Neurology - headache

Question 1

Differential diagnosis in headache

Answer 1

Primary headaches e.g. tension, migraine, cluster

Sinusitis

GCA

Intracranial or subarachnoid haemorrhage

Analgesia overuse headache

Hormonal headache

Trigeminal neuralgia

Raised ICP e.g. due to SOL

Meningitis/Encephalitis

Cervical spondylosis

Question 2

Red flags in headache

Answer 2

Fever, photophobia or neck stiffness (meningitis or encephalitis)

New neurological symptoms (haemorrhage, malignancy or stroke)

Visual disturbance (temporal arteritis or glaucoma)

Sudden onset occipital headache (subarachnoid haemorrhage)

Worse on coughing or straining (raised intracranial pressure)

Postural, worse on standing, lying or bending over (raised intracranial pressure)

Severe enough to wake the patient from sleep

Vomiting (raised intracranial pressure or carbon monoxide poisoning)

History of trauma (intracranial haemorrhage)

Question 3

Which general examination is important when assessing a headache if suspect a raised ICP (but also probably generally)

Answer 3

Fundoscopy to look for papilloedema

Papilloedema indicates raised intracranial pressure, which may be due to a brain tumour, benign intracranial hypertension or an intracranial bleed.

Question 4

Tension headaches are associated with

Answer 4

Stress
Depression
Alcohol
Skipping meals
Dehydration

Question 5

Treatment of tension headaches

Answer 5

Reassurance
Basic analgesia
Relaxation techniques
Hot towels to local area

Question 6

Classic presentation of sinusitis? Treatment

Answer 6

Facial pain behind the nose, forehead and eyes

There is often tenderness over the affected sinus

Resolves in 2-3 weeks and is typically viral

Nasal irrigation with saline can help

Prolonged symptoms can be treated with nasal spray

Antibiotics only occasionally needed

Question 7

What is the presentation of hormonal headache?

Answer 7

They produce a generic, non-specific, tension-like headache.

They tend to be related to low oestrogen:

• Around the start of menstrual period
• Around the menopause
• Pregnancy

COCP can improve hormonal headaches

Question 8

Cervical spondylosis presentation

Answer 8

Degenerative changes in the cervical spine.

It causes neck pain, usually made worse by movement.

However, if often presents with headache.

Important to exclude other causes of neck pain e.g. inflammation, malignancy, infection, and spinal cord or nerve root lesions.

Question 9

How does trigeminal neuralgia present?

Answer 9

Facial pain that comes on spontaneously and can last anywhere between a few seconds and hours

Electric like shooting pain

Mostly (90%) unilateral

Can affect any of combination of the three branches of CN5

Question 10

What may cause trigeminal neuralgia?

Answer 10

The cause is unclear but it is thought to be caused by compression of the nerve.

Question 11

How is trigeminal neuralgia treated?

Answer 11

Carbamazepine is first line

Surgery to decompress or intentionally damage CN5 is also an option

Question 12

Differential diagnosis for facial pain

Answer 12

Trigeminal neuralgia

Cluster headaches

Temporomandibular or dental cause - ask about pain on eating

Sinusitis

Ramsay Hunt syndrome (VZV reactivation - same virus that causes chickenpox)