Headache

Question 1

define and give an example of a primary headache

Answer 1

there is no underlying medical cause:
> tension
> migraine
> cluster

Question 2

define of a secondary headache

Answer 2

there is an identifiable/biochemical cause

Question 3

give some examples of causes of secondary headaches

Answer 3

> tumour
> meningitis
> vascular disorders
> systemic infection
> head injury
> drug induced

Question 4

describe a tension headache

Answer 4

> primary
> most frequent
> not disabling
> mild
> bilateral
> pressure/tightening
> no significant associated features

Question 5

what abortive treatment can be given for tension headaches?

Answer 5

> aspirin/paracetamol
NSAIDs
limit to 10 days per month

Question 6

why must abortive treatment for tension headaches be limited to 10 days per month?

Answer 6

to avoid the development of medication overuse headache

Question 7

what preventative treatment could you offer for tension headaches?

Answer 7

tricyclic antidepressants (amitriptyline, dothiepin, notriptyline)

Question 8

what is migraine?

Answer 8

a chronic disorder with recurrent, reversible episodic attacks due to complex changes in the brain.

Question 9

describe a migraine attack

Answer 9

> headache
> nausea
> photophobia
> phonophobia
> functional disability

Question 10

name some triggers for migraine

Answer 10

> dehydration
> sleep disturbance
> diet
> environmental stimuli
> hunger
> stress
> changes in oestrogen levels in women

Question 11

describe the pre-headache in migraine

Answer 11

premonitory:
> mood change
> fatigue
> congnitive changes
> muscle pain
> food craving

aura
> somatosensory

Question 12

describe the early headache in migraine

Answer 12

> dull headache
nasal congestion
muscle pain

Question 13

describe the advanced headache in migraine

Answer 13

> unilateral
> throbbing
> nausea
> photophobia
> phonophobia
> osmophobia

Question 14

describe post headache symptoms in migraine

Answer 14

> fatigue
cognitive changes
muscle pain

Question 15

what is aura?

Answer 15

transient neurological symptoms from cortical or brainstem dysfunction that may involve visual, sensory, motor or speech symptoms.

Question 16

what can aura in migraine be confused with?

Answer 16

transient ischaemic attack

Question 17

how do you differentiate between aura and a transient ischaemic attack?

Answer 17

in a TIA the symptoms all start at the same time and can be localised to a specific vascular area. in aura there is a slow evolution of symptoms

Question 18

define chronic migraines

Answer 18

headache on more than or equal to 15 days a month of which more than or equal to 8 days have to be migraine for more than 3 months

Question 19

what is a transformed migraine?

Answer 19

> history or episodic migraine with increasing frequency of headaches
migrainous symptoms becomes less frequent and severe
there are often episodes of migraine on a background of a severe and featureless frequent headache

Question 20

when patients with chronic migraine with medication overuse what affect can discontinuing the medication have?

Answer 20

can dramatically improve the headache frequency

Question 21

what is a medication overuse headache?

Answer 21

a headache that is present on more than or equal to 15 days a months which has developed or worsened whilst taking regular symptomatic medication

Question 22

what abortive treatment is available for migraine?

Answer 22

> aspirin/NSAIDs
triptans
limited to 10 days per month

Question 23

what prophylactic treatment is available for migraines?

Answer 23

> propranolol, candesartan
anti-epileptics
tricyclic antidepressants
venlafaxine

Question 24

what sort of migraine gets better in pregnancy?

Answer 24

migraine without aura

Question 25

in what migraine in the combined pill contraindicated in?

Answer 25

active migraine with aura but it is okay if there is no attacks for 5 years but stop if aura recurrs

Question 26

in what patients should you avoid anti-epileptic drugs for migraine?

Answer 26

in women of child bearing age

Question 27

what is the treatment for migraine in pregnancy?

Answer 27

> paracetamol for an acute attack | > propranolol or amitriptyline for preventative

Question 28

name some trigeminal autonomic cephalalgias

Answer 28

> cluster headache > paroxysmal hemicranias > SUNCT > SUNA

Question 29

describe the attack in a cluster headache

Answer 29

``` > pain is mainly orbital and temporal > very severe > unilateral > rapid onset (9mins max) > lasts 15mins to 3 hours > pains ceases rapidly > prominent ipsilateral autonomic symptoms > patients are restless and agitated in the attacks ```

Question 30

what migrainous symptoms may be present in a cluster headache attack?

Answer 30

> premonitory symptoms (tiredness and yawning) > associated symptoms (vomiting, photophobia and phonophobia) > typical aura

Question 31

describe the bouts in cluster headaches

Answer 31

> attacks cluster in bouts lasting 1-3months with periods of remission of about a month in between

Question 32

in a bout of a cluster headache how frequently do attacks occur?

Answer 32

1 every other day to 8 per day

Question 33

what may be present between cluster headache attacks?

Answer 33

background pain

Question 34

what can trigger a cluster headache attack in a bout but not in remission?

Answer 34

alcohol

Question 35

is there a rhythm in the time of the attacks and bouts?

Answer 35

yes as attacks occur at the same time each day and bouts at the same time each year

Question 36

what is chronic cluster headache?

Answer 36

when bouts last more than a year without remission or remission lasts less than a month

Question 37

in what trigeminal autonomic cephalalgia is carcidian periodicity absent?

Answer 37

SUNCT, paroxysmal hemicrania

Question 38

what features of pain are different in paroxysmal hemicranias compared to cluster headache?

Answer 38

the features of pain are the same but the attacks last 2-30 minutes and only 50% are restless.

Question 39

how frequent can paroxysmal hemicrania attacks be?

Answer 39

2-40 times a day

Question 40

to what do paroxysmal hemicranias have an absolute response to?

Answer 40

indometacin

Question 41

describe the pain in SUNCT

Answer 41

> unilateral orbital, supraorbital or temporal > stabbing or pulsating > 10-240 second duration

Question 42

what are cutaneous triggers of SUNCT?

Answer 42

> wind, cold > touch > chewing

Question 43

what is the attacks frequency of SUNCT?

Answer 43

3-200 per day with no refractory period

Question 44

what Is pain in SUNCT accompanied by?

Answer 44

conjunctival injection and lacrimation

Question 45

describe the pain in trigeminal neuralgia

Answer 45

> unilateral maxillary/mandibular division pain > stabbing > 5-10 second duration

Question 46

what are the triggers for trigeminal neuralgia?

Answer 46

> wind/cold > touch > chewing

Question 47

what is the difference between trigeminal neuralgia and SUNCT?

Answer 47

trigeminal neuralgia had a refractory period

Question 48

what abortive treatment is there for an cluster headache attack?

Answer 48

> subcutaneous sumatriptan > nasal zolmatriptan > 100% oxygen 7-12 minutes via tight fitting mask

Question 49

what is the abortive treatment for cluster headache bouts?

Answer 49

> occipital depomedrone injection (same side as the headache) > tapering course of oral prednisone

Question 50

what is the preventative treatment for cluster headaches?

Answer 50

> verapamil > lithium > methysergide > topiramate

Question 51

what is the abortive treatment for paroxysmal hemicrania?

Answer 51

there is no abortive treatment for this

Question 52

what is the prophylactic treatment for paroxysmal hemicrania?

Answer 52

indometacin

Question 53

what is the preventative treatment for SUNCT/SUNA?

Answer 53

> lamotrigine > topiramate > gabapentin > carbamazepine

Question 54

what prophylactic treatment is available for trigeminal neuralgia?

Answer 54

> carbamazepine | > oxcarbazepine

Question 55

what surgical intervention in available for trigeminal neuralgia?

Answer 55

> glycerol ganglion injection > stereotactic radiosurgery > decompressive surgery

Question 56

what presentation of secondary headache more likely has a sinister cause?

Answer 56

``` > associated head trauma > first/worst > thunderclap > new daily persistent headache > change in pattern or type > returning patient ```

Question 57

what are some red flags in secondary headache?

Answer 57

``` > new onset > change in headache: aged over 50, immunosuppressed or cancer > change in frequency, characteristic, associated symptoms > focal neurological symptoms > non-focal neurological symptoms > abnormal neurological examination > neck stiffness > high pressure > low pressure > Giant cell arteritis ```

Question 58

what would suggest the headache is high pressured?

Answer 58

``` > worse lying down > on awakening > physical exertion > Valsalva manoeuvre > cerebral venous sinus thrombosis ```

Question 59

what would suggest a low pressure headache?

Answer 59

> precipitated by standing up

Question 60

what features would point to giant cell arteritis?

Answer 60

> jaw claudication > visual disturbances > beaded temporal arteries

Question 61

define a thunderclap headache

Answer 61

high intensity headache reaching maximum intensity in less than one minute

Question 62

what is the differential diagnosis for a thunderclap headache?

Answer 62

``` > primary > subarachnoid haemorrhage > intracerebral haemorrhage > TIA/stroke > carotid dissection > cerebral venous sinus thrombosis > meningitis/encephalitis > pituitary apoplexy > spontaneous intracranial hypotension ```

Question 63

describe the presentation of a subarachnoid haemorrhage?

Answer 63

presenting with a sudden severe headache that peaks within a few minutes and last for a at least an hour

Question 64

what investigations are carried out in a suspected sub arachnoid haemorrhage?

Answer 64

> CT brain > lumbar puncture after 12hours of headache onset > after 2 weeks an angiography is the only reliable investigation

Question 65

what is the treatment for subarachnoid haemorrhages?

Answer 65

surgical clipping or coiling

Question 66

describe meningitis

Answer 66

> nausea > photo/phonophobia > stiff neck > rash

Question 67

describe encephalitis

Answer 67

> altered metal state > focal symptoms > seizures > rash

Question 68

what should be considered for any patient presenting with headache and fever?

Answer 68

CNS infection

Question 69

what features of a headache would suggest that there is an occupying lesion or raised intracranial pressure?

Answer 69

``` > worse on awakening > worse lying flat > focal signs/symptoms > non-focal symptoms (cognitive) > seizures > visual obscurations and pulsatile tinnitus ```

Question 70

what can cause intracranial hypotension?

Answer 70

> dural CSF leak > spontaneous > iatrogenic

Question 71

describe the postural component to the headache in intracranial hypotension

Answer 71

> worse upright > better lying down > can lose this postural component when it becomes chronic

Question 72

what investigations are carried out in intracranial hypotension?

Answer 72

MRI or spine and the brain

Question 73

what is the treatment for intracranial hypotension?

Answer 73

``` > bed rest > fluid > analgesia > caffeine (IV) > epidural blood patch ```

Question 74

describe the headache in giant cell arteritis

Answer 74

> diffuse > persistant > severe

Question 75

what features may accompany the headache in giant cell arteritis?

Answer 75

``` > systemic upset > scalp tenderness > jaw claudication > visual disturbance > enlarged temporal arteries ```

Question 76

what is used to diagnose giant cell arteritis?

Answer 76

> elevated ESR > raised CRP > raised platelet count

Question 77

what is the management for giant cell arteritis after a diagnosis is made?

Answer 77

> high dose prednisolone | > temporal artery biopsy