Headaches

Question 1

Red flags for headaches

Answer 1

Worst ever headache
Worse in morning, bending forwards or coughing 
Neck stiffness
Decreased GCS
Neurological deficit 
Scalp tenderness
Pregnant - preeclampsia

Question 2

Causes of thunderclap headache

Answer 2

Subarachnoid haemorrhage
Carotid dissection
Vertebral dissection
Cerebral venous thrombosis
Meningoencephalitis
Intermittent hydrocephalus - 3rd ventricle cyst

Question 3

What is coning

Answer 3

Brain herniation through foramen magnum following lumbar puncture with raised ICP

Question 4

Describe exertional headaches

Answer 4

Feels like being hit over back of head with a brick
Pain subsides in 10-15mins
Brought on by exertion e.g weight lifting and after intercourse

Question 5

Describe tension headaches

Answer 5

Tightness in scalp, forehead, sudoccipitals and neck

Gets worse towards evening and clears overnight

Question 6

Treatment for tension headache

Answer 6

Amitriptyline

Question 7

Describe cluster headaches (5)

Answer 7

Headaches on daily basis, usually waking patient up at night. Then go months with no headaches, then they return on daily basis.
Middle aged men
Associated with autonomic features - nose and eye secretions, ptosis, swelling
Red hot poker sensation in orbit and nostril on one side
Rapid onset and offset

Question 8

What triggers cluster headaches

Answer 8

Alcohol
GTN spray
Exercise

Question 9

Treatment for cluster headaches

Answer 9

Subcutaneous Triptan

Verapamil to prevent onset

Question 10

First line migraine treatments

Answer 10

Paracetamol
NSAIDs including aspirin
Oral triptan

Question 11

Add on treatment for migraines

Answer 11

Dopamine antagonists e.g metoclopramide and domperidone

Question 12

Stepwise treatment for migraine prophylaxis

Answer 12

1st line- beta blocker, topiramate
2nd line- amitriptyline, acupuncture
3rd line- duloxetine, gabapentin

Question 13

Factors causing migraines

Answer 13

Stress
Seasonal
Menstrual cycle or pregnancy related
Exercise
Infection
Small head injuries

Question 14

Areas affected by migraines

Answer 14

Frontotemporal
Occipitoorbital
Orbital 
Cheiro-orbital - arm, face, mouth in that order can mimic TIA due to dysphasia 
Facial

Question 15

Symptoms associated with migraine

Answer 15

Photophobia
Aura - visual most common
Hemiparesis
Nausea 
Vertigo 
Dysphasia

Question 16

Significance of migraine + vertigo

Answer 16

If sudden onset or vomiting with positional change,
NEED FURTHER INVESTIGATION
look for tumour in posterior cranial fossa

Question 17

Describe trigeminal neuralgia

Answer 17

Excruciating deep pain in face lasting a few seconds every few minutes
Rarely at night

Question 18

Where is the pain felt in trigeminal neuralgia and what is the trigger

Answer 18

Mouth-ear: triggered by motor activity

Nose-orbit: triggered by cutaneous sensory activity

Question 19

Investigations needed in trigeminal neuralgia

Answer 19

MRI to rule out meningioma or trigeminal schwannoma

Question 20

Treatment for trigeminal neuralgia

Answer 20

Baclofen

Gabapentin

Question 21

How to distinguish paroxysmal hemicrania from cluster headaches

Answer 21

Paroxysmal hemicrania F>M, Cluster headache M>F
Episodes are shorter and more frequent in paroxysmal hemicrania
Patient will be agitated in cluster headache
Paroxysmal hemicrania is triggered by head movements

Question 22

What is SUNCT

Answer 22

Short lasting
Unilateral
Neuralgiform headache
With conjunctival tearing

Question 23

Treatment for SUNCT

Answer 23

None

Question 24

Describe atypical facial pain and treatment

Answer 24

Feels like bone is ‘going rotten’

Treat with tranquillisers and antidepressants