ILA 3 - Headache and domestic abuse

Question 1

Mnemonic for predicting migraine likelihood

(92% sensitivity in patients who report at least four of the five POUND symptoms, 64% in patients with three of the symptoms, and 17% in patients with two or less).

Answer 1

Pulsatile nature
One day duration (4 - 72h)
Unilateral
Nausea/vomiting
Disabliing

Question 2

Red flags for headache.

- Mnemonic: SNOOP

Answer 2

Systemic symptoms (fever, weight loss, vomiting)
Neurological symptoms
Onset new or changed and > 50 years (first or worst)
Onset sudden (thunderclap)
Papilloedema, positional, precipitated by cough/exercise, pulsatile tinnitus (?carotid stenosis)

Question 3

Migraine.

a) Acute treatment
b) Preventive
c) If aura - avoid what class of drugs

Answer 3

a) Paracetamol/NSAID +/- oral triptan. (+/- anti-emetic)
b) Propanolol, topiramate, avoid triggers, riboflavin (vitamin B2), acupuncture, Botox
c) COCP

Question 4

TTH.

a) Acute treatment
b) Preventive

Answer 4

a) Paracetamol/NSAIDs (avoid opioids!)

b) Acupuncture

Question 5

Cluster.

a) Acute treatment
b) Preventive

Answer 5

a) Oxygen + SC/nasal triptans (not oral)

b) Verapamil (must do ECG monitoring), corticosteroids

Question 6

Medication-overuse headache.

a) Acute treatment. Advise patients what?
b) Preventive treatment

Answer 6

a) Abrupt withdrawal of all headache medications (worst offenders: triptans and opioids). Advise patients that they will get worse for about a month
b) Prophylactic treatment for underlying headache disorder

Question 7

Medication-overuse headache: definition

Answer 7

Headache in patients with a pre-existing primary headache disorder that:

• Occurs on ≥15 days per month
• For >3 months
• And is caused by overuse of medication intended for acute or symptomatic headache treatment

Question 8

Headache investigations.

a) NICE guidance
b) Acutely red, painful eye - gold standard investigation?

Answer 8

a) Investigations not necessary for primary headache diagnosis; only necessary if secondary/serious cause suspected
b) Ocular pressure measurment - AACG

Question 9

Domestic abuse.

a) 5 types

Answer 9

a) Sexual, physical, emotional, financial, neglect

Question 10

Domestic abuse.

a) Risk factors
b) When to suspect

Answer 10

a) - Female, pregnant, history of abuse, known violent partner, mental health issues, substance misuse

b) - Depression, tiredness, chronic pain, tearfulness, self-harm
- Injuries, genital injuries, STIs

Question 11

Domestic abuse: HARK consultation method

Answer 11

Humiliation: “In the last year, have you been humiliated or emotionally abused in other ways by your partner?” “Does your partner make you feel bad about yourself?” “Do you feel you can do nothing right?”

Afraid: “In the last year have you been afraid of your partner or ex-partner?” “What does your partner do that scares you?”

Rape: “In the last year have you been raped by your partner or forced to have any kind of sexual activity?” “Do you ever feel you have to have sex when you don’t want to?” “Are you ever forced to do anything you are not comfortable with?”

Kick: “In the last year have you been physically hurt by your partner?” “Does your partner threaten to hurt you?”

Question 12

Domestic abuse: management

Answer 12

• Risk assessment (including any children/ dependents)
• Initiate child protection/ safeguarding measures if appropriate
• Be supportive
• Refer to mult-agency risk assessment conference (MARAC)
• Involve independent domestic violence adviser (IDVA)