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Flashcards in Symposium 2: Headache Deck (23):

What proportion of headaches seen in primary care are sinister?



What are the key questions that need to be addressed during the consultation.

- Can I classify the headache?
- Do I need to investigate?
- How do I explain the diagnosis?
- What are the patients expectations?
- Is treatment appropriate?


What are the important considerations regarding the pattern of pain?

Acute (seconds to minutes)
- SAH/Intra-cerebral haemorrhage/coital/thunderclap
Evolving (hours to days)
- Infection/inflammatory/↑ICP
Chronic (weeks to months)
- Chronic daily headache/ ↑ICP


What associated features need to be considered?

- Diurnal variation/postural element
- Nausea and vomiting (meningeal irritation)
- Photophobia/ phonophobia (meningeal irritation)
- Autonomic features (lacrimation/Horners/red eye)


What features of periodicity need to be considered?

Episodic (at least a few days free between attacks)
- Migraine /Cluster headache
Chronic (headache most days)
- Medication overuse/chronic migraine/hemicrania continua


What red flag must you be aware of?

- Cognitive effects
- Seizures
- Fever
- Visual disturbance
- Vomiting
- Weight loss


What are the other important questions to ask?

- Lies down in dark room (Migraine)
- Agitation/pacing (Cluster)

Family History
- Migraine is often familial

Medication/ self medication
- Analgesia (what? And how often?)

What is the patient concerned about?


What should you look for on examination?

- Fever/rash/neck stiffness/↑BP/organomegaly
- Fundal changes (papilloedema)
- Cranial nerve signs/Horners Syndrome
- Focal abnormalities
- Long tract signs


What are the primary headache syndromes?

- Migraine
- Tension headache
- Cluster headache
- Paroxysmal hemicrania
- Exertional headache
- Ice-pick headache
- Coital headache
- Hypnic headache


What are the secondary headache syndromes?

- Intra-cerebral haemorrhage/Stroke
- Meningoencephalitis
- Intracranial venous thrombosis
- Giant cell arteritis
- Tumour with raised ICP
- Cervicogenic headache
- Benign intracranial hypertension


If a CT scan is normal in a patient presenting with the symptoms of a SAH what further steps need to be taken?

Perform a 24hr LP and look for xanthochromia (bilirubin released from lysing red cells). If negative then SAH can be ruled out.


- 54 year old female
- Diabetic
- 72 hours evolving generalised headache and nausea
- Left ear pain for 3 days prior to start of headache
- Received antibiotic ear drops from GP
- Presents
- Obtunded, pyrexial, hyperreflexia in right arm and leg with right extensor plantar.
- Intubated and taken to ITU

What is the possible diagnosis?

Raised ICP and SOL on LHS (causing RHS hyperreflexia) - possible abscess secondary to ear infection.


What is the difference between a prodrome and an occipital seizure?

Occipital seizure - couloured dots/lines

Prodrome - black and white, straight lines


What are the possible causes of raised ICP?

- Mass Effect (brain tumour, abscess)
- Brain swelling (Hypertensive encephalopathy)
- Increased venous pressure
- CSF outflow obstruction (hydrocephalus)
- Increased CSF production (meningitis/SAH)


What are the symptoms of raised ICP?

- Headache (worse on lying or awakening)
- Vomiting
- Seizures


What are the signs of raised ICP?

- Papilloedema
- lateralising signs


What is the most common first presenting sign of a tumour? (90%)



- 70 year old female
- General malaise and left temporal headache for 2 weeks
- Radiates into jaw and worse when eating
- Tender temporal area and scalp feels sensitive
- Can’t sleep on left side
- This morning visual disturbance
- Top half of visual completely obscured for several minutes then seemed to resolve
- Feels nauseated

Giant cell arteritis (temporal arteritis)


What are the features of temporal arteritis?

- Think in patient >60 years old (F>M)
- Association with PMR
- Signs/symptoms
- Weight loss
- Myalgia
- Transient loss of vision
- Jaw claudication
- Tender non-pulsatile temporal artery

- Do ESR which is often elevated but not always


How would you manage temporal arteritis?

- Commence immediate high dose steroids
- Prednisolone 60mg od for 1st week
- Slow taper over 6 weeks to 15-20mg od
- Response is excellent within 48 hours
- Arrange temporal artery biopsy


What are the characteristics of the trigeminal autonomic cephalagias?

- short-lasting headaches
- variable autonomic features


What are the types of trigeminal autonomic cephalagias?

- Cluster headache (attacks last 30-180 minutes; 1 per 24hrs)
- Paroxysmal hemicrania (2-30 minutes; >5 per 24hrs)
- SUNCT (v. rare; seconds; up to 200 attacks per 24hrs)


How is 'chronic daily headache' defined?

Defined as headache lasting >4 hours on >15 days per month, for >3 months.