headache

Question 1

are most headaches primary or secondary?

Answer 1

primary

Question 2

what would be types of secondary headaches?

Answer 2

Tumour
Meningitis
Vascular disorders
Systemic infection
Head injury
Drug-induced

Question 3

what would be types of primary headaches?

Answer 3

Tension Type Headache
Migraine
Cluster Headache

Question 4

what is tension type headache?

Answer 4

Mild, bilateral headache which is often pressing or tightening in quality, has no significant associated features and is not aggravated by routine physical activity

Question 5

what are tension type headache treatments?

Answer 5

Aspirin or paracetamol
NSAIDs
Limit to 10 days per month (~2 days per week) to avoid the development of medication overuse headache

Preventative treatment
Rarely required
Tricyclic antidepressants
amitriptyline, dothiepin, nortriptyline

Question 6

what is the most frequent dsiabling primary headache?

Answer 6

migraine

Question 7

what is a migraine?

Answer 7

A chronic disorder with episodic attacks

Complex changes in the brain

Question 8

what happens during migraine attacks?

Answer 8

Headache
Nausea, photophobia, phonophobia
Functional disability

Question 9

what happens in between migraine attacks?

Answer 9

Enduring predisposition to future attacks

Anticipatory anxiety

Question 10

what are migraine triggers?

Answer 10

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

Question 11

what percentage of people does aura affect?

Answer 11

33%

Question 12

what is aura?

Answer 12

Transient neurological symptoms resulting from cortical or brainstem dysfunction

May involve visual, sensory, motor or speech systems

Question 13

how long does aura occur for?

Answer 13

15-60 minutes

Question 14

how would you define a chronic migraine?

Answer 14

Headache on ≥ 15 days per month, of which ≥ 8 days have to be migraine, for more than 3 months

Question 15

how does medication overuse in headaches occur?

Answer 15

Headache present on ≥15 days / month which has developed or worsened whilst taking regular symptomatic medication

Question 16

what is the treatment for migraines?

Answer 16

Abortive treatment
Aspirin or NSAIDs
Triptans
Limit to 10 days per month (~2 days per week) to avoid the development of medication overuse headache

Prophylactic treatment
Propranolol, Candesartan
Anti-epileptics
Topiramate, Valproate, Gabapentin
Tricyclic antidepressants
amitriptyline, dothiepin, nortriptyline 
Venlafaxine

Question 17

when are you likely to get your first migraine as a woman?

Answer 17

during pregnancy

Question 18

what treatment would you use for someone that is haveing an acute attack of migraines but is pregnant?

Answer 18

paraceamol

Question 19

what preventatives would you give a pregnant person with migraines

Answer 19

Propranolol or Amitriptyline

Question 20

what are Trigeminal Autonomic Cephalalgias

Answer 20

group of headache disorders characterised by attacks of moderate to severe unilateral pain in the head or face, with associated ipsilateral cranial autonomic features such as lacrimation, conjunctival injection, rhinorrhoea, nasal congestion, eyelid oedema and ptosis.

Question 21

where would the pain most likely be due to a cluster headache?

Answer 21

mainly orbital and temporal

Question 22

how long would a cluster headache be?

Answer 22

15 mins to 3 hours

Question 23

what are the different types of Trigeminal Autonomic Cephalalgias

Answer 23

Paroxysmal Hemicrania
SUNCT
cluster headache

Question 24

which of the TAC’s attack the most frequent

Answer 24

Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing
(SUNCT)

Question 25

which os the TAC's last the longest?

Answer 25

cluster headache

Question 26

which of the TAC's have a burning sensation?

Answer 26

SUNCT

Question 27

where would the pain be due to paroxysmal hemicrania?

Answer 27

mainly orbital and temporal

Question 28

how long would a paroxysmal hemicrania attack last?

Answer 28

2-30 mins

Question 29

what are cutaneous triggers for SUNCT?

Answer 29

Wind , cold Touch Chewing

Question 30

what type of a pain is trigeminal neuralgia?

Answer 30

stabbing

Question 31

how long does trigeminal neuralgia last?

Answer 31

5-10 seconds

Question 32

what are the treatments for cluster headache?

Answer 32

Abortive (Headache) Subcutaneous sumatriptan 6mg or nasal zolmatriptan 5mg 100% oxygen 7-12 l/min via a tight fitting non-rebreathing max is effective and safe Abortive (Headache bout) Occipital depomedrone injection (same side as the headache) Or tapering course of oral prednisone ``` Preventative Verapamil (high doses may be required) Lithium Methysergide (risk of retroperitoneal fibrosis) Topiramate ```

Question 33

what are the treatments for paroxysmal hemicrania?

Answer 33

No abortive treatment Prophylaxis with indometacin Alternatives – COX-II inhibitors, Topiramate

Question 34

what are the treatments for SUNCT?

Answer 34

No abortive treatment ``` Prophylaxis: Lamotrigine Topiramate Gabapentin Carbamazepine / Oxcarbazepine ```

Question 35

what are the treatments for trigeminal neuralgia?

Answer 35

No abortive treatment Prophylaxis: Carbamazepine Oxcarbazepine Surgical intervention: Glycerol ganglion injection Steriotactic radiosurgery Decompressive surgery

Question 36

what are presentations of a secondary headache?

Answer 36

``` Associated head trauma First or worst Sudden (thunderclap) onset New daily persistent headache Change in headache pattern or type Returning patient ```

Question 37

what are red flags for a secondary headache?

Answer 37

new onset headache new or change in headache aged over 50 Immunosupression or cancer change in headache frequency, characteristics or associated symptoms focal neurological symptoms non-focal neurological symptoms abnormal neurological examination

Question 38

what is a thunderclap headache?

Answer 38

A high intensity headache reaching maximum intensity in less than 1 minute Majority peak instantaneously

Question 39

what are differential diagnosis for thunderclap headaches?

Answer 39

``` Primary (migraine, primary thunderclap headache, primary exertional headache, primary headache associated with sexual activity) Subarachnoid haemorrhage Intracerebral haemorrhage TIA / stroke Carotid / vertebral dissection Cerebral venous sinus thrombosis Meningitis / encephalitis Pituitary apoplexy Spontaneous intracranial hypotension ```

Question 40

who is likely to get a subarachnoid haemorrhage?

Answer 40

``` All patients presenting with a sudden severe headache that peaks within a few minutes and lasts for at least 1 hour Examination is often normal! Never consider a patient ‘too well’ for SAH ```

Question 41

what are features suggestive of a space occupying lesion or raised intracranial pressure?

Answer 41

Progressive headache with associated symptoms and signs Headache worse in morning or wakes patient from sleep Headache worse lying flat or brought on by valsalva (cough, stooping, straining) Focal symptoms or signs Non-focal symptoms e.g. cognitive or personality change, drowsiness Seizures Visual obscurations and pulsatile tinnitus

Question 42

what is intracranial hypotension

Answer 42

a condition in which there is negative pressure within the brain cavity

Question 43

causes of intracranial hypotension?

Answer 43

Dural CSF leak

Question 44

investigations for intracranial hypotension

Answer 44

MRI brain and spine

Question 45

treatment of intracranial hypotension

Answer 45

Bed rest, fluids, analgesia, caffeine (e.g. 1 can red bull qds) i.v. caffeine Epidural blood patch

Question 46

when would you consider someone with arteritis of large arteries?

Answer 46

in any patient over the age of 50 years presenting with new headache

Question 47

what are specific features of giant cell arteritis?

Answer 47

include scalp tenderness, jaw claudication and visual disturbance Prominent, beaded or enlarged temporal arteries may be present An elevated ESR supports the diagnosis (usually >50, often much higher, rarely normal) Raised CRP and platelet count are other useful markers