headaches

Question 1

what are the signs of raised ICP?

Answer 1

papilloedema (blurred vision), worse in morning and bending/strain/cough, N+V, wake up at night

Question 2

what investigations could you do for raised ICP?

Answer 2

ophthalmoscopy, visual fields and acuity

investigate CSF pressure via LP- >30 abnormal (scan first as might be SOL and then could cause coning aka hernia)

Question 3

What are the differentials of raised ICP?

Answer 3

Hydrocephalus
SOL
trauma
stroke
pseudopapilloedema- due to calcium deposits
Intracranial Hypertension Secondary to:
Subdural Venous Thrombosis
Arteriovenous Malformation
Menigitis/Encephalitis 
sagittal sinus thrombosis- do a CT venogram
malignant htn
benign/idiopathic intracranial htn

Question 4

What red flags do you look for with a headache?

Answer 4

seizure, neck stiffness, older person, systemic symptoms, confusion, LOC, PMH of cancer, duration

Question 5

How does benign/idipathic intracranial htn present?

Answer 5

young, obese women usually with normal CT and papilloedema, shoulder pain, pulsatile tinnitis, need to treat as can go blind; manage with estezoloamide

Question 6

What are the symptoms of a subarachnoid haemorrage?

Answer 6

thunderclap, acute, stiff neck, photophobia, N+V, confusion and LOC

Question 7

What are the investiations for SAH if seen straight away? What about if they’re seen two weeks later?

Answer 7

LP and CT head- see xanthochromia after 12 hours, will vanish after 12 days. After 12 days do a CT angiogram

Question 8

What is a typical history for giant cell arteritis?

Answer 8

over 55 yrs, temporal tenderness and loss of vision (curtain fall- amaurosis), jaw claudication, PMH stroke in postural circulation

Question 9

What investigations do you do for giant cell arteritis?

Answer 9

check ESR and CRP

temporal biopsy

Question 10

How do you tell the difference between a TIA and a migraine?

Answer 10

TIA is acute, with negative symptoms eg loss vision, numbness.
Migraines are normally aura gradual roughly 1 hour, sequential, positive symptoms eg pain, tingling, visual additions

Question 11

How does a tension headache typically present?

Answer 11

bilateral, tight, squeezing and worse in evening

Question 12

How does a migraine present?

Answer 12

unilateral throbbing for 4-72 hrs, aura, triggers, faitgue, want to be still, usually don’t get multiple in one day

Question 13

What is the management for migraines?

Answer 13

1. NSAIDs
2. anti emetic (such as metoclopramide or prochlorperazine) and sumatriptan (SE-IHD)
3. preventative eg propranolol (1st line), topiramate (SE of kidney stones and teratogenic), Amitriptyline and candesartan
   - add preventative if struggle with triptans or are getting over two attacks a month
4. botox

Question 14

How does a cluster headache present?

Answer 14

severe, unilateral, episodic, multile in one day, lasts 10 mins to one hour, worse in morning, relieve by pacing, autonomic symptoms (tearing, running nose and red eye), in young male smokers, stereotyped

Question 15

What is the management for a cluster headache?

Answer 15

acute: oxygen + SC triptan
prophylactic: 1st line is verapamil (SE: heart block)

Question 16

How does meningitis present?

Answer 16

pyrexia, N+V, stiff neck, rash, confusion, photophobia, LOC, seizures

Question 17

What are kernigs and brudzinskis signs?

Answer 17

brudzinskis is hips flex on bending the head forward

kernigs is pain and resistance on passive knee extension with hips fully flexed

Question 18

what are the investigations for meningitis?

Answer 18

LP- if no signs of raised ICP for cultures
CT scan
blds
culture urine
U+Es
may do coagulation profile for DIC

Question 19

what is the management for meningitis?

Answer 19

supportive
dexamethasone
IV cefotaxime
acyclovir if viral

Question 20

mx of SAH?

Answer 20

Re-bleeding is the most imminent danger; a first aim is therefore occlusion of the aneurysm. Endovascular obliteration by means of platinum spirals (coiling) is now the preferred mode of treatment, but some patients require a direct neurosurgical approach (clipping)

CCB to prevent vasospasm - Nimodipine

Question 21

presentation of trigeminal neuraliga?

Answer 21

a unilateral disorder characterised by brief electric shock-like pains, abrupt in onset and termination, limited to one or more divisions of the trigeminal nerve
the pain is commonly evoked by light touch, including washing, shaving, smoking, talking, and brushing the teeth (trigger factors), and frequently occurs spontaneously
the pains usually remit for variable periods

Question 22

mx trigeminal neuralgia?

Answer 22

carbamazepine is first-line