Headache

Question 1

Acute single headache

Answer 1

Febrile illness, sinusitis
First attack of migraine
Following a head injury
Subarachnoid haemorrhage
Meningitis, tumour, drugs, toxins, stroke
Thunderclap (sudden onset), low pressure

Question 2

Dull headache, increasing in severity

Answer 2

Usually benign
Overuse of medication (e.g. codeine)
Contraceptive pill, hormone replacement therapy
Neck disease
Temporal arteritis
Benign intracranial hypertension
Cerebral tumour
Cerebral venous sinus thrombosis

Question 3

Triggered headache

Answer 3

Coughing, straining, exertion
Coitus
Food and drink

Question 4

Recurrent headaches

Answer 4

Migraine
Cluster headache
Episodic tension headache
Trigeminal or post-herpetic neuralgia

Question 5

Dull headache, unchanged over months

Answer 5

Chronic tension headache

Depressive, atypical facial pain

Question 6

Red Flags

Answer 6

Thunderclap, acute, subacute - onset
Photophobia, phonophobia, stiff neck, vomiting - meningism
Fever, rash, weight loss - systemic
Visual loss, confusion, seizures, hemiparesis, double vision, 3rd nerve palsy, Horner syndrome, papilloedema - neurological
Better lying down
Strictly unilateral

Question 7

Focal Signs

Answer 7

Double vision
3rd nerve (oculomotor) palsy
Horner syndrome

Question 8

Subarachnoid Haemorrhage

Answer 8

Sudden generalised headache, ‘blow to the head’.
Meningism - stiff neck and photophobia
Around 50% are instantly fatal.
High risk of a further bleed.
CT brain, Lumbar puncture (RBC and xanthochromia) and MRA, angiogram.

Question 9

Aneurysm treatment

Answer 9

Aneurysms used to be clipped or wrapped.

Nowadays filled with platinum coils.

Question 10

Acute intracerebral bleed

Answer 10

Fatal haemorrhage due to coning.

Question 11

Raised Intracranial Pressure (ICP)

Answer 11

Mechanism of coning.

Question 12

Papilloedema

Answer 12

Optic disc swelling due to raised ICP

Question 13

Carotid and Vertebral Arteries

Answer 13

Headache can also arise due to pathology in the large arteries of the neck.
Headache and neck pain common
Mean age 40, carotid > vertebral

Question 14

Carotid and Vertebral artery treatment

Answer 14

Aspirin or anticoagulation X 6/12

Question 15

Temporal Arteritis

Answer 15

Over the age of 55.
Three times commoner in females.
Constant unilateral headache, scalp tenderness and jaw claudication
25% Polymyalgia Rheumatica-proximal muscle tenderness.
Elevated ESR and CRP.
Visible on ultrasound.
Biopsy shows inflammation and Giant Cells.
High dose steroids and aspirin.
Disruption of the internal elastic lamina

Question 16

Cerebral Venous Thrombosis

Answer 16

Thrombosis in dural venous sinus or cerebral vein
Unusual amount of headache due to raised ICP
Non-territorial ischaemia “venous infarcts”
Haemorrhage
Thrombophilia, pregnancy, dehydration, Behcets

Question 17

Causes of meningitis

Answer 17

Viral- Coxsackie, ECHO, Mumps, EBV

Bacterial - Meningococci, Pneumococci, Haemophilus, Tuberculous

Fungal - Cryptococci

Granulomatous- Sarcoid, Lyme, Brucella, Behçet’s, Syphilis

Carcinomatous

Question 18

Meningitis

Answer 18

Malaise
Headache 
Fever
Neck stiffness
Photophobia
Confusion
Alteration of consciousness

Question 19

Herpes Simplex Encephalitis

Answer 19

Classic haemorrhagic changes in the temporal lobes

Question 20

Meningitis treatment

Answer 20

Treat then diagnose

Antibiotics
Blood and urine culture
Lumbar puncture
		Increased White Cell Count, decreased glucose
		Antigens
		Cytology
		Bacterial Culture
CT or MRI Scan

Question 21

Sinusitis

Answer 21

Malaise, headache, fever.
Blocked nasal passages. 
Loss of  vocal resonance.
Anosmia.
Nasal or postnasal catarrh.
Local pain and tenderness.

Frontal pain characteristically starts 1-2 hours after rising and clears up during the afternoon.

Question 22

Idiopathic Intracranial Hypertension

Answer 22

Pseudotumor Cerebri

Often young obese women
Headache, visual obscurations, diplopia, tinnitus
Papilloedema, +/- visual field loss
Drugs: hormones, steroids, antibiotics, vitamin E
Treatment: weight loss, diuretics, optic nerve sheath decompression, lumboperitoneal shunt, stenting of stenosed venous sinuses.

Question 23

Low pressure headache

Answer 23

CSF leak due to tear in dura
Traumatic post lumbar puncture or spontaneous
Treatment rehydration, caffeine, blood patch

Question 24

Chiari Malformation

Answer 24

Normal brain that just sits very low within the skull

Cerebellar tonsils descending through the foramen magnum. Descend further when patient cough and tug on the meninges causing cough headache.

Question 25

Obstructive sleep apnoea

Answer 25

Often characteristic body habitus, history of loud snoring and apnoeic spells Hypoxia, CO2 retention, non-refreshing sleep Depression, impotence, poor performance at work Require sleep study Nocturnal NIV, Surgery

Question 26

Trigeminal neuralgia

Answer 26

Electric shock like pain in the distribution of a sensory nerve. Often triggered by innocuous stimuli. Any division of the trigeminal can be affected Neurovascular conflict at the point of entry of the nerve into the pons. Can be symptom of M.S. Carbamazepine, lamotrigine

Question 27

Atypical facial pain

Answer 27

Most commonly in middle aged women. Depressed or anxious. Daily, constant, poorly localised deep aching or burning. Facial or jaw bones, but may extend to the neck, ear or throat. Not lancinating. No sensory loss. Pathology in teeth, temporomandibular joints, eye, nasopharynx and sinuses must be excluded. Unresponsive to conventional analgesics, opiates and nerve blocks. Mainstay of management tricyclics.

Question 28

Post traumatic headache

Answer 28

High in victims of car accidents Low in perpetrators of car accidents Low in sports injuries Neck injury Scalp injury Vasodilation ? autonomic damage Depression - often delayed Non-steroidal anti-inflammatories - ibuprofen, naproxen Tricyclic antidepressants - Amitriptyline Prevent analgesic abuse

Question 29

Cervical Spondylosis

Answer 29

Commonest cause of new headache in older patients ``` Usually bilateral Occipital pain can radiate forwards to the frontal region Steady pain No nausea or vomiting Worsened by moving the neck ``` Rest, deep heat, massage. Anti-inflammatory analgesics. Over-manipulation may be harmful

Question 30

Migraine

Answer 30

Disorder ``` Tendency to repeated attacks Triggers easily hung-over visual vertigo motion sickness ``` 3 forms - pain, focal, or both

Question 31

Migraine: phases

Answer 31

Prodrome: Changes in mood, urination, fluid retention, food craving, yawning Aura: Visual, sensory (numbness/paraesthesia), weakness, speech arrest Headache: Head and body pain, nausea, photophobia Resolution: rest and sleep Recovery: mood disturbed, food intolerance, feeling hungover

Question 32

Migraine: aura

Answer 32

Positive & negative symptoms together: scintillations & blindspot Expanding ‘C’s Elemental visual disturbance

Question 33

Migraine: treatment

Answer 33

Acute attack Aspirin/ibuprofen (Non-steroidals) and paracetamol and metoclopramide (anti-emetic) Hit the headache hard and fast Opiates-caution! Analgesic abuse potential. A short nap Look for triggers and avoid them Nasal sumatriptan (serotonin, 5HT1 agonist)

Question 34

Migraine: prophylaxis

Answer 34

Beta-blockers - Propranolol, Atenolol Serotonin antagonists: pizotifen, methysergide Calcium channel blockers: flunarazine, verapamil Tricyclic antidepressants (TCAs): amitriptyline 7pm Erenumab

Question 35

Tension type headache

Answer 35

Tight muscles around head and neck bilaterally, as though head is in a vice. NSAID’s preferred: Ibuprofen Naproxen, Diclofenac Paracetamol Tricyclic antidepressants - amitryptyline

Question 36

Cluster headache

Answer 36

Severe unilateral pain lasting 15-180 minutes untreated. Classified as a trigeminal autonomic cephalgia. At least one of the following, ipsilaterally: Conjunctival redness and/or lacrimation Nasal congestion and/or rhinorrhoea Eyelid oedema Forehead and facial sweating Miosis and/or ptosis A sense of restlessness or agitation Frequency between one on alternate days to 8 per day. Not associated with a brain lesion on MRI

Question 37

Cluster headache: treatment

Answer 37

Acute Inhaled oxygen. Oxygen inhibits neuronal activation in the trigeminocervical complex Prevention Verapamil Prednisolone Lithium Subcutaneous or nasal triptan NO paracetamol or NSAIDs

Question 38

Migraine vs Cluster headache

Answer 38

M - more women C - more men M - longer C - shorter M - monthly C - daily M - long remissions unusual C - long remissions common M - visual or sensory aura. C - eye waters, nose blocked, ptosis M - lie in dark C - pace about