Neurology

Question 1

Classic explanation of a tension headache

Answer 1

Tight band across the head

Question 2

Causes of tension type headache

Answer 2

Most common: psychological stress

Others: sleep disturbance, extended periods of mental tension

Question 3

Typical age of onset of tension headaches

Answer 3

20-30s

Question 4

Pathophysiology of tension headache

Answer 4

release and activation of inflammatory agents leads to sensitisation of peripheral trigeminal afferents and ultimately in central hypersensitivity

Question 5

RFs for tension headache

Answer 5

Stress
Missing meals
Sleep disturbance
Mental tension

Question 6

Clinical presentation of tension headache

Answer 6

generalised head pain 
frontal or occipital head pain 
non-pulsatile head pain 
constricting pain 
normal neurological examination

Question 7

Differentials of CHRONIC headache

Answer 7

MMM IT ACHES

MIGRAINE
MENINGITIS
MEDICATION
ICP CHANGE
TENSION HEADACHE, TEMP. ART. , TRIGEM. NEURALGIA
ARTERIOVENOUS ABNORMALITIES
CLUSTER
HTN , HAEMORRHAGE 
EYE (GLAUCOMA)
SINUSITIS, SYSTEMIC ILLNESS

Question 8

Differentials of ACUTE headache

Answer 8

VICIOUS

VASCULAR: haemorrhage, infarction
INFECTION / INFLAMM.
COMPRESSION: obstructive hydrocephalus, pit. tum. 
ICP: spont/ intracranial hypoten. 
OPHTHALMIC: acute glaucoma
UNKNOWN: situational factors
SYSTEMIC: HTN, CO poisoning

Question 9

Mx of tension headaches

Answer 9

In the acute patient: simple analgesia
In the chronic patient (>7 episodes per month):
-low dose antidepressant i.e. amitriptyline
-+ non pharmacological relaxation therapies

Question 10

Key descriptive features of SAH

Answer 10

Sudden onset (thunderclap)
Worst pain ever
Occipital localisation

Question 11

What is a migraine?

Answer 11

Chronic, genetically determined, episodic disorder presenting with a severe headache causing disability

Question 12

Epidemiology of migraine

Answer 12

F>M = 2:1
Common condition, more so in the west
Prevalence around 8%

Question 13

Pathology of migraines

Answer 13

1. neurogenic inflammation of first-division trigeminal sensory neurons that innervate the large vessels and meninges of the brain
2. trigeminal neurons release substances that cause dilation of meningeal blood vessels, leakage of plasma proteins into surrounding tissue, and platelet activation
3. Sensitises peripheral nerves so that small things like pulsing is considered as pain
4. If the headache continues, second- and third-order neurons are sensitised (central sensitisation) and cutaneous stimuli, such as light touch, are interpreted as painful

Question 14

Migraine RFs

Answer 14

Female
Stress
Overuse of headache medication
\+ FHx
Menstruation
Obesity
Patent Foramen Ovale
Lack of sleep

Question 15

Presentation of migraine

Answer 15

Headache worse with activity
Nausea
Long term headache
Inability to function normally
Sensitivity to light

Question 16

What may come on before a full blown migraine

Answer 16

Aura (changes to vision but no vision loss)

Question 17

What are some features of prodrome

Answer 17

Yawning
Food cravings
Change to sleep pattern, appetite or mood

Question 18

Diagnostic criteria for migraine

Answer 18

Aura + headache or

• > 5episodes of headache + n/v + photophobia + >2:
• • unilateral
• • pulsating
• • inability to function
• • worse on activity

Question 19

Triggers of migraine

Answer 19

CHOCOLATE

CHeese
OCP (contraceptive pill)
Caffeine
alcohOL
Anxiety
Travel
Exercise

Question 20

Mx of migraine

Answer 20

Acute episode

1. analgesia + magnesium therapy (sumatriptan)
2. NSAID (ketoprofen)
3. Rizatriptan

Question 21

Prophylaxis of migraine

Answer 21

Avoid triggers

1. Propanolol + topiramate / amitriptyline
2. Valporate, pizotifen, gabapentin

Question 22

Cluster headache presentation

Answer 22

Rapid onset
Pain around one eye
Red, watery eye
Miosis, ptosis
15min-3hrs duration

Question 23

Epidemiology of SAH

Answer 23

6-8/100K

Average age of onset 35-65

Question 24

Causes of SAH

Answer 24

Most commonly rupture of saccular aneurysm (80%)

Arteriovenous malformations account for the rest

Question 25

Common sites for aneurysms to form

Answer 25

Junctions between:

1. AComm/ACA
2. ICA/PComm
3. MCA Bifurcation

Question 26

Which individuals should be screened for aneurysms?

Answer 26

Those with auto. dom. polycystic kidney disease

Those with 1st/2nd relatives that have had a SAH

Question 27

RFs for SAH

Answer 27

Smoking
Drinking
HTN
\+FHx
ADPKD
Bleeding disorders
Mycotic aneurysms

Question 28

Clinical presentation of SAH

Answer 28

Sudden onset
Vomiting
LoC
'Worst pain ever'
Photophobia
Neck stiffness
Seizures

Question 29

Signs in SAH

Answer 29

+ kernigs

Question 30

Ix in SAH

Answer 30

CT head detected >90% within 48hrs

LP if CT -ve + >12hrs post headache. Will look bloody then xanthacromia will develop (Yellow CSF)

Question 31

Mx of SAH

Answer 31

Refer to neurology
Frequent neuro obs
Maintain cerebral perfusion
Nimodipime for 3 weeks to reduce vasospasm
Surgery with clipping or coiling

Question 32

Complications of SAH

Answer 32

Rebleed
Cerebral ischaemia
Hydrocephalus
Hyponatremia