Headaches

Question 1

Is a rapid onset headache typically concerning?

Answer 1

Yes

Question 2

What can cause a rapid onset headache?

Answer 2

Sub-arachnoid haemorrhage

Meningitis

Encephalitis

Question 3

How is a sub-arachnoid haemorrhage often described?

Answer 3

‘Worst ever headache’

‘Thunderclap headache’

Question 4

Where in the head does a headache caused by a sub-arachnoid haemorrhage typically occur?

Answer 4

Occipital region

Question 5

How does a sub-arachnoid haemorrhage affect consciousness?

Answer 5

Decreased consciousness

Question 6

What can a sub-arachnoid haemorrhage cause within the cranium?

Answer 6

Raised ICP

Question 7

What are some signs of raised ICP that can be seen in GP?

Answer 7

Papilloedema on fundoscopy

History of nausea and vomiting

Double vision (diplopia)

Question 8

Why does raised ICP cause double vision?

Answer 8

Raised ICP disproportionately affects the VI cranial nerve

Question 9

Why does ICP disproportionately affect the VI cranial nerve?

Answer 9

Because it has the longest intracranial course

Question 10

What is the name of the VI cranial nerve?

Answer 10

Abducens

Question 11

What muscle is innervated by the abducens?

Answer 11

Lateral rectus

Question 12

What other symptoms accompany meningitis?

Answer 12

Fever

Photophobia

Purpuric, non-blanching rash

Neck stiffness

Question 13

What other symptoms accompany encephalitis?

Answer 13

Odd behaviour

Fits

Fever

Question 14

How should suspected encephalitis be investigated?

Answer 14

Urgent CT scan

Question 15

What can cause a gradual onset headache?

Answer 15

Sinusitis

Tropical infections

Venous sinus thrombosis

Intra-cranial hypotension

Question 16

What sign may suggest venous sinus thrombosis?

Answer 16

Papilloedema

Question 17

What can make sinusitis pain worse?

Answer 17

Bending over

Question 18

How is a headache caused by sinusitis described?

Answer 18

Dull, constant headache in the distribution of the nasal sinuses

Question 19

What does palpation of the area over inflamed sinuses elicit?

Answer 19

Tenderness

Question 20

Why might a tropical infection be a suspected cause of a headache?

Answer 20

A travel history with accompanying flu-like symptoms

Question 21

What tropical infection can cause headaches?

Answer 21

Typhus

Question 22

What can cause intra-cranial hypotension?

Answer 22

CSF leakage (possibly due to lumbar puncture)

Question 23

When is a headache due to intracranial hypotension worse?

Answer 23

When standing up

Question 24

What do recurrent (not ongoing) headaches typically suggest?

Answer 24

Usually benign

Question 25

What can cause recurrent headaches?

Answer 25

Migraines Cluster headaches Trigeminal neuralgia

Question 26

How does a cluster headache present?

Answer 26

The most disabling of primary headaches Pain around the eye Watery/bloodshot eye Unilateral

Question 27

What can be used to treat cluster headaches?

Answer 27

100% O₂ for ~15 mins through non-rebreath mask Sumatriptan

Question 29

How does trigeminal neuralgia present?

Answer 29

Unilateral Stabbing pain Typically affects maxillary and mandibular divisions

Question 30

How do migraines typically present?

Answer 30

Preceded by an aura Followed within 1 hr by unilateral throbbing headache

Question 31

What types of aura can precede a migraine?

Answer 31

Visual - melting or jumbling of lines or dots, or hemianopia Somatosensory - parasthesia from fingers to face Motor - dysarthria, ataxia, or dysphasia

Question 32

What percentage of the population do migraines affect?

Answer 32

15%

Question 34

What mnemonic can be used to remember migraine triggers?

Answer 34

CHOCOLATE

Question 35

What does C stand for in the CHOCOLATE mnemonic?

Answer 35

Chocolate/Cheese/Caffiene

Question 36

What does H stand for in the CHOCOLATE mnemonic?

Answer 36

Hangovers

Question 37

What does O stand for in the CHOCOLATE mnemonic?

Answer 37

Orgasms/oral contraceptives

Question 38

What does C stand for in the CHOCOLATE mnemonic?

Answer 38

Chocolate/Cheese/Caffiene

Question 39

What does O stand for in the CHOCOLATE mnemonic?

Answer 39

Orgasms/Oral contraceptives

Question 40

What does L stand for in the CHOCOLATE mnemonic?

Answer 40

Lie-ins

Question 41

What does A stand for in the CHOCOLATE mnemonic?

Answer 41

Alcohol

Question 42

What does T stand for in the CHOCOLATE mnemonic?

Answer 42

Travel

Question 43

What does E stand for in the CHOCOLATE mnemonic?

Answer 43

Exercise

Question 44

What are migraines associated with?

Answer 44

Obesity Family history

Question 45

How are migraines diagnosed?

Answer 45

Clinical diagnosis based on history: If no aura: ≥5 headaches lasting 4-72 hours + N&V + any 2 of: Pulsating Unilateral Impairs (or worsened by) regular activity

Question 46

What is a chronic progressive headache suggestive of?

Answer 46

Raised ICP due to: Haemorrhage Tumour Aneurysm

Question 47

A head ache with eye pain +/- visual loss may suggest what?

Answer 47

Acute glaucoma

Question 48

How should acute glaucoma be handled?

Answer 48

Immediate referral

Question 49

What can cause headaches?

Answer 49

Food Sex Analgesia Trauma

Question 50

What part of a social history is it important to identify when thinking about headaches?

Answer 50

Possible stressors

Question 51

What part of a drug history is it important to identify when thinking about headaches?

Answer 51

Medication overuse

Question 52

How can migraines be treated?

Answer 52

Avoid triggers Prophylactic treatment - 1st line = propranalol During attack - oral triptan + NSAID or paracetamol Non-pharmacological therapies

Question 53

What percentage of migraines can the CHOCOLATE mnemonic be applied to?

Answer 53

50%