Neurology

Question 1

Features of tension-type headaches?

Answer 1

Band of pressure/tightening, bilateral or generalised, referred to or form the beck, relieved by simple analgesia (think of other causes if not), come on towards late-afternoon, not aggravated by routine activities i.e. not debilitating

Question 2

Management of tension-type headaches?

Answer 2

Simple analgesia (paracetamol and NSAIDs acutely), reassurance. If debililating, prophylaxis i.e. stress reduction, amitryptylline

Question 3

Features of migraines?

Answer 3

4-72 hours, unilateral, pulsing or throbbing, moderate to sevree pain, aggravated by ADLs, associated with nausea and vomiting and photophobia. May get aura (zigzags/palisades/scotoma, speech, sensory). May be related to menstrual cycle. Get prodrome (hyper before) and post-drome (fatigue) in some.

Question 4

Management of migraines?

Answer 4

Acute is simple analgesia (ibuprofen), triptans (often intranasal) and anti-emetics.
Prophylaxis: headache diary to identify triggers, propranolol, topiramate, amitriptylline. Also stress reduction and acupuncture etc. Consider prophylaxis if affecting QoL, debilitating, or if getting medication overuse headache

Question 5

Features of cluster headaches?

Answer 5

Occur in bouts over weeks i.e. clusters, typically at night, pain comes on rapidly over 10 minutes, severe retro-orbital pain (unilateral), watery eye/runny eye/eyelid swelling, restlessness and agitation, can be triggered by alcohol

Question 6

Management of cluster headache?

Answer 6

Acute attack give SC sumatriptan and high flow oxygen

Prophylaxis includes verapamil and prednisolone (usually during the ‘cluster’)

Question 7

Features of TGN?

Answer 7

Sudden, unilateral shooting pain. Shock-like sensation. Lasts seconds/minutes and is recurrent. Preceded by tingling or numbness. Triggers include skin contact, cold air, oral intake, brushing teeth.

Question 8

Management of TGN?

Answer 8

Support and education, carbamazepine (give effective dose and titrate down)

Question 9

Features of sinusitis?

Answer 9

Acute, chronic or recurrent (chronic if >), frontal headache, tender to touch, worse leaning forward, usually unilateral, following URTI, nasal discharge (post-nasal drip_, related to allergic rhinitis. Can be bacterial or viral. Bacterial >10 days, purulent discharge, fever.

Question 10

Management of sinusitis?

Answer 10

If viral (up to ten days), conservative and supportive. If seems bacterial or high risk, give co-amox or phenoxymethylpenicillin.
Can try high dose nasal steroids for 14 days.
ENT referral may be indicated if chronic or recurrent.

Question 11

Features of medication overuse headache?

Answer 11

Previous headache or pain history, occurs 15 days or more per month. Developed or worsened while taking regular analgesia. Had headache that CHANGED. If simple analgesia must be taking for at least 15 days per month, if opiates or triptans than at least 10. To diagnose must stop analgesia and headache changes or goes away within two months.

Question 12

Management of medication overuse headache?

Answer 12

Stop analgesia and review. Consider prophylaxis of their type of headache.

Question 13

Features of TMJ dysfunction headache?

Answer 13

Get facial pain referred to head/neck/ear. Headache around temples. Restricted ROM in jaw. Joint clicking or grinding. Hx of bruxism, dystonias, anxiety. Musicians and singers at risk.

Question 14

Management of TMJ dysfunction headache?

Answer 14

Reassurance, psychological support, relaxation techniques, analgesia. Can give mouth guards. All very conservative!

Question 15

Features of GCA headache?

Answer 15

> 50, temporal headache, scalp tenderness, jaw claudication, transient visual symptoms (red flag), malaise and fever i.e. systemic features, high ESR. 50% have PMR. Temporal artery biopsy positive in 90%.

Question 16

Management of GCA?

Answer 16

Urgent management to prevent vision loss (40-60mg prednisolone daily and titrate down). Also 75mg aspirin and PPI.
Regular monitoring of symptoms and ESR for relapses.

Question 17

What causes visual loss in GCA?

Answer 17

Mostly arteritic anterior ischaemic optic neuropathy (AAION), can be secondary to central retinal artery occlusion

Question 18

SAH features?

Answer 18

Thunderclap, sudden, occipital. Reaches peak in seconds (rare for headaches). Associated with HTN, cocaine, alcohol excess, Marfan’s syndrome. Get nausea and vomiting, seizures, meningism (DD meningitis)

Question 19

Management of SAH?

Answer 19

A-E, stop any anticoagulation, prevention of vasospasm with nifedipine, control HTN, surgical

Question 20

Features of encephalitis?

Answer 20

Get headache, fever, neck stiffness, vomiting, altered GCS (i.e. similar to meningitis). Key is get personality changes. Focal neurology and flu-like prodrome

Question 21

Features of SoL headache?

Answer 21

Headache worsens when lying down, associated with papilloedema, vomiting, neuro deficit, cognitive/personality changes, seizures. New onset headache in person over 50 is red flag.

Question 22

Management of SoL headache?

Answer 22

Treat cause (malignancy, cerebal abscess, haematoma, hydrocephalus, cysts or granulomas).
Management of raised ICP (elevate head of bed, avoid fever, CSF drainage. Mannitol acutely, hyper-ventilation (prevent CO2 rising?), sedation and NM blockage in ITU setting).

Question 23

Features of headaches requiring urgent CT head?

Answer 23

Thunderclap, focal neurological including low GCS, signs of raised ICP, cancer, immunocompromised (separate for trauma)