It's all in the mind

Question 1

What is a migraine?

Answer 1

Migraines are a complex neurological condition that cause headache and other associated symptoms. They occur in “attacks” that often follow a typical pattern.
A recurrent headache associated with both visual and gastrointestinal disturbance.

Question 2

What are the symptoms of a migraine?

Answer 2

Unilateral intense headache
Moderate or severe throbbing sensation
Aggravated by daily activities
Discomfort with lights (photophobia)
Discomfort with loud noises (phonophobia)
With or without aura
Nausea and vomiting
Lasts between 4 hours and 3 days

Question 3

How common are migraines?

Answer 3

10% prevalence
Sometimes a strong family history
Before age 30 years

Question 4

What causes migraines?

Answer 4

Unknown
Due to vasodilatation or oedema of blood vessels, with stimulation of the nerve ending near affected extracranial meningeal arteries. This vasodilatation is thought to be caused by nitric oxide, 5-hydroxytryptamine and neuropeptide C-related peptide.

Question 5

What are aura symptoms?

Answer 5

Sparks in vision
Blurring vision
Lines across vision
Loss of different visual fields
Aura symptoms typically develop over the course of about 5 minutes and last for up to an hour.

Question 6

What are the different types of migraine?

Answer 6

Migraine without aura
Migraine with aura
Silent migraine (migraine with aura but without a headache)
Hemiplegic migraine

Question 7

What are Hemiplegic migraines?

Answer 7

Hemiplegic migraines can mimic stroke. It is essential to act fast and exclude a stroke in patients presenting with symptoms of hemiplegic migraine.
Symptoms: Typical migraine symptoms, sudden or gradual onset, hemiplegia (unilateral weakness of the limbs), ataxia, changes in consciousness

Question 8

What are some common triggers of migraines?

Answer 8

CHeese and chocolate
Oral contraceptive pill
Caffeine
AlcohOL
Anxiety
Travel
Exercise

Question 9

What are the 5 stages of migraines?

Answer 9

Premonitory or prodromal stage (can begin 3 days before the headache) - subtle symptoms
Aura (lasting up to 60 minutes)
Headache stage (lasts 4-72 hours)
Resolution stage (the headache can fade away or be relieved completely by vomiting or sleeping)
Postdromal or recovery phase

Question 10

What is the acute treatment for migraines?

Answer 10

Avoid trigger factors
Paracetamol
Triptans (e.g. sumatriptan 50mg as the migraine starts)
NSAIDs (e.g ibuprofen or naproxen)
Antiemetics if vomiting occurs (e.g. metoclopramide)

Question 11

What is the prophylaxis for migraines?

Answer 11

Headache diary
Propranolol (beta blocker)
Topiramate (this is teratogenic and can cause a cleft lip/palate so patients should not get pregnant)
Amitriptyline at night is sometimes useful
Acupuncture is an option recommended by NICE for the treatment of migraines. It is reported to be as effective as prophylactic medications.
Supplementation with vitamin B2 (riboflavin) may reduce frequency and severity.
NSAIDS (e.g. mefanamic acid) or triptans (frovatriptan or zolmitriptan)

Question 12

What is domestic abuse?

Answer 12

Domestic violence, also called domestic abuse, includes physical, emotional and sexual abuse in couple relationships or between family members.

Question 13

What are the different types of abuse?

Answer 13

Emotional abuse
Physical abuse
Sexual abuse
Threats and intimidation

Question 14

How would you support someone experiencing domestic abuse?

Answer 14

Listen
Acknowledge their difficult situation
Refer if they have experienced physical abuse
Help them to report it to the police if they choose to
Be ready to provide information about organisations that offer help

Question 15

What is a space occupying lesion?

Answer 15

A space-occupying lesion of the brain is usually due to malignancy but it can be caused by other pathology such as an abscess or a haematoma.

Question 16

How would a space occupying lesion present?

Answer 16

A new headache with features suggestive of raised intracranial pressure, including papilloedema, vomiting, posture-related headache, or headache waking the patient from sleep.
A new headache with focal neurological symptoms, or non-focal neurological symptoms such as blackout, and change in personality or memory.
An unexplained headache that becomes progressively severe.
An unexplained headache in anyone previously diagnosed with cancer or HIV.
A new onset of epileptic seizures.

Question 17

What symptoms could indicate a space occupying lesion?

Answer 17

Tension-type presentation or migraine
Vomiting
Nausea
Change in mental status or a behavioural change
Weakness, ataxia or disturbance of gait
Deficits of speech or vision
Generalised convulsions

Question 18

What are the red flags for headaches?

Answer 18

Sudden onset
New headache over the age of 50
Abnormal neurological signs
Headache changing with posture (Indicating raised ICP)
Headache made worse by coughing, sneezing, bending, straining (May indicate raised ICP)
Fever
History of HIV
History of cancer

Question 19

What would you include in a history for a headache?

Answer 19

Onset, duration, frequency and temporal pattern
Pain characteristics including severity, site and spread of pain
Associated symptoms: aura, nausea, photophobia, phonophobia, autonomic symptoms, systemic and neurological features
Precipitating and relieving factors
Comorbidities and PMH
Drugs history

Question 20

What would you include in an examination for a headache?

Answer 20

Vital signs
General appearance and mental state
Extracranial structures - carotid arteries, temporal arteries, sinuses and temporomandibular joints
Look for signs of meningeal irritation, tenderness of cervical paraspinal muscles, limitation in range of movement and crepitation in the neck.
Fundoscopy (looking for papilledema, pupillary asymmetry and reactivity).
Cranial nerve examinations

Question 21

How would you test CNI?

Answer 21

Olfactory

Test each nostril separately by asking the patient to close one nostril and smell different odours from small bottles.

Question 22

How would you test CNII?

Answer 22

Optic
Test visual acuity using a Snellen’s charts.
Test coloured vision using pseudo – isochromatic plates.
Test visual fields with either confrontation test or using perimeter. The Red Pin test can also be used to outline the central field.
Ophthalmoscopy is essential to visualise the optic disc.

Question 23

How would you test CNIII, IV and VI?

Answer 23

Oculomotor, Trochlear, Trigeminal
Tested together as they control the external ocular muscles responsible for ocular movements.
Ask the patient to look at and follow your finger (Each eye separetly and both simultaneously) and make a H shaped movement.

Question 24

How would you test CNV?

Answer 24

Trigeminal
Sensory: Test all sensory modalities at the three main branches.
Motor: Test the temporal and masseter muscles by asking patient to clench their teeth.

Question 25

How would you test CNVII?

Answer 25

Facial
Ask patient to shut their eyes as tight as possible, then raise their eyebrows, then smile and whistle at you. Also taste sensation on the anterior 2/3 of the tongue.

Question 26

How would you test CNVIII?

Answer 26

Vestibulocochlear

Simply whisper in each ear and ask patient to repeat. Use a vibrating tuning fork to perform Rinne and Weber tests.

Question 27

How would you test CNIX?

Answer 27

Glossopharyngeal

Tickle the back of the pharynx for the sensory branch of the IX and not if reflex contraction occurs.

Question 28

How would you test CNX?

Answer 28

Vagus

Tickle the back of the pharynx for motor branch (Palatal or ‘gag’ reflex)

Question 29

How would you test CNXI?

Answer 29

Accessory
Test the function of the Trapezius muscle by asking patient to shrug their shoulders against resistance and of the Sternocleidomastoid muscle by asking patient to turn head on each side against resistance.

Question 30

How would you test CNXII?

Answer 30

Ask patient to put out the tongue as far as possible is it straight or deviated to one side.

Question 31

What investigations would you do to diagnose a headache?

Answer 31

Investigations are generally not required to diagnose primary headache.
Arrange review and ask the person to keep a diary over a few weeks to record frequency, duration and severity of headaches; associated symptoms; all prescribed and over the counter medications taken to relieve headaches and possible triggers.

Question 32

What features indicate a serious cause of headache?

Answer 32

New severe or unexpected headache:
Sudden onset - intracranial haemorrhage, venous sinus thrombosis, hypertensive encephalopathy and vertebral artery dissection
New onset in over 50s - giant cell arteritis or space occupying lesion
Progressive or persistent headache or headache that has changed dramatically
Associated symptoms

Question 33

What does a thunderclap headache suggest?

Answer 33

Subarachnoid haemorrhage, venous sinus thrombosis, bacterial meningitis, spontaneous cerebral spinal fluid leak, carotid dissection and hypertensive encephalopathy.

Question 34

If there is a patient with a headache with a change in neurological function?

Answer 34

Urgent direct access for MRI scan of the brain within 2 weeks
Very urgent referral (within 48 hours) should be considered to assess for suspected brain or CNS cancer in young people

Question 35

What is a progressive headache?

Answer 35

A headache that worsens with time can be due to a progressive intracranial lesion such as tumour, subdural hematoma or hydrocephalus.