🤔 MEDIUM

Is studying for headaches giving you a headac—- … no I won’t do it. Sorry. Stop reading this and try some questions. I’m tired haha.

Reviewed by Jonathan Loomes-Vrdoljak

Approach to the Patient with Headache - Part One

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Question 1

Stem 1 of 4

A 27 year-old woman comes to her GP fed up. She’s had one-sided, aching head pain for about 2 years now. It lasts the “whole damned day” when she gets a flare of it, and she has to wear sunglasses. She can’t eat much more than dry toast during the “attacks” as she puts it, and is also worried because now she’s started seeing “flashing stars before the headache comes on - like its warning me!”.

What is the best matched differential?
A
Cluster headache
B
Medication headache
C
Migraine headache
D
Tension headache
E
Tic douloureux
Question 1 Explanation: 
Think of a migraine as a POUND - pulsatile, photophobia, pounding headache, One day duration, Unilateral in origin, N&V and disabling to ADL.
Question 2

Stem 2 of 4

Which of the following is a true statement about this diagnosis?
A
An aura succeeds the headache usually
B
Migraine affects about 1 in 70 people worldwide
C
Migraine is more common in males
D
Pregnancy often improves symptoms
E
Prognosis is worsened with age
Question 2 Explanation: 
According to NICE, auras precede or accompany many migraines, 1 in 7 suffer with the condition, it is two-to-three times more common in women, and improved with age and pregnancy.
Question 3

Stem 3 of 4

When taking the history, which red flags are most appropriate to ascertain?
A
Constitutional symptoms
B
Focal neurological signs
C
Thunderclap headache
D
Post-exertion headache
E
Pulsatile tinnitus associated sign
Question 3 Explanation: 
The mnemonic SNOOP is often used to remember the red flags of headache presentations - systemic signs, neuro signs, onset thunderclap, onset in older patients, precipitated via position/stress, pulsatile tinnitus.
Question 4

Stem 4 of 4

How would you initially manage this patient’s acute episode?
A
Avoid triggers
B
Lifestyle changes
C
Paracetamol
D
Tripitan
E
Metoclopramide
Question 4 Explanation: 
Remember the acute response to migraine with ATM - analgesia, triptan, metoclopramide.
Question 5

Stem 1 of 4

A 19 year-old university student is brought to his GP. He is drowsy and poorly responsive with a fever. His friend accompanying him says that he’s been rubbing his neck constantly for a few days and complaining of a worsening headache. Whilst in the waiting room the patient has a generalised seizure.

Given the most likely diagnosis, what is the most common aetiology?
A
Capnocytophagia canimorsus
B
Streptococcus agalactiae
C
Listeria monocytogenes
D
Streptococcus pneumoniae
E
Streptococcus suis
Question 5 Explanation: 
SP remains the top cause of bacterial meningitis despite significant success of the PCV13 vaccine (decreasing incidence by some 30%). In adults, the most common cause of bacterial meningitis remains S. pneumoniae - see NICE for more information here: https://cks.nice.org.uk/topics/meningitis-bacterial-meningitis-meningococcal-disease/background-information/causes/
Question 6

Stem 2 of 4

The patient is positive of Kernig’s sign. Which of the following best describes this test?
A
Erythematous rash on flanks and anterior torso
B
Flexion of the neck causes a flexion of hip
C
Hip flex, knee extend causes back pain
D
Knee flex, hip extend causes back pain
E
Non-blanching purpuric rash on flanks
Question 6 Explanation: 
This sign is seen in 11% of all meningitis adult patients.
Question 7

Stem 3 of 4

The patient has a non-blanching purpuric rash. What would be the first line step in PRIMARY care?
A
Administer parenteral antibiotics and monitor 20 minutes
B
Call 999 and administer parental antibiotics
C
Call 999 but without antibiotics
D
Send home with antipyretics
E
Send home with antipyretics and emollient cream
Question 7 Explanation: 
The patient requires IM/IV benzylpenicillin (unless allergic) and to be blue-lighted to secondary care as soon as possible via 999. This is, of course, a medical emergency. See NICE guidelines.
Question 8

Stem 4 of 4

Which of the following is an expected result for the CSF of this patient?
A
Elevated CSF lactate suggests bacterial infection
B
Elevated CSF protein should be expected
C
Glucose concentration will be elevated relative to plasma
D
Polymorphonuclear leukopenia is common in CSF
E
There is no need for a LP
Question 8 Explanation: 
You should take a LP sample within an hour of presentation at the latest and have samples prioritised. Culture, gram stain, check cells, proteins, glucose and lactate.
Question 9

Stem 1 of 4

A 52 year old female presents to her primary care practitioner complaining of a year’s worth of “headaches at the end of her busy work day”. She is a lawyer, denying any occupational health exposures, but is getting frustrated. She denies photophobia, nausea or pain sufficient to disable.

During the differential process, the clinician considers “medication overuse headache”. Which are the top two drug classes responsible for this diagnosis?
A
Benzodiazepine
B
Barbiturates
C
Anti-epileptic medication
D
Opioid medication
E
Biguanide medication
Question 9 Explanation: 
The top two causes of medication overdue headache are opioids and barbiturate-analgesia (BMJ Best Practice). NICE/the International Classification of Headache Disorders highlights the following drugs as possibly being the cause of medication overuse headaches: paracetamol, NSAIDs, aspirin, triptans, opioids, combined analgesics and ergotamine.
Question 10

Stem 2 of 4

The patient is diagnosed with a tension-type headache. Which muscle group(s) are LEAST tender in this patient demographic?
A
Deltoid
B
Lateral pterygoid
C
Sternocleidomastoid
D
Temporalis
E
Trapezius
Question 10 Explanation: 
SCM, trapezius and the masticatory muscles are most likely affected by tension-headache. Deltoid is not in this category.
Question 11

Stem 3 of 4

Which risk factor is LEAST associated with tension-type headache?
A
Avoiding meals
B
Female sex
C
Mental tension
D
Stress
E
Tiredness
Question 11 Explanation: 
Although 3:2, female:male the literature states this is less a causal link than the other mentioned risk factors. Source: "Risk Factors" of Migraine subsection - (BMJ Best Practice, 2021).
Question 12

Stem 4 of 4

Which medication below would you NOT consider as a first-line option in acute tension-type headache?
A
Aspirin
B
Celecoxib
C
Ibuprofen
D
Naproxen
E
Paracetamol
Question 12 Explanation: 
Several Cochrane reviews show that simple analgesia listed above to be effective in most cases. It is important that any treatment be started as soon as possible in the attack.
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