Headaches

Question 1

Differentials of Headaches

Answer 1

+Migraine - photophobia, phonophobia, episodic, unilateral, throbbing. Females.
+Subarachnoid haemorrahge - THUNDERCLAP.
+Meningitis - pyrexia, vomiting, neck stiffness.
+Cluster headache - Unilateral pain around eye in clusters of a couple a day and then period of none. Male.
+Tension headache - band-like dull headache
+Giant cell arteritis - tenderness on scalp, jaw claudication. Elderly.
+Raised ICP/SOL - generalised, aggregated on bending, cough, in morning, progressive severity.
+Trigeminal neuralgia - paroxysms of intense stabbing pain, unilateral. Triggered on washing face, shaving, eating.
+Stroke

Question 2

Migraine symptoms

Answer 2

Unilateral pulsatile or throbbing headache.
Nausea and vomiting.
Photophobia
Phonphobia
Impairs and is worsened by activities of daily living.
Aura before heachache with visual and sensory symptoms (flashing lights, blurred vision, parasethsia, numbness).

Question 3

Triggers and risk factors of migraines

Answer 3

More common in females. More common in obesity. Risk also increased in COCP, smoking, hypertension, hyperlipidaemia.
Triggers = chocolate, oral contraceptive pill, hangover, alcohol, orgasm, exercise, menses.

Question 4

Treatment of an acute migraine

Answer 4

Triptan e.g. sumatriptan +NSIAD/pcm. Triptans only licenced for over 18yrs. Do NOT use ergots or opioids. Consider anti-emetic treatment.

Question 5

Preventative treatment of migraines

Answer 5

Consider if severe, frequent disabling migraines, making patients at risk of OD on analgesic and acute Rx meds (could lead to medication overuse headache).
1st line = Propranolol or topiramate.
2nd line = sodium valproate, gabapentin, pregabalin.
3rd line = Acupuncture.

Question 6

Giant cell arteritis pathogenesis

Answer 6

Chronic granulomatous inflammation big arteries (vasculitis). Most commonly temporal and occipital.

Question 7

Epidemiology of giant cell arteritis

Answer 7

More common in females than males. Most common in elderly (if <55yrs consider Takayasu’s arteritis). Commonly seen with polymyalgia rheumitica

Question 8

Clinical features of giant cell arteritis

Answer 8

Unilateral scalp tenderness (on brushing hair)
Jaw claudication
Visual disturbance - amaurosis fugax, total sudden blindness.

Question 9

Investigations + treatment for giant cell arteritis

Answer 9

Increases = ESR, CRP, LFT, platelets
Decrease= Hb
Biopsy of temporal artery but do not delay treatment of Prednisolone.

Question 10

Tension headache info

Answer 10

Throbbing, unilateral, band-like headache. No nausea or neck-stiffness. Treatment with basic analgesia (paracetamol) and stress relief.

Question 11

Cluster headache epidemiology

Answer 11

More common in males, more common in smokers.

Question 12

Clinical features of a cluster headache

Answer 12

Unilateral, severe periorbital pain.
Blood shot, watery eyes.
lacrimation
Rhinorrhea
Miosis 
In clusters of multiple headaches over consecutive days then periods of no pain days.

Question 13

Treatment of acute and preventative meds for cluster headache

Answer 13

Acute = 100% O2 via non-rebreathable mask + Subcut sumatriptan.
Preventative = verapamil.

Question 14

Trigeminal neuralgia causes

Answer 14

Vascular compression of nerve, AVM

Question 15

Epidemiology of trigeminal neuralgia

Answer 15

more common in females. Mostly mandibular and maxillary branches

Question 16

Symptoms of trigeminal neuralgia

Answer 16

Severe episodic pain in region of trigeminal branches.

Question 17

Triggers fo trigeminal neuralgia

Answer 17

Washing area, cleaning teeth, shaving area, talking, cold wind, vibration.

Question 18

Management of trigeminal neuralgia

Answer 18

Carbamazepine, keep pain diary and arrange follow-up.

Question 19

Meningitis symptoms

Answer 19

Headache
Neck stiffness
Kernig's sign
Photophobia
Petechial, non blanching rash
Seizures
Decrease consciousness

Question 20

Treatment for Meningitis

Answer 20

Dexamethasone + Cefotaxime.

Question 21

Subarachnoid haemorrhage symptoms, investigations and management

Answer 21

Thunderclap headache.
Kernig's sign
Neck stiffness
Star shaped haematoma on CT
Nimodipine, surgical clipping.

Question 22

Medicine over headaches:

1. What medicines can cause them?
2. Presentation
3. Rx

Answer 22

1. triptans opioids, NSAIDs, paracetamol.
2. Headache for 15 or more days per month in a patient with a pre-existing headache + regular use of medicines for that headache. Headache may worsen on stopping medicine.
3. Supported withdrawal of medication. Advise on withdrawal headaches. Arrange follow-up to monitor progress and support. Ensure co-morbidities are adequately controlled e.g. anxiety.

Question 23

Red flag symptoms in headache 🚩🚩

Answer 23

Fever, photophobia, neck stiffness
Dizziness
Visual disturbance
Sudden severe onset
Worse on lying down, coughing, straining
Severe enough to wake from sleep

Question 24

Non-neuro causes of headache

Answer 24

Alcohol
Carbon monoxide poisoning
Drug side effect

Question 25

3 branches of trigeminal nerve

Answer 25

CN5
Ophthalmic
Maxillary
Mandibular