Headaches

Question 1

what are the common types of headache (benign)

Answer 1

migraine
muscular tension
analgesia overuse
systemic illness
cervicogenic

Question 2

what are some serious types of headache

Answer 2

subarachnoid haemorrhage
raised intercranial pressure
infection-meningitis
temporal arteritis
cerebral venus sinus thrombosis
low intercranial pressure

Question 3

what questions should you ask in a headache history

Answer 3

-how long?
-position?
-character- pressure, sharp, ache dislike of light/noise?
-frequency?
-diurnal variation?
-change in character? progression
-nausea/vomiting?
-postural- worse lying down?
-other neurological symptoms- aura? double vision?
-previous medical history, fam history?
-medicine- how often?

Question 4

what is IBS linked to (headache wise)

Answer 4

venous sinus thrombosis

Question 5

what history of symptoms do you get with a tension headache

Answer 5

-lasts week, months, years
-tightness, pressure round the head
-constant- worse in evening (stress build throughout day)
-frequently used analgesia
-rarely present with nausea

Question 6

what is treatment for a tension headache

Answer 6

-reassurance about severity and duration
-won’t go away overnight
-relaxation exercises
-reduce analgesia- to stop analgesia induced headache
LOW DOSE AMITRIPTYLINE (10-20mg)

Question 7

what are some symptoms of a migraine

Answer 7

-classically on one side
-most headache with nausea will be migraine
-unilateral or bilateral, usually hours-days
-photophobia, phonophobia, gut symptoms
(IBS may be a form of gut migraine- responds to amitriptyline)
-pulsating, sharp
-women more common, especially mid-cycle, menopause (oestrogen)
- can have an AURA

Question 8

discuss auras that might be found in migraines

Answer 8

visual problems – such as seeing flashing lights, zig-zag patterns or blind spots.
can be visual, weakness, sensory and spread over minutes
can look similar to hemiplegia from stroke
BLACK AND WHITE SCOTOMA

Question 9

what does a coloured scotoma indicate

Answer 9

it is a danger sign as is associated with epilepsy

Question 10

what is a scotoma

Answer 10

blind spot or partial loss of vision in what is otherwise a perfectly normal visual field

Question 11

what are some causes of migraine

Answer 11

-vascular (reduce blood flow-increase toxicity) and neural (overstimulated neurons) mechanisms together
look for triggers- FOOD, ALCOHOL, BEGINNING OR END OF WORKING WEEK
might be exacerbated by physical activity, bang on the head
family history
keep a DIARY

Question 12

what treatments do you use for acute migraines

Answer 12

aspirin, paracetamol
anti-nausea

TRIPTANS

Question 13

what are some anti-nausea drugs

Answer 13

prochlorperazine
metoclopramide

Question 14

what treatments do you use if migraines occur more than twice a month
-prophylactics

Answer 14

beta blockers- propranolol
low dose amitriptyline
pizotifin
topiramate
sodium valproate
candesartan
flunarazine
lisinopril
methysergide
botulinum toxin injection every 90 days
anti-cgrp monoclonal antibodies - ERENUMAB
acupuncture

Question 15

what is the issue with methysergide

Answer 15

ergot derivative
therefore:
retroperitoneal fibrosis
hallucinations

Question 16

when can you use erenumab to treat migraines

Answer 16

if have more than 4 migraines a month
must have tried at least 3 other prophylactics

Question 17

can women use OCP if have migraine and aura

Answer 17

no
due to a stroke risk

Question 18

describe symptoms of trigeminal autonomic cephalagia (TAC)

Answer 18

rare
commonest cause is CLUSTER HEADACHE
-unilateral, often around eye
-circadian rhythm, same time of day
-clustering in period usually a few weeks, then goes comes back- SUICIDE HEADACHES

recurrent pain in trigeminal distribution
autonomic features- eye watering, nasal congestion, redness eye
MORE COMMON IN MEN

other causes-
PAROXYSMAL HEMICRANIA
more common in WOMEN
shorter, more frequent attacks
respond to INDOMETHACIN

Question 19

how do analgesic abuse headaches present

Answer 19

worse with analgesia
present for over 15days/month- bad headaches

common if taking common analgesia more than 15 days a month
or
more than 10 days for other acute- triptans

Question 20

what is a thunderclap headache

Answer 20

instant or rapidly appearing within 60 seconds
very severe
must consider SUB-ARACHNOID HEAM
therefore urgent investigation
-CT
-lumbar puncture after 12 hours (look for blood/bilirubin and oxyhaemaglobin in CSF)

Question 21

what is coital cephalgia

Answer 21

type of migraine from vasospasm
quickly reversible
comes back - which is reassuring
occurs during sex

Question 22

what is coital cephalgia

Answer 22

type of migraine from vasospasm
quickly reversible
comes back - which is reassuring
occurs during sex
exertional

Question 23

what can cause early morning headaches

Answer 23

1. CERVICOGENIC
   -poor posture in bed pillow bending neck
   -anatomical position in bed
   -over exertion
   -spinal degeneration- spondylosis
   -usually muscular if not presenting with neurological compromise (reflex loss, weakness)

break pain/spas, cycle

2. sleep apnoea with co2 retention
   build up of biproducts of cellular respiration

-obesity
-history snoring- common with alcohol
-tested by monitoring chest movements
-treated with positive pressure oxygen

Question 24

how does raised intracranial pressure present as

Answer 24

mild headache
diurnal variation- worse in MORNING, gone by lunchtime
mild nausea
NILATERAL PAPILLOEDEMA
-could be from tumours, abscess or CSF blockage (spina bifida)

Question 25

how does meningitis present

Answer 25

fever photophobia neck stiffness altered consciousness (encephalitis) petechial rash from meningococcal meningitis

Question 26

how does temporal arteritis present

Answer 26

relatively rare never occur below 50 jaw claudication polymyalgia (tired, stiff in morning) then temporal headache can cause blindness through embolism into eye (clots from inflammation break off into eye)

Question 27

how do you test for temporal arteritis

Answer 27

-palpate temporal arteries for tenderness (if there are pulsations, and not tender= unlikely to be be this) -check for raised erythrocyte sedimentation rate (ESR>50) - US, or temporal artery biopsy for inflammation

Question 28

what is management for temporal arteritis

Answer 28

high dose steroids early problems if getting them- cause osteoporosis, hypertension, muscle wasting, truncal obesity

Question 29

how does cerebral venous sinus thrombosis present

Answer 29

-often female on OCP-> pro antithrombotic effect of oestrogen -headache, often severe -raised ICP -papilloedema and seizures (pressure of motor cortex- neurons break down) -maybe MR bilateral heam -empty delta sign (empty sinus) therefore build up pressure -refer to neurosurgical centre

Question 30

what is low icp due to , treatment, presentation

Answer 30

happens after lumbar puncture -due to CSF leakage through hole left in dura -tear covering of spinal cord -reduced by using atraumatic needles or angle of needle bevel present headaches on standing, eased with lying can develop into fits as brain is supported less can cause death LOW CSF IN SYSTEM- IF CORRECT SITS RIGHT, BRAIN SETTLES DOWN WHEN STANDING, COMES THROUGH FORAMA treatment blood patch for post-LP headache-- stops leaking TAKE SAMPLE OF BLOOD AND REINJECT SAME SITE, SQUIRT BLOO OVER DURA NEEDLE WENT IN--BLOOD CLOTS- PATCH ON MEMBRANE CSF PRODUCED NORMALLY AND BACK TO NORMAL AND BRAIN FLOATS