Headache

Question 1

What are differentials for an acute, single headache?

Answer 1

• febrile illness, sinusitis
• 1st attack of migraine
• following head injury
• subarachnoid haemorrhage
• meningitis
• tumour
• drugs, toxins
• stroke
• thunderclap
• low pressure

Question 2

What are red flags with headaches?

Answer 2

• acute, subacute, thunderclap onset
• photophobia, phonophobia, stiff neck, vomiting–> meningism
• fever, rash, weight loss
• visual loss, confusion, seizures, hemiparesis, double vision, 3rd nerve palsy, Horner syndrome,
• unilateral
• orthostatic= better lying down headaches

Question 3

How does a subarachnoid haemorrhage present?

Answer 3

• sudden generalised headache ‘blow to head’
• often occipital
• meningism- stiff neck and photophobia
• most caused by ruptured aneurysm
• v fatal
• nimodipine to prevent vasospasm and bp control
• CT brain, MR angiogram

Question 4

What is coning?

Answer 4

• when the brain slides through the foramen magnum- squeezed out of skull
• due to raised intracranial pressure

Question 5

What is papilloedema?

Answer 5

optic disc swelling due to raised intracranial pressure

Question 6

Where might a headache be if a patient has a vertebral artery dissection?

Answer 6

occipital headache

Question 7

Where might a headache be if a patient has a carotid artery dissection?

Answer 7

pain around eye/forehead ‘phantom of the opera’

Question 8

How do you treat a carotid or vertebral artery dissection?

Answer 8

aspirin or anticoagulation

bc turbulent flow–>clots–>stroke

Question 9

What is temporal arteritis?

Answer 9

• most common in females >55
• constant unilateral headache
• scalp tenderness and jaw claudication
• 1/4 have shoulder muscle pain
• involvement of posterior ciliary arteries causes blindness
• inc. ESR + CRP
• temporal artery inflamed and tortuous
• visible of US and biopsy shows inflammation and giant cells
• give steroids and aspirin

Question 10

What is cerebral venous thrombosis?

Answer 10

• thrombosis in dural venous sinus or cerebral vein
• unusual amount of headache bc raised ICP
• venous infarcts, haemorrhage
• risk factors: thrombophilia, pregnancy, dehydration

Question 11

How does meningitis present?

Answer 11

• malaise
• headache
• fever
• neck stiffness
• photophobia
• confusion
• alteration of consciousness

Question 12

How does sinusitis present?

Answer 12

• malaise
• headache
• fever
• blocked nasal passages
• anosmia
• loss of vocal resonance
• nasal or postnasal catarrh
• local pain and tenderness
• periodic pain

Question 13

What is idiopathic intracranial hypertension?

Answer 13

• psuedotumor cerebri
• often young obese women
• headache, visual obscurations, diplopia, tinnitus
• papilloedema +- visual field loss
• lose weight!
• diuretics, opti nerve sheath decompression, lumboperitoneal shunt, stunting of stenosed venous sinuses

Question 14

What is a low pressure headache?

Answer 14

• CSF leak due to tear in dura
• traumatic post lumbar puncture or spontaneous
• pressure drops when stand up
• rehydration, caffeine, blood patch

Question 15

What is a chiari malformation?

Answer 15

normal brain that sits very low in skull- descends further when you cough, tugging on meninges–> pain

Question 16

Why does obstructive sleep apnoea cause a headache?

Answer 16

they retain CO2

Question 17

What is atypical facial pain?

Answer 17

• most commonly in middle aged women
• depressed or anxious
• poorly localised eep aching or burning pain
• facial or jaw bones
• no sensory loss
• treat w/opiates, nerve blocks and tricyclic antidepressants

Question 18

What is cervical spondylosis?

Answer 18

• commonest cause of new headache in older patients
• usually bilateral pain, occipital but can radiate
• steady pain, worse by moving neck
• no nausea or vomiting
• rest, deep heat, massage, anti-inflammatory analgesic
• over manipulation can be harmful

Question 19

What is migraine disorder?

Answer 19

• repeated attacks
• triggers
• easily hungover
• visual vertigo
• motion sickness
• pain and/or focal symptoms

Question 20

What is a prodrome?

Answer 20

changes in mood, urination, fluid retention, excessive yawning, food craving

Question 21

What is an aura?

Answer 21

• weakness, speech arrest, visual/sensory

- +ve and -ve symptoms e.g. scintillations and blindspot

Question 22

How do you treat an acute migraine attack?

Answer 22

• aspirin/ibuprofen and paracetamol
• metoclopramide (anti-emetic)
• soluble preparations to aid absorption
• triptans for the headaches
• treat headache hard and fast
• caution opiates!
• a short nap
• TMS interrupts spread of electrical depression across cerebral cortex

Question 23

What is migraine prophylaxis?

Answer 23

• over counter e.g. magnesium, riboflavin
• serotonin antagonists e.g. methysergide
• CCBs
• anticonvulsants
• TCAs
• beta-blockers
• botox
• greater occipital nerve blocks
• suppress ovulation
• erenumab= injectable monoclonal antibody

Question 24

What is tension headache?

Answer 24

• tight muscles around head and neck bilaterally
• NSAIDs
• paracetamol
• TCAs
• relaxation

Question 25

What is cluster headache?

Answer 25

- more common in men - severe unilateral pain lasting 15-180mins untreated - trigeminal autonomic cephalgia - conjunctival redness/lacrimation, nasal congestion, eyelid oedema - forehead/facial sweating - miosis and/or ptosis - restlessness/agitation - 1-3 attacks daily, often at night - nausea rare

Question 26

How do you treat cluster headaches?

Answer 26

- inhaled oxygen- inhibits neuronal activation - nasal sumatriptan - prevention: prednisolone, lithium, valproate, verapamil...