Which ONE of the following features is LEAST likely to be helpful in making a clinical diagnosis of migraine?
Answer: D: Migraine headache can be associated with two types of symptoms:
The usual prodromal symptoms are lethargy, yawning, hyperactivity and food craving. These symptoms start many hours before the onset of headache.
The majority of migraine headaches are not associated with an aura. When associated with aura, it can precede or accompany the headache. Aura does not usually last more than 60 minutes. A variety of neurological symptoms can occur during aura. The most common of these symptoms are visual (dark spots and flashing lights etc.). Other symptoms may include hemiparaesthesia, hemiparesis and speech deficits. The headache in migraine can be unilateral or bilateral and pulsating or non-pulsating. External ocular muscle palsy can be associated with migraine. This occurs in ophthalmoplegic migraine, which is a less common type of migraine. In this type the headache is associated with cranial nerve palsies involving III, IV and VI. When a patient presents with ophthalmoplegia associated with a headache for the first time other causes for focal neurological deficit should be carefully excluded before diagnosing migraine. Migraine is a diagnosis of exclusion in these patients.
Which ONE of the following statements is TRUE regarding a patient aged over 50 years who presents to the emergency department (ED) with a severe headache?
Answer: B: The primary causes of headache (migraine, tension type headaches and cluster headaches) are more common than secondary causes, even in patients over 50 years of age. However, careful consideration should be given to exclude life-threatening and other secondary-type headaches. The most common location of a SAH headache is the occipito-nuchal location but other intracranial pathology may also cause headaches in this location. Although the location of the headache needs to be considered seriously, its PPV for diagnosis of a serious pathology is relatively low. About 25% of the SAH are associated with an exertional onset.
Patients over 50 years of age who present with new onset unilateral headache should be carefully assessed to exclude temporal arteritis. The most significant complication associated with temporal arteritis is sudden visual loss secondary to ischaemic optic neuritis. Irregularity, tenderness or loss of pulsation over the temporal artery and an erythrocyte sedimentation rate (ESR) >50 mm are some of the other features of this condition.
Regarding secondary causes of headache, all of the following statements are true EXCEPT:
Answer: B: The risk of cerebral venous thrombosis increases in hypercoagulability states such as:
This diagnosis should be considered in all pregnant patients who present to the ED with headache. In cerebral venous thrombosis neurological findings may not correspond to any anatomical region and they may fluctuate. In the majority of patients, pregnancy improves the migraine symptoms. Therefore, before attributing headache to migraine in a pregnant patient, other serious causes should be considered.
At the initial presentation, the majority of patients with a brain tumour do not have abnormal neurological findings. Hypertension can cause headache and higher diastolic pressures have been found to cause more severe headaches. Usually headache related to hypertension resolves when blood pressure (BP) is adequately controlled. Only 2% of all ischaemic strokes are secondary to spontaneous dissection of cervical arteries. However, this is a very important cause of ischaemic stroke in the young and middle-aged population, responsible for 10–25% of all ischaemic strokes. Although it affects all age groups including children, the peak incidence is in the fifth decade of life.
Regarding temporal arteritis, all of the following statements are correct EXCEPT:
Answer: B: Temporal arteritis is a steroid-responsive large-vessel vasculitis with both local arteritic and non-specific systemic inflammatory features. This condition itself is relatively rare.
1- Local arteritic features include:
a- Temporal artery abnormalities such as:
b- Jaw claudication (34% of patients have this symptom)
c- Visual loss and ischaemic optic neuropathy
d- Scalp and tongue necrosis
2- Systemic features include (these are non-specific):
Polymyalgica rheumatica (PMR) – up to 40% of patients with temporal arteritis have concomitant PMR, hence this diagnosis should be considered in patients with PMR:
Temporal arteritis is almost exclusively limited to the over-50 age group and the patient’s classic presentation is a severe throbbing frontotemporal headache in the area of the temporal artery, which may often be a new onset headache (65–75% of patients). However, some patients do not present with headache. In these patients jaw claudication may be a prominent feature. Ischaemic optic neuropathy is the cause of loss of vision in this condition and, once established, the visual loss is permanent. The most important feature associated with the least chance of having a positive temporal artery biopsy (therefore able to rule out this disease), is the absence of an elevated ESR > 50 mm/h (negative likelihood ratio of 0.2). Once clinically suspected, temporal artery biopsy should be arranged to establish or rule out the diagnosis. The sensitivity of unilateral biopsy is approximately 90% and bilateral biopsy is slightly higher. Considering all clinical features and judgment when the pretest probability is high for a diagnosis of temporal arteritis, corticosteroid therapy should be commenced while waiting for an urgent biopsy. In the absence of a well-established optimal dose and route of administration, the common practice is to give prednisolone at 1 mg/kg.
Regarding subarachnoid haemorrhage (SAH), which ONE of the following is TRUE?
Answer: A: A non-contrast CT may help to predict the site of the rupture of an aneurysm, especially involving the anterior cerebral artery and anterior communicating artery. Only 20% of the patients with SAH have another aneurysm in addition to the one that ruptured. However, this is important to identify for intervention. In the absence of trauma, subhyaloid haemorrhage is pathognomonic, but this is seen only in <25% of the patients presenting with SAH. SAH does not present with syncope as a sole symptom and usually there are associated symptoms, mainly headache, prior to or after the syncopal event.
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