Headaches

Question 1

Red flags associated with headaches

Answer 1

Fever, photophobia or neck stiffness
New neurological symptoms
Dizziness
Visual disturbance
Sudden onset occipital headache
Worse on coughing or straining (raised intracranial pressure)
Postural, worse on standing, lying or bending over
Severe enough to wake the patient from sleep
Vomiting
History of trauma

Question 2

Important assessment in headaches

Answer 2

Fundoscopy examination to look for papilloedema is an important part of an assessment of a headache. Papilloedema indicates raised intracranial pressure, which may be due to a brain tumour, benign intracranial hypertension or an intracranial bleed.

Question 3

Presentation of tension headaches

Answer 3

Classically they produce a mild ache across the forehead and in a band-like pattern around the head.

This may be due to muscle ache in the frontalis, temporalis and occipitalis muscles.

Tension headaches comes on and resolve gradually and don’t produce visual changes.

Question 4

What are tension headaches associated with

Answer 4

Stress
Depression
Alcohol
Skipping meals
Dehydration

Question 5

Treatment of tension headaches

Answer 5

Reassurance
Basic analgesia
Relaxation techniques
Hot towels to local area

Question 6

What can secondary headaches be secondary to

Answer 6

Underlying medical conditions such as infection, obstructive sleep apnoea or pre-eclampsia
Alcohol
Head injury
Carbon monoxide poisoning

Question 7

How does sinusitis usually present

Answer 7

Causes a headache associated with inflammation in the ethmoidal, maxillary, frontal or sphenoidal sinuses.

This usually produces facial pain behind the nose, forehead and eyes. There is often tenderness over the affected sinus, which helps to establish the diagnosis.

Question 8

Sinusitis disease course

Answer 8

usually resolves within 2-3 weeks. Most sinusitis is viral.

Question 9

Management of sinusitis

Answer 9

Nasal irrigation with saline can be helpful.

Prolonged symptoms can be treated with steroid nasal spray.

Antibiotics are occasionally required.

Question 10

What is an analgesic headache

Answer 10

Caused by long term analgesia use. It gives similar non-specific features to a tension headache.

They are secondary to continuous or excessive use of analgesia.

Withdrawal of analgesia important in treating the headache, although this can be challenging in patients with long term pain and those that believe the analgesia is necessary to treat the headache.

Question 11

What are hormonal headaches related to

Answer 11

They produce a generic, non-specific, tension-like headache.

They tend to be related to low oestrogen

Question 12

Presentation of hormonal headache

Answer 12

Two days before and first three days of the menstrual period

Around the menopause

Pregnancy. It is worse in the first few weeks and improves in the last 6 months.

Headaches in the second half of pregnancy should prompt investigation for pre-eclampsia.

Question 13

What can help improve hormonal headaches

Answer 13

Oral contraceptive pill

Question 14

What is cervical spondylosis caused by

Answer 14

Degenerative changes in the cervical spine. It causes neck pain, usually made worse by movement. However, if often presents with headache.

Question 15

Which condition is associated with trigeminal neuralgia

Answer 15

MS

Question 16

How does trigeminal neuralgia present

Answer 16

Presents with intense facial pain that comes on spontaneously and last anywhere between a few seconds to hours. It is often described as an electricity-like shooting pain. Attacks often worsen over time.

Question 17

Possible triggers for pain in patients with trigeminal neuralgia

Answer 17

Cold weather
Spicy food
Caffeine
Citrus fruits

Question 18

First line treatment for trigeminal neuralgia

Answer 18

Carbamazepine

Surgery to decompress or intentionally damage the trigeminal nerve is an option

Question 19

Typical migraine symptoms

Answer 19

Headaches last between 4 and 72 hours. Typical features are:

Moderate to severe intensity
Pounding or throbbing in nature
Usually unilateral but can be bilateral
Discomfort with lights (photophobia)
Discomfort with loud noises (phonophobia)
With or without aura
Nausea and vomiting

Question 20

What does aura refer to

Answer 20

Aura is the term used to describe the visual changes associated with migraines. There can be multiple different types of aura:

Sparks in vision
Blurring vision
Lines across vision
Loss of different visual fields

Question 21

What type of migraines can mimic stroke

Answer 21

Hemiplegic migraines can mimic stroke. It is essential to act fast and exclude a stroke in patients presenting with symptoms of hemiplegic migraine.

Question 22

Symptoms of hemiplegic migraine

Answer 22

Symptoms of a hemiplegic migraine can vary significantly. They can include:

Typical migraine symptoms
Sudden or gradual onset
Hemiplegia (unilateral weakness of the limbs)
Ataxia
Changes in consciousness

Question 23

Migraine triggers

Answer 23

Stress
Bright lights
Strong smells
Certain foods (e.g. chocolate, cheese and caffeine)
Dehydration
Menstruation
Abnormal sleep patterns
Trauma

Question 24

5 stages of migraine

Answer 24

Premonitory or prodromal stage (can begin 3 days before the headache)

Aura (lasting up to 60 minutes)

Headache stage (lasts 4-72 hours)

Resolution stage (the headache can fade away or be relieved completely by vomiting or sleeping)

Postdromal or recovery phase

Question 25

Acute management of migraine

Answer 25

Paracetamol Triptans (e.g. sumatriptan 50mg as the migraine starts) NSAIDs (e.g ibuprofen or naproxen) Antiemetics if vomiting occurs (e.g. metoclopramide)

Question 26

Triptans in migraines

Answer 26

Triptans are used to abort migraines when they start to develop. They are 5HT receptors agonists (serotonin receptor agonists).

Question 27

How do triptans abort migraines

Answer 27

They have various mechanisms of action and it is not clear which mechanisms are responsible for their effects on migraines. They act on: Smooth muscle in arteries to cause vasoconstriction Peripheral pain receptors to inhibit activation of pain receptors Reduce neuronal activity in the central nervous system

Question 28

Migraine prophylaxis

Answer 28

Keeping a headache diary can be helpful in identifying the triggers. Avoiding triggers can reduce the frequency of the migraine. Propranolol Topiramate (teratogenic) Amitriptyline Acupuncture B2 supplements

Question 29

Most common cause of SAH

Answer 29

Head injury - traumatic SAH

Question 30

Causes of spontaneous SAH

Answer 30

Berry aneurysm AVM Pituitary apoplexy Aortic dissection

Question 31

Classical features of SAH

Answer 31

``` Thunderclap headache Nausea and vomiting Meningism Coma Seizures Sudden death ```

Question 32

How is SAH confirmed

Answer 32

CT head | LP if CT is negative 12 hrs after onset of symptoms

Question 33

IX post confirmation of SAH

Answer 33

CT intracranial angiogram +/- digital subtraction angiogram(catheter)

Question 34

Mx of SAH

Answer 34

Coil by IR Craniotomy Bed rest Vasospasm treated with 21-day course of nimodipine

Question 35

Complications of aneurysmal SAH

Answer 35

``` Re-bleeding Vasospasm(7-14 days after onset) Hyponatraemia due to SIADH Seizures Hydrocephalus ```

Question 36

Risk factors for SAH

Answer 36

``` HTN Smoking Excessive alcohol consumption Cocaine use FHx ```

Question 37

Signs of SAH in LP

Answer 37

Red cell count will be raised. If the cell count is decreasing in number over the samples, this could be due to a traumatic lumbar puncture. Xanthochromia (the yellow colour of CSF caused by bilirubin)

Question 38

When should you suspect bacterial aetiology for sinusitis

Answer 38

Symptoms for more than 10 days Discoloured or purulent nasal discharge (with unilateral predominance). Severe local pain (with unilateral predominance). A fever greater than 38°C. A marked deterioration after an initial milder form of the illness (so-called 'double-sickening'). Elevated ESR/CRP

Question 39

Examination in sinusitis

Answer 39

Inspecting and palpating the maxillofacial area to elicit swelling and tenderness. Performing anterior rhinoscopy (using the largest speculum of an otoscope, or a head light and nasal speculum) to identify: Signs which support a diagnosis of acute sinusitis such as nasal inflammation, mucosal oedema, and purulent nasal discharge. Associated pathology such as nasal polyps, or anatomical abnormalities such as septal deviation.

Question 40

What should be examined in trigeminal neuralgia

Answer 40

Examine the person's face and oral cavity (including the trigeminal nerves) to rule out dental causes of pain, and to detect any abnormalities that require referral to a neurologist

Question 41

Which conditions can lead to compression of the trigeminal nerve or cause symptoms similar to those of trigemninal neuralgia

Answer 41

Tumours, such as posterior fossa tumours, extracranial masses along the trigeminal nerve, perineural spread of existing malignancy, cavernous sinus masses Multiple sclerosis Epidermoid, dermoid, or arachnoid cysts Aneurysm, or arteriovenous malformation

Question 42

Common adverse effects of carbamazepine

Answer 42

Nausea and vomiting Sedation Dizziness Ataxia Leuopenia Switching to MR preparation of carbamazepine may help

Question 43

Symptoms of cluster headaches

Answer 43

``` Red, swollen and watering eye Pupil constriction (miosis) Eyelid drooping (ptosis) Nasal discharge Facial sweating ```

Question 44

Acute management of cluster headaches

Answer 44

Triptans (e.g. sumatriptan 6mg injected subcutaneously) | High flow 100% oxygen for 15-20 minutes (can be given at home)

Question 45

Prophylaxis for cluster headaches

Answer 45

Verapamil Lithium Prednisolone (a short course for 2-3 weeks to break the cycle during clusters)

Question 46

What can trigger cluster headaches

Answer 46

Alcohol Strong smells Exercise

Question 47

Presentation of parietal lesions

Answer 47

``` sensory inattention apraxias astereognosis (tactile agnosia) inferior homonymous quadrantanopia Gerstmann's syndrome ```

Question 48

Presentation of occipital lobe lesions

Answer 48

homonymous hemianopia (with macula sparing) cortical blindness visual agnosia

Question 49

Presentation of temporal lobe lesions

Answer 49

Wernicke's aphasia superior homonymous quadrantanopia auditory agnosia prosopagnosia (difficulty recognising faces)

Question 50

Presentation of frontal lobe lesions

Answer 50

``` Broca's aphasia Disinhibition Perseveration Anosmia Inability to generate a list ```

Question 51

Presentation of cerebellum lesions

Answer 51

midline lesions: gait and truncal ataxia | hemisphere lesions: intention tremor, past pointing, dysdiadokinesis, nystagmus