Headaches

Question 1

part. characteristic of cluster headaches necessary for their diagnosis?

Answer 1

presence of autonomic symptoms, must have at least 1 of:
ipsilateral forehead and facial sweating
conjunctival infection or lacrimation
eyelid oedema
miosis or ptosis
nasal congestion or rhinorrhoea

Question 2

main types of primary headaches (no underlying structural abnormality)?

Answer 2

tension
migraine
cluster
other

Question 3

what primary headaches exist other than tension, migraine and cluster?

Answer 3

primary stabbing headache (ice pick)-single stab or series in ophthalmic distribution of trigeminal nerve, no other symptoms
primary cough headache (valsalva)-precipitated by coughing or straining with no other assoc. headache disorder
primary exertional-sudden onset, brought on by exercise, pulsating, can last up to 48hrs, happens part. in hot weather or high altitude.
primary sexual headache-may have explosive onset-must rule out SAH
primary thunderclap-sudden onset severe, max intensity in less than 1min, gen. not recurrent but can recur within 1st wk of onset, lasts from 1hr-10 days.
hypnic-wakes pt from sleep on at least half of all days, dull, lasts at least 15mins post waking
hemicrania continua-persistent unilateral headache for 3mnths or more, daily and continuous, mod intensity with exacerbations-AN symptoms e.g. eye watering, ptosis, nasal congestion, responds completely to indomethacin
new daily persistent-daily and unremitting from onset.

Question 4

give 5 red flags of headaches?

Answer 4

change in ongoing headache
acute onset new headache (also new headache in older man)
neurological symptoms e.g. reduced visual acuity, seizures, reduced consciousness, headache worse on a morning and bending forwards, assoc. N+V
neurological signs
constitutional-fever, weight loss

Question 5

visual symptoms that may be experienced as an aura in patients with migraines?

Answer 5

flickering lights
spots or zig zag lines
fortification spectra
blind spots

Question 6

when do patient’s tend to experience cluster headaches?

Answer 6

often during sleep and may wake the patient
may be triggered within 90mins of drinking alcohol
can occur up to 8 times daily, each lasting anywhere from 15 mins to 3 hours, over a few months, then remissions for months or years.

Question 7

patient groups more at risk of cluster headaches?

Answer 7

males
over 20 years
smokers

Question 8

SAH differential diagnoses?

Answer 8

primary sexual headache
primary thunderclap headache
primary exertional headache
primary cough headache

stroke from other cause
hypertensive emergency
cervical artery, carotid artery and vertebral artery dissection
cortical vein thrombosis
pituitary apoplexy

Question 9

cluster headache acute attack treatment?

Answer 9

100% O2 for 15mins via non-rebreathe mask

sumatriptan (5HT1 agonist) SC 6mg at attack onset, cause cranal artery vasoconstriction.

Question 10

important components to examining a headache pt?

Answer 10

full neurological examination
BP
fundoscopy-looking for papilloedema
temporal artery palpation in pts over 50yrs
exam tailored to presentation e.g. ENT

Question 11

after what time should an LP be done following negative CT in suspected SAH?

Answer 11

after 12hrs post onset of symptoms as can then look for bilirubin-breakdown product of rbc (xanthochromia)-yellowish discolouration of CSF.

Question 12

what diagnosis must be considered in obstetric patient with a headache?

Answer 12

venous sinus thrombosis

backpressure causes venous haemorrhagic strokes

Question 13

NICE recommended preventive treatment for migraines in adults?*

Answer 13

treatment aiming to reduce frequency, severity and duration of migraine attacks, and avoid medication overuse headache
propranolol and topiramate 1st line, propranolol 1st line in women of childbearing age as topiramate associated with risk of fetal malformations and can reduce effectiveness of hormonal contraceptives.
topiramate-do serum HCO3- at 2 wks and then every 3mnths if at increased risk of metabolic acidosis.

Question 14

contraindications to the use of triptans for acute treatment of migraines?

Answer 14

triptans=5HT1 receptor agonists to be taken during the headache phase of a migraine
IHD or CVD
uncontrolled HTN
RFs for IHD or CVD
coronary vasospasm (prinzmetal's angina)

r/f to cardiology if uncertain about risk

Question 15

conditions associated with the development of berry aneurysms?

Answer 15

adult polycystic kidney disease
ehlers-danlos syndrome
aortic coarctation

Question 16

NICE recommended treatment for patients with predictable menstrual migraines?

Answer 16

triptan-frovatriptan or zolmitriptan to be taken daily as ‘mini-prophylaxis’

Question 17

medications associated with idiopathic intracranial HTN?

Answer 17

tetracycline antibiotics
isotretinoin
contraceptives
steroids
levothyroxine
lithium
cimetidine

Question 18

what symptoms are common in children with migraine that are less common in adults?

Answer 18

GI disturbance-N+V, abdo pain

Question 19

give 4 questions that can be asked to determine if a patient with suspected migraine experiences aura?

Answer 19

• jagged lines in your vision?
• blind spots?
• tingling or numbness down 1 side?
• difficulty speaking?

important in prescribing-COCP is contraindicated in patients with migraine with aura due to risk of stroke.