve transmission

Question 24

sinusitis

Answer 24

facial pain that comes on over hours/days
in conjunction with coryzal symptoms (acute inflammation of the nasal mucus membranes)
headaches last several days - associated with time course of infection

Question 25

medication overuse

Answer 25

very common
resemble cluster or tension-type
seen with migraine medications and analgesic overuse
remove medication for a while to treat

Question 26

TMJ syndrome

Answer 26

most common in 20-40 year olds

dull ache in the muscles of mastication

Question 27

trigeminal neuralgia

Answer 27

very rare
mainly in women ages 60-70
unilateral stabbing, sharp facial pain
attacks only last seconds but have many triggers
attacks rarely occur during sleep

Question 28

cluster

Answer 28

mainly affects men
onset of symptoms occurring in clusters of 6-12 weeks every 1-2 years at exactly the same time every day
pain is focused over one eye
very intense pain
red watery eye, rhinorrhea, horners syndrome

Question 29

Sub-arachnoid haemorrhage

Answer 29

sudden onset, worst headache ever - possibly due to ruptured aneurysm
order CT scan to look for blood in CSF
nimodipine - CCB for management
cerebral angioplasty

Question 30

Brain tumour

Answer 30

persistent headache in the occipital area
fundoscopy reveals optic disc cupping
MRI scan to locate
dexamethasone to reduce inflammation
surgery

Question 31

main causes of SAH

Answer 31

rupture of arterial aneurysm (45%)
trauma (45%)
arteriovenous malformation (10%)

Question 32

intracranial tumours

Answer 32

secondary metastatic (90%)
Primary - axial (50%) extra-axial