Headaches

Question 1

2

Fever, photophobia and neck stiffness associated with headache could indicate?

Answer 1

Meningitis, encephalitis or brain abscess

Question 2

Sudden onset occipital headache- worse headache they’ve ever had suggests?

Answer 2

Subarachnoid haemorrhage

Question 3

Headache that is worse on coughing or straining suggests?

Answer 3

That there is raised intracranial pressure

Question 4

Tension headache- presentation and management?

Answer 4

Mild ache or pressure in a band like pattern around the head
Develop and resolve gradually and do not produce visual changes

Associated with:
* Stress
* Depression
* Alcohol
* Skipping meals
* Dehydration

Management:
* Reassurance
* Ibuprofen or paracetamol
* Amitriptyline is 1st line for frequent tension headaches

Question 5

What is sinusitis?

Answer 5

Inflammation of the paranasal sinuses due to viral infection

Question 6

What causes a hormonal headache? Presentation?

Answer 6

Low oestrogen

Unilateral pulsatile headache associated with nausea

Question 7

A condition that usually presents as a headache with neck pain that is worse on movement?

Answer 7

Cervical spondylosis- degenerative changes in the cervical spine

Question 8

Trigeminal neuralgia- presentation and treatment?

Answer 8

Intense facial pain- in distribution of the trigeminal nerve branches- V1, V2 and V3
* Shooting, electricty like stabbing/burning pain

Over 90% of cases are unilateral

Treatment- carbamazepine

Question 9

Investigations and management for subarachnoid haemorrhage

Answer 9

Non contrast CT head-1st line
* If CT head is done within 6 hours of symptom onset and is normal- do not do a lumbar puncture- consider alternative diagnosis
* If CT head is done more than 6 hours after symptomonset do lumbar puncture
* Lumbar puncture findings- xanthochromia- result of red blood cell breakdown- diagnoses heamorrhage

Management:
* Bed rest
* Analgesia
* Venous thromboembolism
* Nimodipine- prevents vasospasm
* Surgery with coil to prevent rebleeding from aneurysm

Question 10

A headache that is recurrent, severe, throbbing and unilateral in nature. Also associated with nausea and photosensitivity?

Answer 10

Migraine

Question 11

Headache described as an intense pain around 1 eye. Attacks occurs one a day, each episode lasting 15 mins-2 hours for the past 8 weeks. Associated with a red and watery eye and constricted pupil?

Answer 11

Cluster headache

More common in men and smoker

Question 12

Patient >60 years old presents with rapid onset unilateral headache associated with pain on chewing and brushing her hair?

Answer 12

Temporal arteritis:
Jaw claudication
Tender, palpable temporal artery
Raised ESR

Question 13

What is the normal intracranial pressure in adults in the supine position?

Answer 13

7-15mmHg

Question 14

What is invasive ICP monitoring?

Answer 14

Catheter placed into the lateral ventricles of the brain to monitor the pressure

Question 15

Management of raised ICP?

Answer 15

• 1st step- head elevation to 30 degrees
• IV mannitol- osmotic diuretic
• Controlled hyperventilation- reduce co2= vasoconstriction of the cerebral arteries= reduced ICP

Question 16

Typical 5 stages of a migraine?

Answer 16

• Premonitory or prodromal stage (can begin several days before the headache)- may have subtle symps e.g. yawning or mood change)
• Aura (lasting up to 60 mins)
• Headache stage (lasts 4 to 72 hours)
• Resolution stage (the headache may fade away or be relieved abruptly by vomiting or sleeping)
• Postdromal or recovery phase

Question 17

Typical features of a migraine headache?

Answer 17

• Usually unilateral
• Moderate-severe intensity
• Pounding or throbbing in nature
• Photophobia (discomfort with lights)
• Phonophobia (discomfort with loud noise)
• Osmophobia (discomfort with strong smells)
• Aura (visual changes)
• Nausea and vomiting

Question 18

Hemiplegic migraine?

Answer 18

• Main feature- hemiplegia- unilateral limb weakness
• Other symps– ataxia and impaired consciousness

Can mimic a stroke or TIA

Question 19

Acute managment of a migraine?

Answer 19

Medical:
* 1st line- combo of oral triptan and an NSAID or paracetamol

Triptans- 5-HT agonists e.g. sumatriptan
* Cause cranial vasoconstriction, inhibit pain signals, inhibit release of inflammatory neuropeptides

Antiemtics e.g. metoclopramide or prochlorperazine

Question 20

Prophylaxis of a migraine?

Answer 20

5-HT antagonists

Meds to reduce the frequency and severity of attacks are:- should only be given if having a sig impact on quality of life e.g. occur more than once a week
* Propanolol
* Amitriptyline
* Topiramate- avoid in women of childbearing age

Other therapies:
* CBT
* Mindfulness
* Vit B2 (riboflavin)