Headaches and migraines

Question 1

Red flag symptoms with headaches (1)
1) If there’s fever, photophobia or neck stiffness associated, what 2 serious diagnoses should be considered?
2) If there’s new neurological symptoms, what 3 serious diagnoses should be considered?
3) If there’s dizziness, what serious diagnosis should be considered?
4) If there’s visual disturbances, what 2 serious diagnosis should be considered?

Answer 1

1) Meningitis, encephalitis
2) Haemorrhage, malignancy, stroke
3) Stroke
4) Glaucoma, temporal arteritis

Question 2

Red flag symptoms with headaches (2)
1) If there’s sudden onset occipital headache, what serious diagnosis should be considered?
2) If the headache is worse on coughing or straining, what serious diagnosis should be considered?
3) If there’s vomiting, what 2 serious diagnosis should be considered?
4) If there’s history of trauma, what serious diagnosis should be considered?
5) If the patient is pregnant, what serious diagnosis should be considered?

Answer 2

1) Subarachnoid haemorrhage
2) Raised ICP
3) Raised ICP, carbon monoxide poisoning
4) Intracranial haemorrhage
5) Pre-eclampsia

Question 3

Tension headaches
1) What do tension headaches typically cause?
2) This can be caused by a muscle ache - name 2 of these muscles
3) Name 2 things that tension headache onset is associated with

Answer 3

1) Mild ache across the forehead and in a band-like pattern around the head
2) Temporalis, frontalis, occipitalis
3) Stress, depression, alcohol, skipping meals, dehydration

Question 4

Secondary headaches
1) Even though secondary headaches present similarly to tension headaches, how are they different?
2) Name 2 causes of a secondary headache

Answer 4

1) They have a clear cause
2) Underlying medical conditions i.e. infection, obstructive sleep apnoea or pre-eclampsia, alcohol, head injury, carbon monoxide poisoning

Question 5

Sinusitis
1) The inflammation that occurs in sinusitis causes a headache and what else?
2) Is sinusitis often viral or bacterial?

Answer 5

1) Facial pain behind the eyes, nose and forehead
2) Viral

Question 6

Trigeminal neuralgia
1) How does it present?
2) How is it often described as?
3) Are most cases unilateral or bilateral?
4) What is the first line treatment?

Answer 6

1) Intense facial pain sensitive to touch
2) Electricity-like shooting pain
3) Unilateral
4) Carbamazepine

Question 7

Cluster headaches
1) Are cluster headaches usually unilateral or bilateral?
2) Name 2 symptoms of cluster headaches
3) What is the classic cluster headache patient?
4) What medication can be given in the acute management of a cluster headache, and which drug within this group is usually used?
5) What else is given in an acute attack?
6) What is the drug of choice for prophylaxis?
7) How long does an episode typically last?

Answer 7

1) Unilateral
2) Intense, sharp, piercing pain around eye, red, swollen and watering eye, pupil constriction (miosis), eyelid drooping (ptosis), nasal discharge, facial sweating
3) 30–50 year-old male smoker
4) Triptans - subcutaneous sumatriptan
5) 100% oxygen
6) Verapamil (prednisolone can also be used)
7) 1-2hrs

Question 8

Migraine (1)
1) Name 3 migraine symptoms
2) What is an aura?
3) Name 2 features of an aura
4) What condition can a hemiplegic migraine mimik?
5) Symptoms of a hemiplegic migraine can vary significantly, but name 2 possible symptoms

Answer 8

1) Moderate to severe, pounding or throbbing headache that’s usually unilateral, photophobia, phonophobia, aura sometimes, nausea and vomiting
2) Visual changes associated with migraines
3) Sparks in vision, blurring vision, lines across vision, loss of different visual fields
4) Stroke
5) Typical migraine symptoms, hemiplegia, ataxia, changes in consciousness

Question 9

Migraine (2)
1) Name 3 potential triggers of a migraine
2) What are the 5 stages of a migraine?
3) Name 2 medications that can be used in the management of a migraine
4) What kind of drugs are triptans?
5) Name 1 of their mechanisms of action

Answer 9

1) Stress, bright lights, strong smells
Certain foods (e.g. chocolate, cheese and caffeine), dehydration, menstruation, abnormal sleep patterns, trauma, alcohol
2) Prodrome, aura, headache, resolution, postdrome
3) Paracetamol, triptans, NSAIDs, antiemetics
4) 5HT receptors agonists
5) Cause vasoconstriction, Inhibit activation of pain receptors, reduce neuronal activity in the central nervous system

Question 10

Migraine (3)
1) Name 2 medications or treatments that can be used for migraine prophylaxis
2) In migraines specifically caused by menstruation, what can be given as a prophylactic measure?
3) An adverse effect of triptans is triptans sensation - name 2 of these sensations
4) What is the main contraindication of triptans?

Answer 10

1) Medications i.e. propranolol, topiramate and amitriptyline. Acupuncture, vitB12 supplementation
2) NSAIDs or triptans
3) Heat, tingling, chest or throat tightness, heaviness, pressure
4) Px with a history or significant risk factors for IHD or cerebrovascular disease

Question 11

Name a medication that increases risk of medication overuse headache

Answer 11

• Triptans
• Opioids
• Analgesics i.e. paracetamol

Question 12

1) What is paroxysmal hemicrania characterised by?
2) How is it managed?

Answer 12

1) Severe unilateral temporal/orbital/supraorbital headache lasting less than 30mins normally. Associated autonomic features
2) Indomethacin