Headaches

Question 1

What are the Red Flag Symptoms for a Headache?

Answer 1

• Fever, photophobia, neck stiffness
• Neurological symptoms (haemorrhage, malignancy and stroke)
• Dizziness
• Visual Disturbance
• Sudden onset headache
• Worse on coughing/ straining
• Worse on standing/lying/bending over
• Wakes up from sleep
• Vomiting associated
• History of Trauma
• Pregnancy (pre-eclampsia)

Question 2

What are the key red flag diagnoses you want to exclude in Headache?

Answer 2

• Raised Intracranial Pressure
• Intracranial Haemorrhage

Question 3

What would you be looking for on Fundoscopy?

Answer 3

• Papilloedema

Question 4

What does Papilloedema suggest?

Answer 4

• Raised Intracranial pressure
• Brain tumour
• Benign Intracranial Hypertension
• Intracranial Bleed

Question 5

How would you describe a tension headache?

Answer 5

• A mild ache across the forehead
• Band-like pattern around the head
• Muscle Ache in the Frontalis, Temporalis and Occipitalis
• Tension Headaches come on and resolve gradually they do not produce visual changes

Question 6

What are the Risk Factors for tension headaches?

Answer 6

• Stress
• Depression
• Alcohol
• Skipping Meals
• Dehydration

Question 7

What is the treatment for tension headaches?

Answer 7

• Reassurance
• Basic Analgesia
• Relaxation techniques
• Hot towels to local area

Question 8

What is a Secondary Headache?

Answer 8

• A similar presentation to a Tension Headache but with a clear cause

Question 9

What are some of the causes of a Secondary Headache?

Answer 9

• Medical conditions: infection, apnoea, pre-eclampsia
• Alcohol
• Head Injury
• Carbon Monoxide poisoning

Question 10

What is Sinusitis?

Answer 10

• Sinusitis is a headache associated with inflammation in the ethmoidal, maxillary, frontal or sphenoidal sinuses
• Organisms: Streptococcus Pneumonia, Haemophilus Influenzae, Rhinoviruses

Question 11

How does Sinusitis present?

Answer 11

• Facial Pain behind the nose, forehead and eyes
• Tenderness over the affected sinus
• Frontal Pressure Pain worse on bending forward
• Nasal Discharge: thick and purulent
• Nasal Obstruction

Question 12

What are the predisposing factors for Sinusitis?

Answer 12

• Nasal Obstruction (septal deviation or nasal polyps)
• Recent local infection
• Swimming/ diving
• Smoking

Question 13

What is the managment for Sinusitis?

Answer 13

• Analgesia
• Nasal irrigation with Saline
• Intranasal corticosteroids if the symptoms have been present for more than 10 days
• Oral Abx are not normally required BUT consider:
  1. Phenoxymethylpenicillin
  2. Co-amoxiclav - systemically unwell, signs and symptoms of a more serious illness
• Double Sickening = initial viral sinusitis worsens due to secondary bacterial infection

Question 14

What is an Analgesic Headache?

Answer 14

• A headache caused by long term analgesia use
• non-specific features of a tension type headache
• Treated by removing the analgesia

Question 15

What is a Hormonal Headache?

Answer 15

• Hormonal Headaches are related to oestrogen
• Typically low oestrogen

Question 16

How do Hormonal Headaches present?

Answer 16

• Two days before and three days of the menstrual period
• Around the menopause
• Pregnancy - worse in the first few weeks and improves in the last 6 months (headaches in the second half of pregnancy should prompt investigation for pre-eclampsia
• The oral contraceptive pill can improve hormonal headaches

Question 17

What is Cervical Spondylosis?

Answer 17

• Common condition caused by degenerative changes in the cervical spine
• Caused by neck pain and worse on movement
• Presents with headaches
• important to exclude other causes of neck pain such as inflammation, malignancy and infection
• important to exclude spinal cord/ nerve root lesions

Question 18

What is Trigeminal Neuralgia?

Answer 18

• The compression of the Trigeminal nerve
• The trigeminal nerve has 3 branches: Ophthalmic, Maxillary and Mandibular

Question 19

How does Trigeminal Neuralgia present?

Answer 19

• Facial Pain described as electricity-like shooting pain
• Attacks often worsen over time

Question 20

What are the triggers of trigeminal neuralgia?

Answer 20

• cold weather, spicy food, caffeine, citrus fruits

Question 21

What is the treatment for Trigeminal Neuralgia?

Answer 21

• Carbamazepine
• Surgery - to decompress/ intentionally damage the trigeminal nerve

Question 22

What are Cluster Headaches?

Answer 22

• Severe unbearable unilateral headaches around one eye
• They come in clusters of attacks and then disappear for a while
• A patient may suffer 3/4 attacks a day for weeks/ months with them lasting 15/ 30 mins
• Followed by a pain-free period lasting 1/2 years

Question 23

What are the symptoms of Cluster Headaches?

Answer 23

• Red, swollen, watery eye
• Pupil constriction
• Eyelid dropping
• Nasal Discharge
• Facial sweating
• Known as suicide headaches as they can be so severe

Question 24

What are the treatment options for Cluster Headaches?

Answer 24

Acute:
- Triptans (sumatriptan 6mg injected subcutaneously)
- High flow 100% oxygen 15-20 minutes

Prophylaxis:
- Verapamil
- Lithium
- Prednisolone ( short course for 2/3 weeks to break the cycle during clusters