Secondary Headaches

Question 1

What is a primary headache?

1 - no known underlying cause
2 - trauma related headache
3 - infectious related headache
4 - headaches associated with a specific aetiology causing traction on or inflammation of pain-sensitive structures

Answer 1

1 - no known underlying cause

Question 2

What is a secondary headache?

1 - no known underlying cause
2 - trauma related headache
3 - infectious related headache
4 - headaches associated with a specific aetiology causing traction on or inflammation of pain-sensitive structures

Answer 2

4 - headaches associated with a specific aetiology causing traction on or inflammation of pain-sensitive structures

Question 3

Are primary or secondary headaches more common?

Answer 3

• primary

Question 4

Which of the following is NOT a cause of a secondary headache?

1 - Tumour
2 - CNS infection
3 - Intracerebral/ subarachnoid haemorrhage
4 - Arteritis
5 - Migraine
6 - Idiopathic intracranial hypertension (IIH)
7 - Venous sinus thrombosis
8 - Carotid dissection

Answer 4

5 - Migraine

Question 5

A common secondary headaches is a thunderclap headache. Do these come on gradually or rapidly?

Answer 5

• rapidly
• incredibly painful felt in head and/or neck

Question 6

Typically what is the onset of a thunderclap headache?

1 - 30mins to 1 week
2 - 4-72h
3 - 15-180 minutes
4 - 3-5 minutes

Answer 6

4 - 3-5 minutes

Question 7

Which type of headache would most likley be associated with the following:

• hemiparesis (weakness on 1 side)
• monoparesis (loss of function in one limb)
• fever, nausea, vomiting
• flu like symptoms

1 - migraines
2 - cluster headaches
3 - medication overuse headaches
4 - thunderclap headaches

Answer 7

4 - thunderclap headaches

• always associated with some form of pathophysiology
• most common secondary form of headache

Question 8

What ages do thunderclap headaches typically affect?

1 - >20
2 - >40
3 - >50
4 - >65

Answer 8

3 - >50

Question 9

In thunderclap headaches, are they more likely to be present when a patient wakes up in the morning, or is the headache more likely to wake patients up?

Answer 9

• more likely to wake patients whilst they are asleep
• typically DO NOT wake up with it when they would wake up normally

Question 10

It can be very difficult to distinguish between a primary and secondary headache. Which of the following is NOT a useful symptom that may confirm pathology in a patient with a thunderclap headache?

1 - severity or response to treatment
2 - idiopathic intracranial hypertension causing papilledema
3 - CNS infection – systemic features eg pyrexia, +/- focal neurological features
4 - giant cell arteritis with systemic features, polymyalgia rheumatica, jaw claudication

Answer 10

1 - severity or response to treatment

Question 11

Thunderclap headaches are the most common form of secondary type headaches with an underlying cause. Although these can be caused by a myriad of things, what is potentially the most severe that needs to be treated urgently?

1 - subarachnoid haemorrhage
2 - meningitis
3 - arteritis
4 - tumour

Answer 11

1 - subarachnoid haemorrhage

Question 12

A sentinel headache can be dangerous, what is a sentinel headache?

1 - headache caused by stress and dehydration and is very painful
2 - the initial headache that precludes developing cluster headaches
3 - a mild headache that precludes a major potentially life threatening bleed such as an aneurysm
4 - could be any of the above

Answer 12

3 - a mild headache that precludes a major potentially life threatening bleed such as an aneurysm

Question 13

If you suspect a patient has a thunderclap headache, what should be the first line management?

1 - refer to GP for close monitoring
2 - admit to hospital for fluids and close monitoring
3 - admit to hospital and request an urgent CT head scan
4 - admit to hospital and begin sepsis 6 protocol

Answer 13

3 - admit to hospital and request an urgent CT head scan

Sensitivity of CT scan:
- <6 hours of onset = 95.8-99.85%
- >6 hours = 90%

• sensitivity = positive test in those with condition
• specificity = negative test in those without the condition

Question 14

If a patient has a suspected thunderclap headache and the CT scan is negative, what would be the next investigation?

1 - lumbar puncture
2 - MRI
3 - blood sample culture for microorganisms
4 - all of the above

Answer 14

1 - lumbar puncture

Question 15

If a patient has a suspected thunderclap headache and the CT scan is negative, a lumbar puncture should be performed. All of the following should be performed on the CSF sample taken from the lumbar puncture, but which is potentially the most important?

1 - Protein Glucose (plus blood glucose)
2 - Bilirubin and xanthochromia (sampling MUST be protected from light)
CSF should not be examined for bilirubin > 12 hours after ictus
4 - microscopy culture and sensitivity

Answer 15

4 - microscopy culture and sensitivity

Question 16

If a patient has a suspected thunderclap headache and the CT scan is negative, a lumbar puncture should be performed. When analysing the CSF, bilirubin and xanthochromia (sampling MUST be protected from light) should be examined. Why are these markers important?

1 - sign of hepatic encephalopathy which can cause thunderclap headaches
2 - markers of RBC breakdown that would occur in a haemorrhage
3 - marker of splenomegaly which can increase intracranial pressure
4 - all of the above

Answer 16

2 - markers of RBC breakdown that would occur in a haemorrhage

• bilirubin should only be measured after >12 hours following initial neurological issue

Question 17

If a patient has a suspected thunderclap headache and the CT scan is negative, a lumbar puncture should be performed. If both the CT and lumbar puncture are negative, what time frame can a subarachnoid haemorrhage be ruled out?

1 - >24h
2 - >48h
3 - 1 week
4 - 2 week

Answer 17

4 - 2 week

Question 18

In the first few days following a subarachnoid haemorrhage, does blood appear whiter or darker on a CT scan?

Answer 18

• whiter

Question 19

A subarachnoid haemorrhage is one of the most common causes of a thunderclap headache. What is the most common cause of a subarachnoid haemorrhage?

1 - berry aneurysm
2 - tumour
3 - hypertension
4 - head trauma

Answer 19

1 - berry aneurysm

Question 20

A subarachnoid haemorrhage is one of the most common causes of a thunderclap headache. The most common cause of a subarachnoid haemorrhage is a berry aneurysm. All of the following are required to treat this, EXCEPT which one?

1 - bed rest and anti-hypertensives
2 - start nimodipine (Ca2+ channel blocker reducing vasospasm)
3 - low molecular weight heparin (Enoxaparin)
4 - endovascular treatment by placing platinum coils via a catheter in the aneurysm sac
5 - promote thrombosis and ablation of the aneurysm
6 - surgical clipping of the aneurysm neck

Answer 20

3 - low molecular weight heparin (Enoxaparin)
- thinning blood could be fatal if the aneurysm ruptures

Question 21

A subarachnoid haemorrhage is one of the most common causes of a thunderclap headache. The most common cause of a subarachnoid haemorrhage is a berry aneurysm. All of the following are required to treat this. Which option is 1st line treatment?

1 - bed rest and anti-hypertensives
2 - start nimodipine (Ca2+ channel blocker reducing vasospasm)
3 - endovascular treatment by placing platinum coils via a catheter in the aneurysm sac
4 - promote thrombosis and ablation of the aneurysm
5 - surgical clipping of the aneurysm neck

Answer 21

4 - promote thrombosis and ablation of the aneurysm

Question 22

In addition to a subarachnoid haemorrhage, an arterio-venous malformation can occur. What is this?

1 - genetic mutation leading to increased risk of thrombosis in the brain
2 - abnormal formation of blood vessels that typically occurs at a young age
3 - non-contractile blood vessels that are increased risk of aneurysms
4 - all of the above

Answer 22

2 - abnormal formation of blood vessels that typically occurs at a young age

• can be treated with glue embolisation