Neuro - Headaches

Question 1

A 27yo woman presents to the GP with occasional severe, unilateral, throbbing headaches associated with nausea and photophobia.
She has tried ibuprofen and aspirin for these, to no effect.
Which medication would you suggest to help with these acute episodes? What is the MOA? What are the contraindications?

Answer 1

SUMATRIPTAN 50-100mg PO (or SC/intranasal) to be taken at start of headache.

Selective stimulation of 5-hydroxytryptamine receptors in brain.

CI: coronary heart disease, cerebrovascular disease, uncontrolled HTN

Question 2

A 22yo woman presents to the GP with 4-5 acute migraine attacks per month. Triptans only partially help. Which medications would you suggest as prophylaxis? What are their contraindications?

Answer 2

1. PROPRANOLOL - CI: asthma, PVD

2. TOPIRAMATE - CI: pregnancy, depression - not in women of child-bearing age

Question 3

A 32yo man is urgently referred to a neurologist for ?cluster headaches.
What treatment can help during an acute attack? If attacks occur frequently and last >3/52, what treatment can be used as prophylaxis?

Answer 3

Acute:

1. 100% O2 12-15L for 15mins up to 5x/day
2. SC SUMATRIPTAN

Prophylaxis:

1. VERAPAMIL daily
2. PREDNISOLONE (short-term prophylaxis)

Question 4

A 47yo man is brought to ED. He is confused and complains of an extremely severe headache after ‘someone hit him behind the head with a baseball bat’.

What is the likely diagnosis? What signs might you find on examination?

Answer 4

Subarachnoid haemorrhage

O/E:

• meningism e.g. photophobia, neck stiffness
• focal neuro. signs e.g. oculomotor n. palsy
• unilateral dilated pupil
• intraocular haemorrhages (on fundoscopy)
• reduced GCS, coma, seizures

Question 5

What are the common causes of SAH?

Answer 5

1. head trauma (most common)
2. ruptured intracranial arterial aneurysm (85%)
3. non-aneurysmal peri-mesencephalic haemorrhage (10%)
4. AVM, vasculitis, tumour (5%)

Risk factors:

• connective tissue disease e.g. Marfan’s syndrome, EDS, APKD
• HTN
• smoking
• cocaine

Question 6

A 47yo man is brought to ED. He is confused and complains of an extremely severe headache after ‘someone hit him behind the head with a baseball bat’.

How would you investigate this patient?

Answer 6

1. urgent non-contrast CT brain
2. bloods: FBC, U&Es (?SIADH), clotting, troponin, glucose
3. ECG (abnormal in 50%)

if CT -ve: LP >12hrs post-onset (?xanthochromia)

if SAH confirmed: CT/MR angiography

Question 7

A 47yo man is brought to ED. He is confused and complains of an extremely severe headache. SAH is confirmed after CTB + CT angiography. How should this patient be managed?

Answer 7

1. Urgent referral to neurosurgeons.
2. NIMODIPINE PO/NG asap for 21/7 (cerebral vasodilator - to prevent delayed cerebral ischaemia and prevent vasospasm)
3. secure aneurysm within 48hrs by:
   - endovascular coiling OR
   - surgical clipping
4. other measures:
   - stop any anticoagulants/anti-platelets
   - analgesia e.g. paracetamol, codeine, tramadol, morphine
   - stool softener e.g. docusate + antiemetic e.g. promethazine
   - if hydrocephalus: external ventricular drain

Question 8

A 31yo obese woman is urgently referred to neurology due to 1mth Hx of:

• headaches: generalised throbbing, worse in early morning and on straining
• N+V
• blurred vision

O/E papilloedema + RAPD is seen.

What is the likely diagnosis? How would you investigate?

Answer 8

Idiopathic intracranial hypertension

Ix to rule out other causes of RICP:

1. bloods: FBC, CRP, iron studies, ANA, coagulation screen
2. MRI brain: normal or decreased size ventricles (cf. hydrocephalus)
3. visual field assessment: enlarged blind spot + peripheral field constriction
4. LP (once imaging rules out intracranial mass): opening pressure >250 mmH20

Question 9

A 31yo obese woman referred to neurology due to headaches is diagnosed with idiopathic intracranial HTN.
What options are included in management?

Answer 9

1. eliminate causal factors
   - weight loss: usually aim for 5-10% loss
   - discontinue causative medications e.g. COCP, tetracyclines, lithium, vitA
2. medications
   - acute: PREDNISOLONE (to relieve headache + papilloedema)
   - chronic: ACETAZOLAMIDE PO or 2nd line: TOPIRAMATE or FUROSEMIDE
   - serial LPs
3. analgesia: AMITRIPTYLINE or NAPROXEN
4. if other measures ineffective:
   - optic nerve sheath fenestration
   - CSF diversion e.g. ventriculo-peritoneal shunt

Question 10

A 70yo lady presents to the GP due to an ongoing severe temporal headache in the past week. It is mainly on the right side of her head and is worse when she brushes her hair. She also reports 2 episodes of visual disturbance in her right eye, like a ‘curtain coming down’.

What is the likely diagnosis and how would you investigate?

Answer 10

GCA

1. Bloods: CRP/ESR (>50), FBC, LFTs
2. Temporal artery USS: wall thickening, stenosis or occlusion
3. Temporal artery biopsy: granulomatous inflammation +/- multinucleated giant cells

Question 11

How would you manage a patient presenting with suspected GCA?

Answer 11

1. steroids asap:
   - if no ischaemic Sx: PREDNISOLONE 40mg PO OD
   - if ischaemic Sx (e.g. jaw claudication): PREDNISOLONE 60mg PO OD
   - if visual Sx: METHYLPREDNISOLONE IV
2. ASPIRIN 75mg OD
3. prophylaxis:
   - bisphosphonates e.g. ALENDRONATE
   - PPI e.g. OMEPRAZOLE