Headache

Question 1

What are the most common headaches?

Answer 1

• Tension/muscular
• Migraine
• Analgesia overuse
• Systemic illness
• Cervicogenic - arising from the neck

Question 2

What are the most serious headaches?

Answer 2

• Subarachnoid haemorrhage
• Meningitis
• Tumours
• Other space occupying lesion
• Temporal arteritis
• Strokes including CV sinus thrombosis

Question 3

Describe a typical history of a patient with a tension headache

Answer 3

• Weeks, months or years
• Tightness or pressure, like an elastic band around the head
• Constant, worse towards the evening
• rarely with nausea

Question 4

What are the treatments for tension headaches?

Answer 4

• Reassurance, explain the muscles of the head
• Reduce analgesia - won’t take away the tightness
• Use relaxation exercise
• Low dose amitriptyline (tricyclic antidepressant)
• Wont go away overnight)

Question 5

Describe common presenting complaint of patient with migraine

Answer 5

• With or without aura, spreads over minutes
• Unilateral or bilateral
• Pulsating, sharp
• Photophobia, phonophobia, gut symptoms e.g. diarrhoea
• may be exacerbated by physical activity
• Often a family history

Question 6

Acute migraine treatment

Answer 6

• Triptans
• Aspirin, paracetamol
• Anti-nausea

Question 7

Prophylactic migraine treatment

Answer 7

• Beta blockers
• Low dose amitriptyline
• Pizotifen
• Topiramate
• Sodium valproate
• Candesartan
• Flunarazine
• Lisinopril
• Methysergide

Question 8

Other migraine treatments

Answer 8

• Botulinum toxin injections
• Anti CGRP monoclonal antibodies, erenumab
• Acupuncture

Question 9

why should women with migraine not use a combined oral contraceptive pill?

Answer 9

Increased risk of stroke

Question 10

What is trigeminal neuralgia?

Answer 10

• Shooting pain in one or more divisions of the trigeminal nerve
• Extremely painful, may be triggered by cold or eating
• In young people consider demyelination, in older people often abberant blood vessel touching CNV

Question 11

What is the treatment of trigeminal neuralgia?

Answer 11

• Carbamazepine
• Gaba pentin
• Injection
• surgery

Question 12

What is trigeminal autonomically cephalagia?

Answer 12

• Recurrent pain in the trigeminal distribution with autonomic features (eye watering, nasal congestion, eye redness)
• Cluster headaches
• Paroxysmal hemicranias

Question 13

what do paroxysmal hemicranias respond to?

Answer 13

Indomethacin

Question 14

Describe medication overuse headache

Answer 14

• Present for >15 days a month
• Worsened while analgesia has been used
• If using simple analgesia >15 days a month or >10 days for other acute

Question 15

Describe thunderclap headahces

Answer 15

• Instant or rapidly appearing headache

Question 16

What should be considered in a patient presenting with thunderclap headaches?

Answer 16

Sub arachnoid haemorrhage

Question 17

If a patient presents with thunderclap headaches, what investigations should be carried out?

Answer 17

• CT head

* Lumbar puncture after 12 hours look for bilirubin and oxyhemoglobin

Question 18

What are the symptoms of raised intracranial pressure?

Answer 18

• Headache (usually mild)
• Diurnal variation (worse in the morning - red flag if waking from pain)
• Maybe worse with coughing or straining
• Often mild nausea
• Neurological features
• Look for papilloedema (swelling of optic disc)

Question 19

What could be causing raised intracranial pressure?

Answer 19

• Tumour
• Abscess
• CSF blockage

Question 20

What are the symptoms of meningitis?

Answer 20

• Fever
• Photophobia
• Neck stiffness
• Altered consciousness
• Petechial rash

Question 21

What should you treat meningitis with?

Answer 21

• Ceftriaxone/cefotaxime

* Benzl penicillin

Question 22

What are the symptoms of temporal arteritis?

Answer 22

• Features of polymyalgia - weak proximal muscles
• Jaw claudication
• Tender temporal arteries and may be thickened
• Raised ESR (erythrocyte sedimentation rate)

Question 23

Investigations for temporal arteritis

Answer 23

• Ultrasound

* Temporal artery biopsy

Question 24

What is the danger of temporal arteritis?

Answer 24

Blindness

Question 25

Features of cerebral venous sinus thrombosis

Answer 25

* Headache, often severe * Often seizures * maybe bilateral

Question 26

What is transient global amnesia

Answer 26

* thought to be a variant of migraine * Often during stress/exposure to the cold * Period of amnesia, unable to lay down any new memory * Lasts a few minutes to a few hours