Headac

Question 1

What are the three types of primary headaches?

Answer 1

• Cluster headaches
• Migraine headaches
• Tension headaches

Primary headaches are not caused by underlying medical conditions.

Question 2

How do cluster headaches present?

Answer 2

unilateral, orbital/supraorbital or frontal regions of head. It will be a stabbing, burning/sharp pain and lasts for 5minutes up to 3 hours.

There may be up to 1-8 episodes in a day; associated symptoms include rhinorrhea, lacrimation and conjunctival hyperaemia de to excessive parasympathetic stimulation with partial Horner’s syndrome.

Patients will be restless and there may be meningism.

Question 3

How do tension headaches present?

Answer 3

BILATERAL headaches in the frontal/temporal regions, non pulsating and band-like vice-like tightening headache. Common duration is 4-6 weeks but can be from 30 minutes up to 1 week. There is no meningism.

Question 4

What are the features of secondary headaches?

Answer 4

Secondary headaches typically have associated symptoms like loss of vision, indicating fatal or life threatening conditions

Question 5

What are red flag signs for secondary headaches represented by the acronym SNOOPPP?

Answer 5

• S: Systemic symptoms (fever, weight loss)
• N: Neurological deficit
• O: Old age (greater than 50)
• O: Onset is abrupt or acute
• P: Papilledema (indicating intracranial hypertension)
• P: Positional (worse when lying down)
• P: Pattern change from baseline headaches
• P: Precipitated by Valsalva maneuver

These signs indicate potentially serious underlying conditions.

Question 6

Secondary headaches can be categorized into mass occupying lesions from what?

Answer 6

• Increase in blood
• Brain tissue
• CSF

These categories include various conditions that can lead to secondary headaches.

Question 7

What are some examples of mass occupying lesions that can cause secondary headaches?

Answer 7

• Trauma linked to intracranial hemorrhages
• Pituitary adenoma
• Brain abscess
• Brain tumor (e.g., meningioma, glioblastoma)
• Hydrocephalus

Each of these conditions presents with specific symptoms and complications.

Question 8

What symptoms are associated with meningitis or encephalitis?

Answer 8

• Fever
• Meningeal signs (photophobia, phonophobia)
• Brudzinski sign
• Altered mental status
• Neurological deficits

These symptoms indicate inflammation of the protective membranes covering the brain and spinal cord.

Question 9

How does central venous sinus thrombosis present?

Answer 9

Central venous sinus thrombosis will cause ICP and headache present with:
*Nausea and vomiting due to compression of chemoreceptor trigger zone
*Papillaoedema due to compression of optic nerve
*Decreased LOC

Question 10

True or false: Idiopathic intracranial hypertension is more common in obese women and females on oral contraceptives.

Answer 10

TRUE

This condition presents with headache, high ICP, and symptoms like nausea and diplopia.

Question 11

What are the symptoms of carotid/vertebral artery dissection?

Answer 11

• Trauma
• Neck pain
• Horner syndrome
• Pulsatile tinnitus

This condition may occur secondary to trauma and can lead to serious complications.

Question 12

How does idiopathic intracranial hypertension present?

Answer 12

Headache, persistently high ICP (n/v, pailloedema and decreased LOC and compression of cranial nerve 6 causing diplopia) precipitated by valsalva.

It is more common in obese women and females on oral contraceptives

Question 13

What external CNS disorders cause headache?

Answer 13

*Sinusitis
*acute closure glaucoma
* giant cell arteritis
* trigeminal neuralgia

Question 14

What are the features of sinusitis?

Answer 14

Sinusitis causing tenderness on palpation, purulent rhinorrhea and headache

Question 15

What are the features of giant cell arteritis?

Answer 15

Giant cell arteritis causing tenderness on chewing food/jaw claudication, and on palpation and if affecting Opthalmic artery will have visual changes and blindness. It is associated with polymyalgia rheumatica

Question 16

How does trigeminal neuralgia present?

Answer 16

Trigeminal neuralgia will present with stabbing or electric lightening type of pain

Question 17

What is a scintillating scotoma?

Answer 17

A visual aura that can precede a migraine headache.

It may be a blind spot or area of distorted vision that can flicker, appear as wavy lines, or grow from dark to ligh

It appears as a temporary blind spot or distorted vision.

Question 18

What is the diagnostic criteria for migraines with aura?

Answer 18

• Must have scintillating, sensory, or motor scotoma
• Must have at least 2 attacks

This criteria helps differentiate migraines from other headache types.

Question 19

What is the diagnostic criteria for migraines without aura?

Answer 19

must have minimum 5 attacks
-> presentation of POUND mnemonic
-> worse with Exertion

Question 20

What is the criteria for cluster headache diagnosis?

Answer 20

minimum of 5 attacks
-> 1 autonomic scotoma (lacrimation or rhinorrhea)
-> restless patient

Question 21

How are tension headaches diagnosed?

Answer 21

Minimum of 2 episodes
-> non pulsatile
-> absence of meningeal symptoms
-> unaffected by exertion
-> increased sensitivity to light and sound without aura

Question 22

What is the POUND mnemonic used for?

Answer 22

To present the criteria for migraine without aura

• Pulsatile/Photophoia/Phonophobia
• One day duration
• Unilateral
• Nausea and vomiting
• Disabling intensity

It includes symptoms like Pulsatile quality, duration, and nausea.

Question 23

What is the minimum number of attacks required for a diagnosis of cluster headaches?

Answer 23

5 attacks

Diagnosis also requires the presence of autonomic symptoms.

Question 24

What are the management options for headaches?

Answer 24

• Abortive therapy (saline, anti-emetics, NSAIDs)
• Triptans (sumatriptan, zolmitriptan)
• Ergot’s alkaloid (dihydroergotamine)
• Dexamethasone

These treatments aim to relieve headache symptoms.

Question 25

What anti-emetics are used for headaches?

Answer 25

metaclopramide and prochlorperazine

Question 26

What is given to counteract vessel dilation?

Answer 26

Triptan, serotonin agonist to counteract vessel dilation -> sumatriptan -> zolmatriptan

Question 27

What are some **prophylactic therapies** for headaches?

Answer 27

* Beta blockers (Propranolol, Metoprolol) to inhibit vasoconstriction * Anticonvulsants (Valproate, Topiramate) * Tricyclic antidepressants (Amitriptyline) * CGRP antagonists (Erenumab) to reduce pain transmission * Botox-A injections every 12 weeks ## Footnote These therapies aim to prevent headache occurrences.

Question 28

What is the **abortive therapy** for cluster headache management?

Answer 28

* 1L bolus of saline for fluid loss via vomiting * Anti-emetics such as metoclopramide and prochlorperazine * NSAIDs (oral: ibuprofen, naproxen; IV: ketorolac) * Triptans (sumatriptan, zolmitriptan) * Ergot’s alkaloid (dihydroergotamine) * Dexamethasone ## Footnote These therapies aim to provide immediate relief from headache symptoms.

Question 29

Name the drug used in prophylactic therapy for headaches.

Answer 29

* Propranolol * Metoprolol ## Footnote Beta blockers inhibit vasoconstriction and are commonly prescribed for headache prevention.

Question 30

What are the **first-line** treatments for **cluster headache prophylaxis**?

Answer 30

* CCB Verapamil * Anticonvulsants (topiramate, valproate) ## Footnote These medications are used to prevent the occurrence of cluster headaches.

Question 31

Fill in the blank: **Prophylactic therapy for headaches includes** _______.

Answer 31

beta blockers, anticonvulsants, tricyclic antidepressants, CGRP antagonists, Botox-A injections ## Footnote These therapies aim to reduce the frequency and severity of headaches.

Question 32

What is the **abortive therapy** for **cluster headaches**?

Answer 32

* Non-rebreather mask with high flow oxygen (6-12/min) * Sumatriptan (intranasal or IM) * Ergot’s therapy (IV or IM) * Intranasal lidocaine ## Footnote These treatments focus on providing immediate relief during a cluster headache attack.

Question 33

What are the **first-line** treatments for **chronic headache therapy**?

Answer 33

* Amitriptyline * Mirtazapine * Venlafaxine (SNRIs) ## Footnote These medications are supported by evidence for managing chronic headaches.

Question 34

True or false: **Dexamethasone** is used to inhibit inflammation in headache management.

Answer 34

TRUE ## Footnote Dexamethasone is part of the abortive therapy for headaches.

Question 35

What are the **types of medications** used in **prophylactic therapy** for headaches?

Answer 35

* Beta blockers * Anticonvulsants * Tricyclic antidepressants * CGRP antagonists * Botox-A injections ## Footnote These medications help in preventing headaches from occurring.

Question 36

What is the role of **triptans** in headache management?

Answer 36

Counteract vessel dilation ## Footnote Triptans, such as sumatriptan and zolmitriptan, are used in abortive therapy.

Question 37

What is the **mechanism** of **ergot’s alkaloid** in headache treatment?

Answer 37

Increase serotonin and cause vasoconstriction ## Footnote Dihydroergotamine is an example used in headache management.

Question 38

What is the **episodic therapy** for headaches?

Answer 38

* NSAIDs * Acetaminophen * Caffeine ## Footnote These treatments are used for managing headache episodes as they occur.

Question 39

What is used as a final resort for cluster headaches?

Answer 39

Managing trier exposure CBT and physical therapy Chiropractic care

Question 40

What does a young woman with high BMI and regular use of lithium ith headache indicate?

Answer 40

idiopathic intracranial hypertension -> presentation will be characteristic of a raised intracranial pressure (ICP) such as headache, blurred vision, abducens nerve palsy, and tinnitus.

Question 41

What investigation must be done for IIH?

Answer 41

excluding other causes of a raised ICP, such as cerebral venous sinus thrombosis, which requires an MR venography

Question 42

What is the gold standard for diagnosing IIH?

Answer 42

Lumbar puncture (LP) is the gold standard for diagnosing raised intracranial pressure (ICP) and is essential in evaluating suspected idiopathic intracranial hypertension (IIH

Question 43

What are the risk factors for IIH?

Answer 43

Risk factors for IIH include obesity, female gender, and, in this case, isotretinoin use for cystic acne.

Question 44

In medication overuse headache, what to withdraw gradually?

Answer 44

Opioid

Question 45

In medication overuse headache, what to immediately stop?

Answer 45

Tristan Simple analgesia

Question 46

What form of Tristan’s are used for acute management of cluster headache?

Answer 46

Subcutaneous or intranasal ONLY

Question 47

What is **spontaneous intracranial hypotension**?

Answer 47

A very rare cause of headaches resulting from a CSF leak ## Footnote The leak is typically from the thoracic nerve root sleeves.

Question 48

Name a **risk factor** for spontaneous intracranial hypotension.

Answer 48

* Connective tissue disorders * Marfan's syndrome ## Footnote These disorders can increase the likelihood of CSF leaks.

Question 49

What is a key feature of headaches associated with **spontaneous intracranial hypotension**?

Answer 49

Strong postural relationship, much worse when upright ## Footnote Patients may be bed-bound due to the severity of the headache.

Question 50

What imaging technique is used for **investigations** in spontaneous intracranial hypotension?

Answer 50

MRI with gadolinium ## Footnote This typically shows pachymeningeal enhancement.

Question 51

What is the usual **management** approach for spontaneous intracranial hypotension?

Answer 51

Usually conservative ## Footnote If conservative management fails, an epidural blood patch may be tried.

Question 52

What is **spontaneous intracranial hypotension**?

Answer 52

A very rare cause of headaches resulting from a CSF leak ## Footnote The leak is typically from the thoracic nerve root sleeves.

Question 53

Name a **risk factor** for spontaneous intracranial hypotension.

Answer 53

* Connective tissue disorders * Marfan's syndrome ## Footnote These disorders can increase the likelihood of CSF leaks.

Question 54

What is a key feature of headaches associated with **spontaneous intracranial hypotension**?

Answer 54

Strong postural relationship, much worse when upright ## Footnote Patients may be bed-bound due to the severity of the headache.

Question 55

What imaging technique is used for **investigations** in spontaneous intracranial hypotension?

Answer 55

MRI with gadolinium ## Footnote This typically shows pachymeningeal enhancement.

Question 56

What is the usual **management** approach for spontaneous intracranial hypotension?

Answer 56

Usually conservative ## Footnote If conservative management fails, an epidural blood patch may be tried.

Question 57

How long do episodes of cluster headaches last?

Answer 57

4 to 12 weeks

Question 58

What is a trigger for cluster headaches?

Answer 58

Alcohol but only during a cluster period Nocturnal sleep

Question 59

What is stress a trigger for?

Answer 59

Tension-type headaches Migraines

Question 60

What is the investigation of choice for cluster headaches?

Answer 60

MRI with gadolinium contrast

Question 61

What is the most common cauase of non infectious encephalitis!

Answer 61

Autoimmune encephalitis from NMDA-receptor-antibody-associated encephalitis, associated with ovarian teratoma in young women

Question 62

What triggers autoimmune encephalitis?

Answer 62

Paraneoplastic syndromes Viral infections that incite immune dysregulation Genetic predisposition

Question 63

How does autoimmune encephalitis present driven by NMDA?

Answer 63

NMDA-receptor-antibody encephalitis: Early psychiatric symptoms such as psychosis, agitation, and hallucinations Seizures and memory deficits Speech disturbances, including mutism Autonomic instability (e.g., fluctuations in blood pressure, heart rate) Movement disorders, particularly orofacial dyskinesias ( involuntary facial and mouth movements)

Question 64

What are other forms of automme encephalitis!

Answer 64

LGI1-antibody encephalitis GABA-receptor-antibody encephalitis

Question 65

How does LGI1 antibody encephalitis present?

Answer 65

Seizures, particularly facial-brachial dystonic seizures (brief, involuntary movements of the face and arm) Cognitive impairment, including confusion and memory loss Hyponatraemia (low sodium levels) Mood changes and behavioural

Question 66

How does CASPR2 antibody encephalitis present?

Answer 66

Cognitive dysfunction and memory problems Neuromyotonia (continuous muscle contractions) Psychiatric symptoms such as anxiety, paranoia, and insomnia Cognitive dysfunction and memory problems Neuromyotonia (continuous muscle contractions) Psychiatric symptoms such as anxiety, paranoia, and insomnia

Question 67

How does GABA encephalitis present!

Answer 67

Severe seizures, often status epilepticus (prolonged seizures) Cognitive decline and memory deficits Behavioural changes, including irritability and aggression Progressive encephalopathy with confusion and altered consciousness

Question 68

What investigation other than brain imaging for autoimmune encephalitis.

Answer 68

Cancer screening to look for any underlying neoplasm CT Chest Abdomen Pelvis FDG-PET Ultrasound Pelvis (due to association of ovarian neoplasms with ovarian tumours in women)

Question 69

What to suspect with fluctuating GCS on a background of a head injury In elderly patient ?

Answer 69

Subdural haematoma, causing crescent shaped haemorrhage on CT head. Delayed presentation is because the system that a subdural haematoma occurs in is lower in pressure than the system that an extradural haematoma occurs in (