headaches

Question 1

headache red flags

Answer 1

new onset headache >55
known/previous malignancy
immunosupressed
early morning headache
exacerbation by valsava - coughing, sneezing -> raised ICP

Question 2

first investigation for headache

Answer 2

fundoscopy - pailloedema -> raised ICP

(headache diary)

Question 3

migraine with aura (20%) criteria

Answer 3

aura fully reversible
aura duration 20-60mins
headache follows <1hr later but aura can occur simultaneously

(trigeminal vascular problem with vasoddilation of crainial blood vessels)

Question 4

migraine without aura criteria

Answer 4

at least 5 attacks
duration 4-72hrs
2of: moderate/severe, unilateral, throbbing pain, worse movement

1of: autonomic features, photphobia

Question 5

migraine triggers

Answer 5

sleep
dietary
stress
hormonal
physical exertion

(keep headache diary to identify)

Question 6

migraine

Answer 6

recurrent, severe headahce which is usually unillateral + throbbing in nature
- assoc aura, nausea + photosensitivity, menstruation

usual trigger

Question 7

tension headache

Answer 7

recurrent, bilaterl headache, often described as “tight band”

not aggravated by routine activities

Question 8

temporal arteritis

Answer 8

> 60yrs old
usually rapid onset (<1month) unilateral headache
jaw claudication
tender, palpable temporal artery
raised ESR
sudden vision loss

Question 9

cluster headache

Answer 9

episodes over weeks - 2 a day, lasting 15-120mins
intense pain around eye - always same side
assoc redness, lacrimation + lid swelling

more common in men + smokers

Question 10

migraine pathophysio

Answer 10

vascular + neural influence cause migraines in susceptible individuals
increased sensitivity, in both cases, the chemicals result in the sensitization of trigeminal neurons + brainstem pain pathways
o this makes otherwise innocuous sensory stimuli (such as CSF pulsation + head movement) painful, and light and sound are perceived as uncomfortable

• Stress triggers changes in brain, these changes cause serotonin to be release
• Blood vessels constrict + dilate
• Chemical including substance P irritate nerves + blood vessels causing pain

Question 11

acute management of migraines

Answer 11

NSAIDs - take as early as poss, 60% reduction in headache at 2hrs

Triptans - treat at strt of headache, too many can induce headache
-> rizatriptan, eletriptan, frovatriptan

Question 12

criteria + management for migraine prophylaxis

Answer 12

> 3 attacks a month or very severe
must trial for min of 3months

• amitriptiline - SE: dry mouth, postural hypotension, sedation
• propranolol - avoid in asthma, PVD, heart failure
• topiramate - not 1st, lots of SE start slow (weight loss, paraesthesia, impaired concentration)

acupuncture if fails

Question 13

autonomic cephalgia

Answer 13

group of headache disorders characterised by unilateral trigeminal distribution pain that occurs in assoc with prominent ipsilateral autonomic features

cluster headaches - males
hemicrania - females

Question 14

autonomic features that can occur in autonomic cephalgia

Answer 14

ptosis
miosis
nasal stuffiness
N+V
tearing
eye lid oedema

Question 15

autonomic cephalgia investigations

Answer 15

MRI brain
MR angiogram

Question 16

trend in cluster headache episodes

Answer 16

striking circadian (around sleeo) + seasonal variation - more common in spring

Question 17

triggers of cluster headaches

Answer 17

alcohol
strong smells
exercise

Question 18

treatment of cluster headaches

Answer 18

high flow oxygen 100% for 20mins
subcutaneous sumatriptan 6mg

prophylaxis
- verapamil
- steroid - reducing course over 2 wks

Question 19

hemicrania

Answer 19

elderly (50s-60s)
women

paroxysmal unilateral autonomic features
duration - 10-30mins
frequency - 1-40 a day
usually in orbital, supraorbital or temporal region

Question 20

hemicrania treatment

Answer 20

indomethacin
–> ABSOLUTE response, if no response probs something else

Question 21

tension headache treatment

Answer 21

reassurance, basic analgesia, relaxation techniques, hot towel

pharmological = antidepressants
- dothiepin or amitriptyline
- give for 3months

Question 22

idiopathic intracranial hypertension features

Answer 22

F>M
obese, young

worse in morning, N+V
worse lying down
vision loss
papilloedema, blurred vision
enlarged blind spot

Question 23

idiopathic intracranial hypertension risk factors

Answer 23

obesity, female
pregnancy
combined oral contraceptive pill
tetracyclines

Question 24

idiopathic intracranial hypertension investigations

Answer 24

MRI brain with MRV sequence - normal, empty sella
cerebrospinal fluid - elevated pressure, normal constituents
visual fields

Fx = empty sella, flattened optic disc

Question 25

idiopathic intracranial hypertension management

Answer 25

weight loss
acetazolamide (diuretic)

ventricular atrial/lumbar shunt
monitor visual fields + CSF pressure

Question 26

trigeminal neuralgia

Answer 26

pain syndrome characterised by severe unilateral pain
-> brief elctric shock like pain, abrupt in oset + terminations

(triggered by touch)
most idiopathic, compression of trigeminal roots by tumours/vascular problems may occur

Question 27

trigeminal neuralgia features

Answer 27

elderly >60
W>M
severe stabbing unilateral pain
duration = 1sec-90sec
frequency = 10-100 aday

bouts of pain may last from a few weeks to months before remission

Question 28

trigeminal neuralgia investigations

Answer 28

MRI
- FLAIR sequence
- Ciss sequence

Question 29

trigeminal neuralgia management

Answer 29

pharmacological
- carbamazepine = 1st line
- gabapentin
- phenytoin

surgical
- ablation
- decompression

Question 30

giant cell arteritis investigation + management

Answer 30

elevation CRP + plasma viscosity
US temporal artery biopsy

steriods