Headaches

Question 1

What are the two types of headaches?

Answer 1

Primary (common, chronic/ recurrent)

Secondary (acute, from specific underlying cause)

Question 2

What are the primary headaches? (3)

Answer 2

• Migraine
• Tension-type
• Cluster

Question 3

What are some secondary headaches? (4)

Answer 3

• SAH
• GCA
• Meningitis
• Medication overuse

Question 4

What is the most common type of primary headache?

Answer 4

Tension-type headache

Question 5

What is the least common type of primary headache?

Answer 5

Cluster headache

Question 6

What are the clinical features of tension-type headaches? (3)

Answer 6

• Bilateral
• Tightening/ pressing, band-like
• Not aggravated by routine physical activity

Question 7

How long do tension-type headaches usually last?

Answer 7

From 30min - 1 week

Question 8

What symptoms wouldn’t you see in tension-type headaches? (2)

Answer 8

No nausea + vomiting

Both photophobia + phonophobia

Question 9

How would you treat tension-type headaches? (3)

Answer 9

• Conservative: reassurance, stress relief, avoid causes
• Acutely: NSAIDs or aspirin
• Chronic pain: amitriptyline (tricyclic antidepressants)

Question 10

What are the triggers of tension-type headaches? (7)

Answer 10

MC SCOLD
Missed meals
Conflict
Stress
Clenched jaw
Overexertion
Lack of sleep
Depression

Question 11

What are the clinical features of a migraine? (7)

Answer 11

• Unilateral
• Pulsating/ throbbing pain
• Aggravated by movement
• N&V
• Photophobia
• Phonophobia
• Aura

Question 12

How long do migraines usually last?

Answer 12

From 4 - 72 hours

Question 13

How would you treat migraines conservatively?

Answer 13

Avoid triggers

Question 14

How would you treat acute attacks (mild + severe) in a migraine?

Answer 14

Mild - NSAIDs +/- antiemetics

Severe - oral triptan (sumatriptan- SSRI)

Question 15

What 1st line prophylaxis would you give for migraines?

Answer 15

Propranolol (beta-blocker) or topiramate (anti-convulsant)

Question 16

What 2nd line prophylaxis would you give for migraines?

Answer 16

Acupuncture

Question 17

What 3rd line prophylaxis would you give for migraines?

Answer 17

Amitriptyline (tricyclic antidepressant)

Question 18

What are the triggers for migraines? (9)

Answer 18

CHOCOLATE
Chocolate
Hangovers
Orgasms
Cheese
OCP
Lie-ins
Alcohol
Tumult (loud noises)
Exercise

Question 19

What are the clinical features of cluster headaches? (4)

Answer 19

• Unilateral
• Excruciating, burning/ hot poker pain behind one eye
• Occurs at same time every day
• Nothing provides comfort (restlessness, agitation)

Question 20

What autonomic symptoms are cluster headaches associated with? (3)

Answer 20

• Ipsilateral eye lacrimation & redness
• Rhinorrhoea (runny nose)
• Miosis and/ or ptosis

Question 21

How would you give acute relief to a pt with a cluster headache? (3)

Answer 21

• 100% oxygen therapy
• SC sumatriptan (SSRI)
• IN zolmitriptan

Question 22

What prophylaxis would you give to a pt with cluster headaches? (4)

Answer 22

• Verapamil (CCB)
• Lithium
• Corticosteroids
• Valproic acid

Question 23

What are the triggers for cluster headaches?

Answer 23

Have been associated with cigarettes and alcohol

Question 24

What is trigeminal neuralgia?

Answer 24

Facial pain

Question 25

What is the cause of trigeminal neuralgia?

Answer 25

Pain disorder due to compression of trigeminal nerve eg by intracranial vessels

Question 26

What are the clinical features of trigeminal neuralgia?

Answer 26

- Unilateral | - Electric shock/ lightning-like pain in V1/2/3

Question 27

What clinical feature wouldn't you expect to see in a pt with trigeminal neuralgia?

Answer 27

Neurological deficit (neuro exam should be NORMAL)

Question 28

How long does the pain last in trigeminal neuralgia?

Answer 28

Lasts a few seconds

Question 29

What are the triggers for trigeminal neuralgia? (5)

Answer 29

Any irritating activity - Chewing - Brushing teeth - Smiling - Talking - Washing affected area

Question 30

What is the first-line treatment for trigeminal neuralgia?

Answer 30

Carbamazepine (anti-convulsant)

Question 31

What is the second-line treatment for trigeminal neuralgia? (2)

Answer 31

Phenytoin Gabapentin (analgesics targeted for neuropathic pain)

Question 32

What are the surgical interventions for trigeminal neuralgia? (2)

Answer 32

- Microvascular decompression | - Stereotactic radiotherapy

Question 33

What type of headache is giant cell arteritis (GCA)?

Answer 33

Secondary headache

Question 34

What is the cause of GCA?

Answer 34

Inflammatory disorder of blood vessels

Question 35

What are the clinical features of GCA? (4)

Answer 35

- Unilateral headache - Scalp tenderness - Jaw claudication (cramping pain) - Amaurosis fugax (loss of vision)

Question 36

What are the extracranial symptoms od GCA? (4)

Answer 36

- Fever - Malaise - Weight loss - Depression

Question 37

What are the signs of GCA? (3)

Answer 37

Palpable, tender and reduced pulsation of the temporal arteries

Question 38

How would you investigate GCA? (2)

Answer 38

- Temporal artery biopsy (gold standard | - Bloods: raised ESR + CRP

Question 39

How would you treat GCA? (3)

Answer 39

- Prednisolone 60mg/d immediately - Low dose aspirin 75mg - PPI eg omeprazole

Question 40

What are the risk factors for GCA?

Answer 40

Age (almost never occurs before age 50)

Question 41

Pt < 55y presents with GCA-like symptoms. What diagnosis should you consider?

Answer 41

Takayasu's arteritis