Headaches

Question 1

Red flags for headaches

Answer 1

Fever, photophobia or neck stiffness - meningitis or encephalitis
New neurological symptoms - malignancy, stroke
Dizziness
Visual disturbances
Sudden onset occipital headache - subarachnoid haemorrhage
Worse on coughing or bending - raised intracranial pressure
Severe in the morning
Vomiting
History of trauma
Pregnancy

Question 2

Investigations for headaches

Answer 2

Fundoscopy - Papilloedema indicating raised ICP

Question 3

Causes of secondary headaches

Answer 3

Alcohol
Head injury
Carbon monoxide poisoning
Underlying medical conditions - infection, obstructive sleep apnoea or pre - eclampsia

Question 4

Hormonal headache features

Answer 4

Related to low oestrogen - causing tension like headache

• 2 days before and first 3 days of menstrual period
• around menopause
• pregnancy - worse during the first week

Question 5

Cervical spondylosis pathophysiology and presentation

Answer 5

Degeneration of the cervical spine causing neck pain which is worse on movement

Question 6

Trigeminal neuralgia pathophysiology

Answer 6

Cause unknown but thought to be due to trigeminal nerve compression

Question 7

Presentation of trigeminal neuralgia

Answer 7

Unilateral, sudden onset, severe facial pain

Often electric shock like shooting pain

Question 8

Triggers of trigeminal neuralgia

Answer 8

Talking 
Chewing 
Combing hair 
Head movements 
In the car

Question 9

Treatment of trigeminal neuralgia

Answer 9

Carbamazepine first line

Consider decompression surgery

Question 10

Features of tension headaches

Answer 10

Site - band like pattern around the head, symmetrical

Onset - gradual

Character - ache

Relieving factors - analgesia, hydration

Aggravating factors - dehydration, stress, skipping meals and infection

Timing - approx 30 mins

Associated features - pale, tired

Question 11

Features of migraines

Answer 11

Site - unilateral, often forehead or eyes

Onset - can be gradual or sudden

Character - sharp, throbbing

Relieving factors - dark room, rest, analgesia (triptans)

Aggravating factors - stress, solvents, dehydration

Timing - takes longer to resolve

Associated features - photophobia, aura, nausea, abdo pain

Question 12

Prophylaxis for migraines and when to use it

Answer 12

Propranolol
Pizotifen
Topiramate
Amitriptyline

Significantly impacting life
Frequent - > 1 per week

Question 13

Types of migraine

Answer 13

Migraine without aura
Migraine with aura
Silent migraine (migraine with aura but without a headache)
Hemiplegic migraine

Question 14

Hemiplegic migraines

Answer 14

Mimics stroke

Symptoms vary :

• Typical migraine symptoms
• Sudden or gradual onset
• Hemiplegia (unilateral weakness of the limbs)
• Ataxia
• Changes in consciousness

Question 15

Treatment of hemiplegic migraines

Answer 15

Essential to act fast and exclude a stroke - CT head

Question 16

Migraine triggers

Answer 16

Stress
Bright lights
Strong smells
Certain foods (e.g. chocolate, cheese and caffeine)
Dehydration
Menstruation
Abnormal sleep patterns
Trauma

Question 17

Management of migraines

Answer 17

Paracetamol
Triptans - sumatriptan
NSAIDs
Antiemetics if vomiting occurs (e.g. metoclopramide)

Question 18

Topiramate side effects

Answer 18

Teratogenic and can cause a cleft lip/palate so patients should not get pregnant

Question 19

Cluster headaches

Answer 19

Site - unilateral, around eye

Onset - sudden

Character - sharp, throbbing, severe

Relieving factors - dark room, rest, analgesia (triptans)

Aggravating factors - alcohol, strong smells, alcohol

Timing - comes in clusters

Associated features - Red, swollen and watering eye
Pupil constriction (miosis)
Eyelid drooping (ptosis)
Nasal discharge
Facial sweating

Question 20

Treatment options for cluster headaches

Answer 20

Triptans - sumatriptan 6mg injected subcutaneously

High flow 100% oxygen for 15-20 minutes (can be given at home)

Question 21

Prophylaxis of cluster headaches

Answer 21

Verapamil
Lithium
Prednisolone (2-3 weeks to break the cycle during clusters)