{"question":{"id":1370,"created":"2023-11-21T00:00:00+00:00","title":"Headaches","body":"

A 26 year old woman complains of a constant, throbbing headache which is worst first thing in the morning. She reports diplopia, and on fundoscopy the optic discs appear swollen with blurred margins. She is overweight but otherwise fit and well.

Select the SINGLE most likely diagnosis from the options below.

","status":"published","content_type_name":"question","path":"/questions/1370","type":"sba","answers":["Migraine with aura","Idiopathic intracranial hypertension","Glioblastoma","Intracranial venous sinus thrombosis ","Medulloblastoma"],"drupal_nid":3479,"stems":[{"id":1627,"body":"","note":{"id":386,"body":"

🔑 Key Learning

\nPrimary headaches: migraine (unilateral, thobbing, aura, photophobia), cluster, CPH.
\nSecondary headaches: red flags and specific signs (e.g. IIH = papilloedema + CN6 palsy).\n
\nTrigeminal neuralgia: electric-shock pain, V1/V2/V3, triggered by touch.\n
\nMOH: >15 headache days/month, frequent triptan/analgesia use.\n
\nAlways rule out secondary causes if red flags (e.g. visual symptoms, focal neurology, sudden onset).\n

🤯 Migraine

👀 Clinical Features

\nSevere unilateral, throbbing headache\n
\nWorsened by activity, improved by lying in darkness\n
\nPhotophobia, phonophobia\n
\n± Aura (most commonly visual)\n

💊 Management

\n1st line: Oral triptan + NSAID or paracetamol
- Triptans are 5-HT1 agonists
- nasal triptan if 12–17 yrs
\n2nd line: Add metoclopramide/prochlorperazine or non-oral routes\n
\nIn pregnancy: 1st line = paracetamol\n
\nMenstrual migraine: mefenamic acid\n
\nAvoid COCP if migraine with aura\n

🔁 Prophylaxis

As per NICE, consider prophylaxis if migraines significant impact quality of life or occur frequently (e.g. > 1x per week on average) or are severe despite optimal acute treatment.
- \n1st line: Propranolol or amitriptyline or topiramate
  - Avoid topiramate in women of childbearing age - teratogenic (or ensure highly effective contraception in place)
  - Also consider: Candesartan (unlicensed) or sodium valproate (if age > 55yrs).
- \n2nd line: Acupuncture (10 sessions over 5–8 weeks), riboflavin or behavioural intervention/CBT.
- \nMenstrual: Frovatriptan/Zolmitriptan 2.5mg BD (“mini-prophylaxis”)\n
- NICE CKS here
\n

💥 Cluster Headache

👀 Clinical Features

\nClusters of attacks: 1–2/day for 2–6 weeks\n
\nDuration ~30 minutes\n
\nSevere, stabbing pain behind/around eye\n
\nAssociated: conjunctival injection, tearing, nasal congestion\n

💊 Management

\nAcute: 100% O2 + SC triptan\n
\nProphylaxis: Verapamil\n
\nAvoid alcohol (trigger)\n

⏱ Chronic Paroxysmal Hemicrania

👀 Clinical Features

\n~20 attacks per day\n
\nDuration: 5–10 mins\n
\nSevere pain with red eye/tearing\n

💊 Management

\nIndomethacin (diagnostic and therapeutic)\n

⚡ Trigeminal Neuralgia

👀 Clinical Features

\nSudden, severe, electric-shock pain affecting CN V (V1/V2/V3)\n
\nTriggered by touch (e.g. washing, shaving)\n

❗ Red Flags

\nOphthalmic division only affected\n
\nAge < 40\n
\nSensory loss, deafness\n
\nSkin/oral lesions\n
\nFHx of MS, optic neuritis\n

💊 Management

\n1st line: Carbamazepine\n

💊 Medication Overuse Headache (MOH)

👀 Clinical Features

\nHeadache on ≥15 days/month\n
\nHistory of regular analgesic/triptan use\n

💊 Management

\nStop simple analgesics and triptans abruptly\n
\nTaper opiates if used\n

🧠 Idiopathic Intracranial Hypertension (IIH)

👀 Clinical Features

\nOverweight woman with headache + visual symptoms\n
\nPapilloedema, CN6 palsy, enlarged blindspot\n

🧪 Investigations

\nCT/MRI head\n
\nLP with opening pressure\n

💊 Management

\nAcetazolamide\n
\nRepeated LPs\n
\nVP shunt or optic nerve sheath decompression\n

🌩 Pituitary Apoplexy

🧬 Pathology

\nAcute haemorrhage/infarction into a pituitary tumour\n

👀 Clinical Features

\nThunderclap headache\n
\nBitemporal hemianopia
\nCranial nerve palsies (III/IV/VI)\n
\nHypotension (adrenal crisis)\n

💊 Management

\nImmediate IV hydrocortisone\n

📝 Exam Clues & Clinchers

Migraine: throbbing, photophobia, aura
- triptan + NSAID = 1st line\n
- prophylaxis: propranolol, amitriptyline, topiramate (teratogenic cautions)
Menstrual migraine: mefenamic acid, prevention: frovatriptan BD starting 2 days before menstruation\n
Cluster: recurrent sharp orbital pain, red eye, 30 mins,
- 100% O2 + triptan\n
CPH: >5 attacks/day, 5–10 mins, responds to indomethacin\n
Trigeminal neuralgia: electric pain, triggered by touch, CN V, carbamazepine\n
MOH: ≥15 headaches/month, daily triptans or codeine\n
IIH: young overweight woman, papilloedema, CN6 palsy, LP shows raised pressure\n
Pituitary apoplexy: SAH-like headache + bitemporal field loss, cranial palsy, hypotension\n

","title":"🤯 Headache"},"note_id":386,"drupal_nid":3480,"key_points":"

✅ Rationale

\nA young, overweight woman with a constant, throbbing headache that is worse in the morning, diplopia, and papilloedema indicates raised intracranial pressure without focal deficit, pointing to idiopathic intracranial hypertension (IIH).\n
\nIIH is characterised by elevated CSF pressure with normal neuroimaging and no mass lesion, classically in obese women of childbearing age.\n
\nMorning worsening occurs because intracranial pressure rises when supine, and papilloedema causes visual symptoms.
- \nDiplopia is commonly due to a sixth cranial nerve palsy caused by raised intracranial pressure.\n
\nOther answer options:\n
- \nA: Migraine with aura – Typically episodic with preceding visual phenomena; does not cause persistent papilloedema or continuous headache.\n
- \nC: Glioblastoma – Usually presents with focal neurological deficits or seizures; imaging shows a mass lesion, not isolated raised intracranial pressure.\n
- \nD: Intracranial venous sinus thrombosis – Usually has acute onset.
- \nE: Medulloblastoma – A posterior fossa tumour of childhood; rare in adults and associated with cerebellar signs.
\n
\nTherefore, idiopathic intracranial hypertension is the single best answer.\n

Idiopathic intracranial hypertension

CFs: Classically, an overweight woman of child-bearing age with headache +/- blurred vision.
O/E: Papilloedema, CN6 palsy, reduced peripheral vision.

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