Headaches

Question 1

What are the three types of primary headache?

Answer 1

Tension type
Migraine
Cluster headache

Question 2

What are six possible causes of secondary headache?

Answer 2

Tumour
Meningitis
Vascular disorders
Systemic infection
Head injury
Drug-induced

Question 3

What are the typical characteristics of a tension type headache?

Answer 3

Bilateral pain, present all the time
NOT disabling
Often related to muscle tightness/stress
No significant associated symptoms

Question 4

What is the treatment for tension type headaches?

Answer 4

Aspirin
NSAIDs
(Limit to 10 days per month)

Question 5

Are there any prophylactic treatments for tension type headaches?

Answer 5

Rarely required
Tricyclic antidepressants (amitriptyline, dothiepin, nortriptyline)

Question 6

What are the typical characteristics of a migraine?

Answer 6

Most disabling primary headache
Episodic attacks
Can be preceded by sensory aura
Can be induced by triggers

Question 7

What might someone experience in migraine attack?

Answer 7

Nausea
Vomiting
Photophobia
Phonophobia

Question 8

What kind of things can trigger migraines?

Answer 8

Stress
Hunger
Sleep disturbance
Dehydration
Diet
Changes in oestrogen in women

Question 9

What abortive treatments are available to treat migraine?

Answer 9

Aspirin
NSAIDs
Triptans
(Limit to 10 days per month)

Question 10

What prophylactic treatments are available to treat migraine?

Answer 10

Propranolol, Candesartan
Anti-epileptics: Topiramate, Valproate, Gabapentin
Tricyclic antidepressants: amitriptyline, dothiepin, nortriptyline
Venlafaxine

Question 11

What are SUNCT headaches?

Answer 11

Short-lasting Unilateral Neuralgiform headache with Conjunctival injection and Tearing

Question 12

What are the typical characteristics of SUNCT?

Answer 12

Unilateral
Orbital, supraorbital or temporal pain
Pain is paired with conjunctival injection (red eye) and lacrimation (tears)

Question 13

How long do SUNCT attacks last?

Answer 13

10-240 seconds

Question 14

How often to SUNCT attacks occur?

Answer 14

3-200 times per day with no refractory period

Question 15

What abortive treatments are available to treat SUNCT?

Answer 15

None

Question 16

What prophylactic treatments are available to treat SUNCT?

Answer 16

Lamotrigine
Topiramate
Gabapentin
Carbamazepine/Oxcarbazepine

Question 17

What are the typical characteristics of paroxysmal hemicrania?

Answer 17

Unilateral
Mainly temporal and orbital pain
Rapid onset and rapid cessation
Excruciatingly severe
Prominent ipsilateral autonomic symptoms

Question 18

How long do paroxysmal hemicrania attacks last?

Answer 18

15 minutes to 3 hours

Question 19

How often do paroxysmal hemicrania attacks occur?

Answer 19

2-40 attacks per day

Question 20

What is the difference between chronic and episodic paroxysmal hemicrania?

Answer 20

Episodic: periods of remission of a month or longer between episodes
Chronic: attacks for over one year with no remission, or remission less than one month

Question 21

What abortive treatments are available to treat paroxysmal hemicrania?

Answer 21

None

Question 22

What prophylactic treatments are available to treat paroxysmal hemicrania?

Answer 22

Attacks can be prevented completely with indomethacin

Question 23

What are the typical characteristics of cluster headaches?

Answer 23

Strictly unilateral
Rapid onset and cessation
Excruciatingly severe
Restless and agitated
Prominent ipsilateral autonomic symptoms 
Circadian rhythmicity to attacks

Question 24

How long do cluster attacks last?

Answer 24

15 minutes to 3 hours

Question 25

How often do cluster attacks occur?

Answer 25

1 every other day to 8 per day | Attacks occur at the same time each day and bouts occur at the same time every year

Question 26

What abortive treatments are available to treat cluster headaches?

Answer 26

Subcutaneous sumatriptan Nasal zolmitriptan 100% oxygen

Question 27

What prophylactic treatments are available to treat cluster headaches?

Answer 27

Verapamil Lithium Topiramate Methysergide

Question 28

What are the four types of trigeminal autonomic cephalalgias?

Answer 28

Cluster headache Paroxysmal hemicrania SUNCT SUNA

Question 29

What classifies a medication overuse headache?

Answer 29

Present 15 or more days a month | Developed or worsened while taking medication

Question 30

What are the typical characteristics of trigeminal neuralgia?

Answer 30

Unilateral maxillary or mandibular division pain (can be ophthalmic) Stabbing pain Autonomic features are uncommon

Question 31

How long does trigeminal neuralgia pain last for?

Answer 31

5-10 second bursts

Question 32

How frequent are attacks of trigeminal neuralgia?

Answer 32

3-200 times a day with a refractory period

Question 33

What abortive treatments are there for trigeminal neuralgia?

Answer 33

None

Question 34

What prophylactic treatments are there for trigeminal neuralgia?

Answer 34

Carbamazepine Oxcarbazepine Or surgery: glycerol ganglion injection, stereotactic radiosurgery, decompressive surgery

Question 35

What classifies a thunderclap headache?

Answer 35

High intensity headache reaching maximum intensity in less than 1 minute, majority peak instantaneously

Question 36

What are the differential diagnoses for thunderclap headaches?

Answer 36

``` 1 in 10 = Subarachnoid haemorrhage Intracerebral haemorrhage TIA/stroke Carotid/vertebral dissection Cerebral venous sinus thrombosis Meningitis/encephalitis Pituitary apoplexy Spontaneous intracranial hypotension ```

Question 37

What investigations can be carried out in suspected subarachnoid haemorrhage?

Answer 37

CT brain scan | Lumbar puncture, test for Xanthochromia

Question 38

CNS infection should be considered in any patient presenting with....?

Answer 38

Headache and fever

Question 39

What symptoms other than headache and fever could suggest meningism?

Answer 39

Nausea +/- vomiting Photo/phonophobia Stiff neck Rash

Question 40

What symptoms other than headache and fever could suggest encephalitis?

Answer 40

Altered mental state or confusion Focal symptoms/signs Seizures

Question 41

Give six possible causes of raised intracranial pressure

Answer 41

``` Glioblastoma multiforme Cerebral abscess Venous infarct with focal area of haemorrhage Meningioma Hydrocephalus Papilloedema ```

Question 42

What symptoms are indicative of raised intracranial pressure?

Answer 42

Progressive headache with associated symptoms and signs

Question 43

What signs and symptoms are warning features to look out for in suspected raised intracranial pressure?

Answer 43

Headache worse in the morning or wakes patient from sleep Headache worse lying flat or brought on by Valsalva Focal symptoms/signs Non-focal symptoms e.g. cognitive or personality change Drowsiness Seizures Visual obscuration and pulsatile tinnitus

Question 44

What is giant cell arteritis?

Answer 44

Arteritis of the large arteries. Should be considered in any patient over the age of 50 presenting with new headache

Question 45

What symptoms are characteristic of giant cell arteritis?

Answer 45

Diffuse, persistent headache May be systemically unwell Scalp tenderness, jaw claudication and visual disturbance Prominent beaded or enlarged temporal arteries

Question 46

What clinical findings support a diagnosis of giant cell arteritis?

Answer 46

Elevated ESR | Raised CRP and platelet count

Question 47

What can be used to treat giant cell arteritis?

Answer 47

High dose of prednisolone and a temporal artery biopsy should be taken