Headache — Viva

Q1: A 55-year-old man wakes at 2 am with excruciating right eye pain, tearing, and a drooping right eyelid. This is his third attack this week. Discuss the diagnosis, the pathophysiology, and the acute and prophylactic management. (3 min)

Cluster headache — strictly unilateral periorbital, 15 to 180 minutes, ipsilateral autonomic features (lacrimation, ptosis, miosis — partial Horner), bouts with circadian/circannual regularity, male predominance, smoking. Pathophysiology: activation of the ipsilateral posterior/inferior hypothalamus (the circadian "cluster generator", May Lancet 1998) driving trigeminal + parasympathetic (sphenopalatine ganglion) discharge with CGRP release. Acute: 100 percent oxygen at 12 to 15 L/min via non-rebreather for 15 to 20 minutes, or subcutaneous sumatriptan 6 mg (oral too slow). Transitional: oral corticosteroid or greater occipital nerve block. Prophylaxis: verapamil 240 to 960 mg/day with baseline and incremental ECG monitoring; alternatives lithium, topiramate; refractory neuromodulation (vagal nerve / hypothalamic DBS).^[1]

Q2: A 35-year-old woman presents to the ED with "the worst headache of my life", reaching maximum intensity within one minute while exercising. How do you proceed? (3 min)

Thunderclap headache — subarachnoid haemorrhage until proven otherwise. ABCDE; immediate non-contrast CT head (sensitivity near 100 percent within 6 hours on modern multidetector CT). If CT positive for subarachnoid blood, CTA to localise the aneurysm and urgent neurosurgical/endovascular referral; control BP (systolic under 160 mmHg pre-securement) and start nimodipine 60 mg PO 4-hourly for 21 days to prevent delayed vasospasm. If CT is negative but clinical suspicion persists, LP after 12 hours for xanthochromia (bilirubin from haemoglobin breakdown) and opening pressure. CT and LP both negative effectively excludes SAH. Apply the Ottawa SAH Rule (age over 40, neck pain/stiffness, witnessed LOC, exertional onset, thunderclap, limited neck flexion) to decide who to investigate. Also consider RCVS, CVST, arterial dissection, and pituitary apoplexy in a thunderclap presentation.^[1]

Q3: A 72-year-old woman has a new temporal headache, scalp tenderness, and aching shoulders. Her ESR is 92 mm/h. What is the diagnosis, the feared complication, and your immediate management? (2 min)

Giant-cell (temporal) arteritis. Feared complication: anterior ischaemic optic neuropathy causing irreversible blindness (fellow eye at risk within days). Management: start prednisolone 40 to 60 mg immediately — do NOT delay for biopsy. If visual symptoms or amaurosis, IV methylprednisolone 500 mg to 1 g daily for 3 days first. Arrange temporal artery biopsy within 2 weeks (skip lesions, so a negative biopsy does not exclude); add low-dose aspirin; begin a slow steroid taper over 12 to 24 months guided by symptoms and CRP. Look for and treat associated polymyalgia rheumatica.^[1]

Q4: Discuss the indications for migraine prophylaxis and name four agents with one key caveat each. (2 min)

Start prophylaxis if: 4 or more headache days/month, disability despite acute therapy, acute therapy failure/contraindication/overuse, hemiplegic/basilar migraine, or patient preference. Aim: 50 percent reduction; review at 3 and 6 months; trial 2 to 3 agents. Agents: propranolol (avoid in asthma, depression), topiramate (teratogenic, weight loss, cognitive effects — avoid in women of childbearing age), amitriptyline (sedating, useful if insomnia), valproate (teratogenic — avoid in women of childbearing age, Pregnancy Prevention Programme), flunarizine (depression, parkinsonism), candesartan (hypotension). Newer: CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab — injectable, few interactions) and onabotulinumtoxinA for chronic migraine only.^[1]

Viva scoring

References3ShowHide

1. [1]Eigenbrodt AK, Ashina H, Khan S, et al. Diagnosis and management of migraine in ten steps Nat Rev Neurol, 2021.PMID 34145431
2. [2]Perry JJ, Stiell IG, Sivilotti MLA, et al. Clinical decision rules to rule out subarachnoid hemorrhage for acute headache JAMA, 2013.PMID 24065011
3. [3]Holroyd KA, O'Donnell FJ, Stensland M, et al. Management of chronic tension-type headache with tricyclic antidepressant medication, stress management therapy, and their combination JAMA, 2001.PMID 11325322