Headaches

Question 1

What are the features of a migraine?

Answer 1

Moderate to severe intensity
Pounding or throbbing pain
Usually unilateral
Photophobia and photophonia
Aura may be present
Nausea and vomiting

Question 2

What are the features of a hemiplegic migraine?

What condition can it mimic?

Answer 2

Typical migraine symptoms
Sudden or gradual onset
Hemiplegia
Ataxia
Change in consiousness

Can mimic a stroke

Question 3

What is the acute and prophylactic management for migraines?

Answer 3

Acute:
Paracetamol
Triptans (50mg sumatriptan)
NSAIDs
Antiemetics if vomiting

Prophylaxis:
Propranolol
Topiramate - a teratogenic that can cause clef lip
Amitriptyline

Question 4

What are the features of tension headaches?

Answer 4

Tight-band headache
Bilateral
Associated with stress

Question 5

What can trigger a migraine?

Answer 5

Stress
Change in diet
Oral contraceptive pill
Exercise
Caffeine 
Alcohol

Question 6

What are the features of a cluster headache?

Answer 6

Excruciating headaches behind eye lasting a few hours, often twice a day at night
Occur in clusters for weeks then headache-free for months
Red, swollen and watering eye
Miosis
Ptosis
Nasal discharge
Facial sweating

Question 7

What group of patients are cluster headaches more common in?

Answer 7

Male

Smokers

Question 8

What is the management for cluster headaches?

Answer 8

Acute:
100% high flow oxygen
Triptan

Prophylaxis:
Verapamil

Question 9

What is the management for tension headaches?

Answer 9

Acute:
Aspirin, paracetamol or NSAIDs

Prophylaxis:
Acupuncture
Low-dose amitriptyline

Question 10

What are the features of temporal arteritis?

Answer 10

>50s
Rapid onset unilateral headache
Jaw claudication 
Scalp tenderness
Visual disturbances
Tender, palpable temporal artery

Question 11

What are the features of a subarachnoid haemorrhage?

Answer 11

Sudden onset severe headache that feels like being hit by baseball bat
Meningism - photophobia, neck stiffness 
Nausea and vomiting
Coma
Seizures
Sudden death
ECG changes including ST elevation

Question 12

What can cause spontaneous SAH?

Answer 12

Diseases associated with intracranial aneurysm:
Adult polycystic kidney disease
Ehlers-Danlos syndrome
Coarctation of aorta

AV malformation

Question 13

What investigations is carried out in SAH?

Answer 13

CT head

Lumbar puncture:
Used if unable to confirm SAH on CT
Perform it 12 hours after onset of symptoms
Presence of xanthochromia and normal or raised opening pressure = SAH

Question 14

What can cause raised ICP?

Answer 14

Idiopathic intracranial hypertension
Trauma
Meningitis
Tumours
Hydrocephalus

Question 15

What are the features of raised ICP?

Answer 15

Severe headache that is worse in morning, when coughing, lying down, bending over or during valsalva manoeuvre 
Vomiting
Visual disturbances
Seizures
Neurological symptoms
Reduced levels of consciousness
Papilloedema

Question 16

What are the features of trigeminal neuralgia?

Answer 16

Intense facial pain lasting for seconds - hours

Electric shock pain

Question 17

What is the management for trigeminal neuralgia?

Answer 17

Carbamazepine

Question 18

What are the red flag symptoms for serious conditions causing headaches?

Answer 18

Fever, photophobia or neck stiffness (meningitis or encephalitis)
New neurological symptoms (haemorrhage, malignancy or stroke)
Dizziness (stroke)
Visual disturbance (temporal arteritis or glaucoma)
Sudden onset occipital headache (subarachnoid haemorrhage)
Worse on coughing or straining (raised intracranial pressure)
Postural, worse on standing, lying or bending over (raised intracranial pressure)
Severe enough to wake the patient from sleep
Vomiting (raised intracranial pressure or carbon monoxide poisoning)
History of trauma (intracranial haemorrhage)
Pregnancy (pre-eclampsia)

Question 19

What medication can be used to lower raised ICP?

Answer 19

Mannitol

If raised ICP is due to tumour, use dexamethasone