Headache DDx

Question 1

What are considered ‘red flags’ when a patient presents with a headache?

Answer 1

Headache waking them from sleep
Known/previous malignancy
Immunosuppressed
Exacerbated by Valsalva (coughing/sneezing)

Question 2

Define a tension headache:

Answer 2

Bilateral non-pulsatile headache potentially with scalp tenderness.
Not associated N&V, photophobia or phonophobia

Question 3

What medication has be shown to have a positive effect on tension headaches?

Answer 3

Anti-depressants

Question 4

What is the management for tension headache?

Answer 4

Physiotherapy

Massage

Question 5

Define a cluster headache:

Answer 5

Severe unilateral headache lasting 15mins - 3 hours with pain often around the eye
Can have up to 1 or 2 a day
Chronic or episodic

Question 6

What are some symptoms of a cluster headache

Answer 6

Watery bloodshot eye
Lid swelling
Lacrimation
Flushing
rhinorrhoea
Miosis

Question 7

What group tend to suffer from cluster headaches?

Answer 7

30-40y/o

M>F

Question 8

What is the treatment options for an acute episode cluster headache?

Answer 8

Acutely:
High flow oxygen
Steroids
Sumatriptan sub cut 6mg

Question 9

What prophylactic treatment can be given for a cluster headache?

Answer 9

Verapamil

Question 10

What is SUNCT syndrome:

Answer 10

Rare headache belonging to a group pf headaches known as trigeminal autonomic cephalagias (TAC)
Short lived
Unilateral
Neuralgic headache
Conjuctival injections
Tearing

Question 11

What treatment can be given for SUNCT?

Answer 11

Lamotrigine

Gabapentin

Question 12

What type of headache presents with severe unilateral pain lasting only seconds but occuring between 10-100 times a day?

Answer 12

Trigeminal Neuralgia

Question 13

What can trigger trigeminal neuralgia?

Answer 13

Touch

Question 14

What branches of CNV are involved in trigeminal neuralgia?

Answer 14

CNV 2 & 3

Question 15

Males are more affected by trigeminal neuralgia. True or false

Answer 15

False.

F>M

Question 16

What ethnicity is trigeminal neuralgia more common in?

Answer 16

Asians

Question 17

What age group is trigeminal neuralgia more common in

Answer 17

> 60y/o

Question 18

List some medications which can be used to treat trigeminal neuralgia:

Answer 18

Carmbamazipine
Lamotrigine
Phenytoin
Baclofen
Gabapentin

Question 19

Other than medication what else can be done to treat trigeminal neuralgia?

Answer 19

Surgical ablation or decompression

Question 20

What type of headache, affecting mainly 50s-60s, presents with severe unilateral pain lasting 10-30mins between 1 and 40 times a day?

Answer 20

Paroxysmal Hemicrania

Question 21

What other type of headache is paroxysmal similar to and how might they differ?

Answer 21

Cluster

A paroxysmal headache is shorter in duration but more frequent

Question 22

What drug has an absolute response in paroxysmal hemicrania?

Answer 22

Indomethicin

Question 23

What are the features of a headache associated with idiopathic intercranial hypertension?

Answer 23

Worse on waking
Nausea and vomiting
Seizures and odd behaviors
May have vision loss
Worsened by lying flat, bending forward and coughing

Question 24

What must you exclude in idiopathic intercranial hypertension?

Answer 24

Space occupying lesion

Question 25

What investigation should you do for a headache assoc with idiopathic intercranial hypertension? What should you avoid?

Answer 25

CT imaging DO NOT lumbar puncture until after imaging - patient is at risk of coning

Question 26

What examinations should be done for idiopathic intercranial hypertension?

Answer 26

Fundoscopy | Visual field exam

Question 27

Are females or males more likely to suffer from headache of idiopathic intercranial hypertension?

Answer 27

Females

Question 28

What is another risk factor for idiopathic intercranial hypertension?

Answer 28

Obesity

Question 29

What is the management for headache associated with idiopathic intercranial hypertension?

Answer 29

WEight loss Monitoring visual fields and CSF Acetazolomide Shunt if necessary

Question 30

List some differential diagnosis of headache?

Answer 30

``` Space occupying lesion Infection Stroke GCA Acute glaucoma Sinusitis Medication overuse ```

Question 31

How many patients with migraine suffer from aura?

Answer 31

20%

Question 32

What is the criteria for a migraine IF no aura.

Answer 32

5 attacks of severe unilateral throbbing headache Lasting 4-72 hours N & V May have photo or phono phobia

Question 33

What can trigger migraine?

Answer 33

``` Diet Stress Sleep Hormones (menstruation) Exercise ```

Question 34

How does stress increase the risk of a migraine?

Answer 34

Stress leads to increased levels of serotonin, which causes blood vessels to constrict and dilate Substance P is then released, stimulating pain receptors

Question 35

What risk factors are there for a migraine? | Use the anagram CHOCOLATE

Answer 35

``` Chocolate Hangovers Orgasms Cheese OCP Lie - ins Tumult Exercise Other risks include female, obesity and smoking ```

Question 36

What medication is used for prophylaxis of migraine?

Answer 36

1st line: Propranolol Amitriptyline and Topimirate | 2nd Line: Valproate, Gabapentin, pregabalin

Question 37

What medications can be used to treat an acute migraine?

Answer 37

NSAIDS e.g. aspirin | oral 5-HT antagonists e.g. triptans and ergots

Question 38

When are triptans contraindicated?

Answer 38

In ischaemic heart disease, coronary spasm and uncontrolled hypertension

Question 39

What is a serious side effect of ergotamine that must be mentioned to the patient before it is prescribed for migraine?

Answer 39

Gangrene | Vascular damage

Question 40

How often do patients tend to suffer from migraines?

Answer 40

1 attack a month