headaches

Question 1

serious types of headaches

Answer 1

• subarachnoid haemoragge
• raised ICP
• cerebral venous sinus thrombosis
• temporal arteritis
• infection (meningitis)

Question 2

been going on for weeks months years

tightness and pressure round the head

Constant or is worse towards the evening

frequent analgesia

no nausea reported

Answer 2

tension headache

Question 3

treatment for tension headache

Answer 3

• reassurance
• relaxation excesses
• reduce analgesia
• low dose amitriptyline (10-20 mg) - normally an anti-depressant at 150 mg +

Question 4

one side at a time
with nausea

• unilateral or bilateral usually hours-days
• photophobia , phnonophobia, gut symptoms
• pulsating, sharp character

women mid cycle or menopause

aura +/-

Answer 4

MIGRAINE

Question 5

Colured scotoma

Answer 5

DANGER SIGN of epilepsy

Question 6

causes of migraine

Answer 6

• assess triggers (food, alcohol, working week)
• physical activity????
• family history ?
• keep a diary and assess patterns to establish treatments

Question 7

treatment for acute headaches

Answer 7

• aspirin and paracetamol

- anti-nausea meds (prochlorperazine, metoclopramide)

Question 8

what are the best treatments for migraines

Answer 8

• Triptans –
agonists at 5HT-1b and 5HT-1d receptors (serotonin)

– and related family of drugs Sumatriptan, rizatriptan, naratriptan, zolmitriptan etc

Question 9

Trigeminal Autonomic Cephalagia (TAC) - quite rare but most common

Answer 9

cluster headache:

• unilateral - often around the eye
• striking circadian rhythm , same time of day
  comes and goes
• Recurrent pain in trigeminal distribution with
• Autonomic features (eye watering, nasal congestion, redness eye)
• More common in males (3:1)

Question 10

• Paroxysmal hemicrania

Answer 10

– More common in women
– shorter, more frequent attacks,
– responds to indomethacin (non steroidal anti-inflammatory) so is a differentiator between cluster headache and paroxysmal hemicrania

Question 11

Treatment of TACs

Answer 11

• Triptans
• Oxygen – High dose
• High dose verapamil (up to 960mg/day) – Ca channel blocker at V high doses
• Indomethacin for P Hemicrania

Question 12

Medication overuse headache

Answer 12

– Present for > 15 days/month
– Worsened while analgesia has been used.

– patient using simple analgesia > 15 days/month, or – >10 days for other acute e.g. triptans

Question 13

thunder clap headache

Answer 13

instant and rapidly appearing (less than 60 seconds), very severe pain

– Sub-Arachnoid Haemorrhage, ie stroke commonly from
leaking aneurism – similar presentation
– Requires urgent investigation,
• CT head looking for blood immediate,
• Lumbar Puncture after 12hours, look for blood or bilirubin and oxyhaemaglobin in CSF

Question 14

(coital cephalgia).

Answer 14

– Type of migraine from vasospasm, quickly reversible and comes back is reassuring

Question 15

Cervicogenic (arising from the neck)

Answer 15

– Poor posture in bed, pillow bends neck. Anatomical position is best.
– Over exertion
– Spinal degeneration – spondylosis
– usually muscular if not presenting with neurological compromise (reflex loss, weakness etc)
– Break pain/spasm cycle – anti-inflammatory or pain treatment

Question 16

Sleep apnoea with CO2 retention

Answer 16

– Obesity
– History snoring – common with alcohol
– Tested by monitoring chest movements
– Treated with +ve pressure Oxygen

Question 17

Raised Intracranial Pressure

Answer 17

– Headache - usually mild
– Diurnal variation – worse in morning, often gone by lunchtime
– Often mild nausea

look for neurological signs such as bilateral papilla

Question 18

Infections – meningitis

Answer 18

– Fever
– Photophobia
– Neck stiffness
– Altered consciousness (encephalitis)
– Petechial rash from meningococcal meningitis
• can lead to purpuric areas and on to amputation

Question 19

treatments for meningitis

Answer 19

– Most meningitis is viral, but cannot distinguish clinically, so treat with Ceftriaxone/cefotaxime or benzyl penicillin.

Question 20

Temporal arteritis

Answer 20

– Never occurs below 50 years of age
– Jaw claudication (jaw pain on chewing)
– Maybe features of polymyalgia (tired, stiff in morning), then temporal
headache.
– Can cause blindness through embolism into the eye

Question 21

Tests for Temporal arteritis

Answer 21

– Palpate temporal arteries for tenderness.
• If you feel pulsations and its not tender, - unlikely to be temporal arteritis but still
– Check for Raised Erythrocyte Sedimentation Rate (ESR>50)
– Can use ultrasound or temporal artery biopsy (sample error) for inflamation

Question 22

management of temporal arteritis

Answer 22

– Use high dose steroids early (osteoporosis, hypertension, muscle wasting, truncal obesity) – problems getting off them

Question 23

Cerebral venous sinus thrombosis

Answer 23

– Often female, on oral contraceptive pill
– Headache, often severe
– Raisedintercranialpressure
– Often with papilloedema and seizures
– Maybe MR bilateral, haem and
– empty delta sign
– Refer on to neurosurgical centre

Question 24

Low ICP

Answer 24

• Following lumbar puncture (not immediate)
– Thought to be due to CSF leakage through hole left in dura
– Reduced by using atraumatic needles or angle of needle bevel
• Presentation
– Headache on standing, eased with lying
– Can develop into fits as the brain is supported less – and if left can cause death.
• Treatment:
– Blood patch for post-LP headache – stops leaking