Headaches

Question 1

Tension headache summary card

Answer 1

Dull, tight band, gradual/acute, generalised/bilateral, lasts 3-4 hrs, moderate severity, analgesics help, neck/shoulder pain
= most common, everyday headache
= stress, disturbed sleep
= normal O/E
= keep a headache diary, avoid triggers, increase relaxation, simple analgesia (but beware of med-overuse headache)

Question 2

Cluster headache summary card

Answer 2

Neuro disorder of recurrent, severe, headaches on one side of head w/ cyclical pattern
= intense, sharp, penetrating pain, lasts 15 mins - 3 hrs, severely debilitating, unilateral, behind eye
= watery red eye, facial flushing, nasal congestion
= occurs in men, 20-40 yo, may present as partial Horner’s

Question 3

Migraine sx and assoc. sx

Answer 3

Unilateral, pulsating/throbbing, paroxysmal/comes on gradually, moderate to severe pain, being in dark room helps

Aura before (flashing lights, tingling), interferes w/ current activities, numbness, tingling, visual changes, photophobia, phonophobia, nausea, vomiting

Question 4

Migraine triggers

Answer 4

C hocolate
H angovers
O rgasms
C heese/caffeine
O CP
L ie-ins
A lcohol
T ravel
E xercise

• also bright lights and hormonal changes

Question 5

Mx of migraines

Answer 5

Conservative
= avoid triggers, keep diary

Acute
= 1) NSAIDs/paracetamol
= 2) triptans

Preventative
= 1) propanolol or topimerate
= 2) amitriptyline

Question 6

Trigeminal neuralgia summary card

Answer 6

Facial pain syndrome in > 1 division of trigeminal nerve
= unilateral headache around trigeminal division, numbness, stabbing/shooting pain, paraosmal/lasts for seconds
= triggers: eating/chewing, washing face, burshing teeth, shaving face, talking
= assoc. with MS

Question 7

Meningitis presentation

Answer 7

Acute and severe headache, neck stiffness, photophobia, fever, rash, vomiting, seizures, shock!

Non-blanching petechial rash, Kernig’s sign (hips flexed, pain/resistance on passive knee extension), Bruzinski’s sign (flexion of hips and knees when neck is flexed)

RFs: closed communities/crowding, age < 5 or > 65

Question 8

Causes of meningitis

Answer 8

Babies = E. Coli, group B strep
Children = H. infulenzae, Strep. pneum.
Young adults = Neisseria meningitidis
Elderly = Strep. pneum., Listeria monocytogenes

Viral = HSV, VZV, HIV, enteroviruses

Question 9

Meningococcal disease

Answer 9

Rapid onset fever
Non-blanching rash
Malaise
Sx of sepsis +/- meningitis

Question 10

Ix of meningitis

Answer 10

LP for CSF analysis (contraindicated if increased ICP)
Blood cultures
CT head if neurodeficit/decreased consciousness before LP

Question 11

CSF analysis for meningitis

Answer 11

Bacterial
= cloudy CSF, increased neutrophils (polymorphic), low glucose, high protein
Viral
= clear CSF, increased lymphocytes (mononuclear), normal glucose, normal/high protein
TB
= fibrin web CSF, increased lymphocytes (mononuclear), low glucose, high protein

Question 12

Mx of meningitis

Answer 12

GP
= benzylpenicillin IM
= urgent referral to hospital

A&E
= broad spectrum Abx (ceftriaxone IV/ benzylpenicillin IM, acyclovir if viral)
= consider IV dexamethasone (secondary to reduce cerebral oedema

Question 13

Complications of meningitis

Answer 13

Hearing loss, sepsis, impaired mental state => meningoencephalitis, seizures

Question 14

Meningitis vs encephalitis

Answer 14

Meningitis
= meninges
= bacterial, viral, TB
= consciousness impaired

Encephalitis
= brain parenchyma
= usually viral
= consciousness altered

Question 15

Encephalitis presentation

Answer 15

Acute onset of febrile illness w/ behavioural, cognitive and psychological manifestations
= viral prodrome (rash, lymphadenoatphy)
= fever, headache
= altered mental state (memory disturbances, personality changes, psychiatric manifestations, impaired consciousness)
= FATAL if not treated

Question 16

Causes of encephalitis

Answer 16

Viral (most commonly)
= HSV1/2, CMV, EBV, HIV, measles

Non-viral
= legionella, Lyme disease, listeria, malaria, TB, bacterial meningitis

Question 17

Ix for encephalitis

Answer 17

LP
Bloods
EEG
CT/MRI
= shows oedemal hyperintense lesions
= bitemporal oedema associated w/ herpes encephalitis

Question 18

Presentation of raised ICP

Answer 18

Bilateral, gradual headache, thorbbing/bursting pain, worse in morning and when coughing/sneezing

Vomiting, altered GCS, seizures may also occur

O/E focal neuro sx, papilloedema*, Cushing’s reflex (increased sBP, bradycardia, irregular breathing), Cheyne-Stoke respiration

Question 19

Ix for raised ICP

Answer 19

URGENT CT head
?SOL (tumour, abscess, haemorrhage), hydrocephalus

LP is completely contraindicated!!!!
= can cause brainstem herniation

Question 20

Extradural haemorrhage summary card

Answer 20

Blood pools between dura and bone
= head trauma hx, pterion, young (20-30 males), as bleeding continues leads to ipsilateral pupil dilation as CNIII externally compressed
= headache acute following lucid interval then becomes increasingly severe
= decreased GCS + sx of increased ICP
= urgent CT head shows lemon/lenticular shape that expands medially

Question 21

Subdural haemorrhage summary card

Answer 21

Blood pools between dural and arachnoid covering of brain
= rupture of bridging veins in elderly and alcoholics
= RFs include head trauma, falls, elderly, alcoholics, anticoagulation
= gradual and continous headaches, sx of increased ICP, personality changes, confusion, fluctuating consciousness
= urgent CT head shows banana/crescent shap

Question 22

Subarachnoic haemorrhage summary card

Answer 22

Bleed into subarachnoid space, likely due to rupture of saccular/berry aneurysm
= RFs include alcohol, smoking, hypertension*, polycystic kidney disease, Ehler-Danos syndrome
= very severe ‘thunderclap’ headache, occipital/diffuse, meningism, sx of increased ICP
= urgent non-contrast CT head most sensitive within 12 hours
= if CT clear then LP shows xanthochromia and oxyhaemoglobin from 12hrs from onset

Question 23

Mx of subdural bleeds

Answer 23

ABCDE and neurosurgery referral:
Small (<10mm) + no significant neuro dysfunction
= observe
Large/significant neuro dysfunction
= Burr hole/craniotomy

Question 24

CNS tumour presentations based on type

Answer 24

Vestibular schwanomma (benign tumour of CNVIII)
= progressive deafness

Frontal lobe tumour
= apathy, impaired intellect, personality disturbance

Right parietal lobe tumour
= left homonymous hemianopia, left sided hemiparesis and sensory loss

Question 25

Sx of CNS tumours

Answer 25

Bilateral and gradual headaches w/ throbbing/bursting pain
Focal neurological sx
Worse in morning, coughing and sneezing
Difficulty walking 
Seizures
Personality changes
Weakness
FLAWS

Question 26

RFs of CNS tumours

Answer 26

Hx of cancer, ionising radiation, FHx of cancer, neurofibromatosis, immunosuppression

Question 27

Ix for CNS tumours

Answer 27

CT (quick)
MRI (better resolution)
CXR, CT thorax, abdo + pelvis to check for mets
Biospy (definitive)

Question 28

Red flags in headaches

Answer 28

SNOOP:
S ystemic sx
= fever, wt loss, malignancy, HIV, meningism, pregnancy
N euro signs + sx
= papilloedema, hemiparesis, hemisensory loss, diplopia, dysarthria
O nset
= thunderclap, worst headache of life
O lder
= new headache at age >/= 50
P rogression of existing headache
= change in quality, frequency or location

Question 29

How do you manage med-overuse headaches?

Answer 29

Pt must stop all meds
Will be worse before it gets better
Must advise pts to not take analgesiscs > 2 days/week in order to avoid these headaches

Question 30

A 40-year-old man complains of a one-year history of 1 to 3
attacks per month of disabling pain over one temple, withnausea and sensitivity to light. He says that his headaches can be triggered by lack of sleep and made worse by
physical exertion. He has tried ibuprofen and NSAIDs but they don’t seem to have an effect and the headaches are being debilitating.

What’s the next most appropriate step
in his management?

A Codeine
B Diclofenac
C Sumatriptan
D Topiramate
E Amitriptyline

Answer 30

C Sumatriptan

Question 31

A 19-year old medical student presentEd to A & E with
headache, fever, and neck stiffness. Once raised ICP is
excluded a lumbar puncture is performed and CSF
analysis reveals the following:
High polymorphs, low glucose and high protein

Given the most likely diagnosis, which is the most likely
causative organism?

A Listeria monocytogenes
B HIV
C HSV
D Neisseria meningitidis
E VZV

Answer 31

D Neisseria meningitidis

Question 32

An older man with a longstanding history of AF on anticoagulation with warfarin is brought into A & E by his carer, who is concerned about the patient’s confusion at home. The carer describes frequent falls over the last several months. On examination, he has a right-sided pronator drift and is weaker on his right side. His mental status testing reveals poor concentration.

What is the most likely cause of his symptoms?
A Stroke
B Subdural haemorrhage
C Alzheimer’s disease
D Encephalitis
E Parkinson’s disease

Answer 32

B Subdural haemorrhage

Question 33

A 33-year-old woman attends her six-month follow-up appointment for headache. They are migrainous in nature but whereas she used to have them every few months, over the last three months she has experienced a chronic daily headache. She takes co-codamol qds and ibuprofen
tds.

What is the best medical management?
A. Stop all medication
B. Start paracetamol
C. Start sumatriptan
D. Start propranolol
E. Continue current medication

Answer 33

A. Stop all medication

Question 34

Plutarch is a 77-year-old male who has come in with a right
sided headache. This started yesterday morning and have
been getting progressively worse. His memory is a little off
because of his dementia, but he says there is a possibility of
trauma. His shoulders and neck also feel a little stiff. On
examination, there is pain on palpation of the right forehead.

A. Intracranial space-occupying lesions
B. Meningitis
C. Subarachnoid haemorrhage
D. Subdural haemorrhage
E. Temporal arteritis

Answer 34

E. Temporal arteritis

Question 35

Euclid is a 19-year-old male currently studying Maths at
university. He has been very unwell for the last few days with
fever and headache and admits to becoming a little confused
lately. He is very anxious about his upcoming exams. He has
been taking caffeine pills to help him with revision, however
this has affected his sleep and for the last couple of nights he
has developed a stiff neck.

A. Medication overuse headache
B. Meningitis
C. Migraine
D. Tension headache
E. Sinusitis

Answer 35

B. Meningitis

Question 36

a
Aphrodite, a 19-year-old female sex-worker presents to A&E
with a sudden onset headache that is the worst pain she has
ever experienced. She occasionally gets mild headaches after
sex and has been given some medication by her GP for his.
She has some neck stiffness and refuses to open her eyes
wide or allow them to be examined.

A. Acute glaucoma
B. Meningitis
C. Migraine
D. Subarachnoid haemorrhage
E. Trigeminal neuralgia

Answer 36

D. Subarachnoid haemorrhage

Question 37

Leonidas, a 24-year-old male, was fencing and suffered an
injury to the head when his rival, Xerxes hit him on the head
with his shield. Leonidas recovered quickly and was able to
continue to fight for the next 20 minutes. However he quickly
developed an excruciating headache, started to lose
consciousness and had to stop the fight to go to the nearest
A&E. He has had a blocked nose for the last week.

A. Epidural haemorrhage
B. Intraventricular haemorrhage
C. Meningitis
D. Subarachnoid haemorrhage
E. Subdural haemorrhage

Answer 37

A. Epidural haemorrhage

epidural = extradural

Question 38

Homer, a 45-year-old male has had excruciating headaches
for the last month. He gets them about 5 times a week and
notices his eyes watering. He had a similar episode 6 months
ago. They are very disruptive to his poetry.

A. Cluster headache
B. Intracranial space-occupying lesion
C. Migraine
D. Subarachnoid haemorrhage
E. Meningitis

Answer 38

A. Cluster headache

Question 39

Andromeda, a 32-year-old female presents with recurrent
headaches. They are severe, on the right side of her head and
often continue for the rest of the day. Before the headaches
start, she gets tingling in her arms, and when the headaches
start she goes to bed. She is worried they might affect her
relationship with her new boyfriend.

A. Cluster headache
B. Intracranial space-occupying lesion
C. Medication overuse
D. Migraine
E. Tension headache

Answer 39

D. Migraine

Question 40

Helen is a 40-year-old woman with a history of multiple
sclerosis. She has developed a headache over the last couple
of days. She has travelled the world and rarely had headaches
in the past. She has stopped eating, as chewing simply makes
her feel worse.

A. Meningitis
B. Migraine
C. Temporal arteritis
D. Tension headache
E. Trigeminal neuralgia

Answer 40

E. Trigeminal neuralgia

Question 41

Zeus, a 56-year-old man has been complaining of a headache that
has progressively worsened over the past three weeks. He has
tried taking simple analgesia, but the pain does not seem to go
away. On examination he has weakness in his lower right limb.
What is the most likely diagnosis?

A. CNS Tumour
B. Migraine
C. Cluster Headache
D. Subarachnoid Haemorrhage
E. Temporal Arteritis

Answer 41

A. CNS Tumour

Question 42

70-year-old Herodotus is brought in by his daughter to the
GP. Over the last week he has developed a headache which
lasts most of the day and rarely goes. He lives with his
daughter and son-in-law as he is prone to falls due to his
recent left hip replacement. The daughter also mentions that
his father’s behavior has changed lately and tends to
exaggerate some of his stories.
What do you think is the most important step in your
management plan?

A. MRI scan
B. Routine CT scan
C. Sumatriptan + NSAIDs
D. Urgent CT scan
E. Watchful waiting

Answer 42

D. Urgent CT scan

Question 43

Alexander, known to his mates as Alex the Great, is a
32-year-old soldier who has just returned from a tour in Iran. He
tells you that he has been getting throbbing bilateral head pain
and puts this down to lack of sleep. As a general, he has
multiple reports to write and is finding this difficult with his four
friends constantly bickering about one thing or the other. He
hasn’t tried any medication and asks that you prescribe some
sleeping pills. What is the most appropriate management?

A. Diazepam
B. Codeine
C. NSAIDs
D. Topiramate
E. Refer to A&E

Answer 43

C. NSAIDs

Question 44

Pythagoras is a 40-year-old man who suffers from headaches.
3 weeks ago he was prescribed ibuprofen and has taken it
religiously. Initially these worked well, however now the
headaches have returned and are worse than ever. He is very
angry and does not think you are taking the right angle
towards managing his issue. What is the next course of
management?

A. Antibiotics
B. Add a β-blocker
C. Refer to A&E
D. Switch medication to carbamazepine
E. Ask to stop ibuprofen and see in 2 weeks

Answer 44

E. Ask to stop ibuprofen and see in 2 weeks

Question 45

Hippocrates is a 71-year-old homeopath who presents with a
left sided headache which came on yesterday morning. He
tried to treat it with a clever paste made of garlic, vinegar and
honey. When he applied the paste he was in great pain, and
so believed that his remedy was working. However, his
skeptical son told him to see “another doctor” for treatment.
What is the most important next step?

A. Prescribe prednisolone and refer patient to A&E
B. Prescribe sumatriptan and send home
C. Refer to A&E for urgent CT scan
D. Refer to A&E for urgent non-contrast CT scan
E. Refer to A&E for MRI

Answer 45

A. Prescribe prednisolone and refer patient to A&E