S5 Managing headaches

Question 1

What are the red flags to look out for in a history of headaches? (6)

Answer 1

Cognitive effects
Seizures
Fever
Visual disturbance
Vomiting
Weight loss

Question 2

What is the presentation of a SAH? (5)

Answer 2

Awakens with severe sudden onset headache “thunderclap”.
Vomiting, confusional, hyper-reflexia.
Possible 3rd nerve palsy means pupils unresponsive.

Question 3

What is the management of a SAH? (3)

Confirmation?

Answer 3

Resuscitation. Pain relief.
Refer to neuro team (berry aneurysm clipping).
If CT normal get LP. Will show xanthocromia (bilirubin release). -ve LP and CT rule out SAH.

Question 4

How does raised ICP present? (5)

Answer 4

Headache (worse on lying)
Vomiting
Seizures
Papillodema
Laterialising signs.

Question 5

What are the causes of raised ICP? (5)

Answer 5

Mass effect
Swelling
Increased venous pressure (hypertensive encephalopathy)
CSF outflow obstruction
Increased CSF production (meningitis/SAH).

Question 6

How does temporal arteritis present?

Who. Symptoms (5). Bloods.

Answer 6

Female over 60yrs.
Weight loss, myalgia, transient vision loss, jaw claudication, tender non-pulsatile temporal artery.
ESR often raised.

Question 7

How is temporal arteritis treated?

Answer 7

Immediate high dose steroids if suspected.

Response is excellent in 48hrs.

Question 8

How does migraine present? (6)

Answer 8

10% prodrome
30% aura (usually visual)
Unilateral headache
Nausea
Photophobia
Dizziness

Question 9

What triggers a migraine? (4)

Answer 9

Sleep deprivation
Hunger
Stress
Oestrogen

Question 10

What is the pathophysiology of migraines?

Answer 10

Cortical spreading depression releases irritants, triggering sensory sensory fibres in meninges.

Question 11

What is the management of migraines?

4 lifestyle, 3 drugs.

Answer 11

Avoid caffeine, increase water intake.
Avoid tyramine foods (cheese, chocolate, red wine).
Sleep hygiene.
Triptans/naproxen/paracetamol.

Question 12

Which drugs prevent migraines? (6)

Answer 12

Propanolol
Pizotifen
Topiramate
Valproate
Amitryptiline
Botox

Question 13

What are the three types of trigeminal autonomic cephalgias?

Answer 13

Cluster: 30-180mins, 1 per 24hr
Paroxysmal hemicrania: 2-30mins, >5 per 24hr
SUNCT: seconds, 200 per 24hr

Question 14

How are trigeminal autonomic cephalgias managed?

Answer 14

Sumatriptan and high flow oxygen.

Question 15

How does tension headache present?

Answer 15

Constricting band with possible eye strain.

Hx of IBS/hypertension common.

Question 16

How are tension headaches managed? (4)

Answer 16

Relaxation.
Possible amitriptyline.
Acupuncture.
Ensure optician check.

Question 17

What is a new daily persistent headache?

Answer 17

Similar to tension headache. No previous Hx of episodic headache.

Question 18

What are the causes of new daily persistent headache? (4)

Answer 18

Raised ICP; idiopathic intracranial hypertension.
Low ICP: spontaneous intracranial hypotension, post LP headache.
Chronic meningitis.
Post head injury.

Question 19

What is idiopathic intracranial hypertension?

What? Who? Management?

Answer 19

Too much CSF.
Affects women of childbearing age.
Weight loss.

Question 20

What is a chronic daily headache?

Usual cause?

Answer 20

Headache lasting >4hrs on >15 days per month for >3 months.

Transformed migraine from medication overuse.