EMQs in Clinical Medicine.pdf - Peshawar Medical College

Treatment of headache – answers 103
40 Treatment of headache
Answers: H J E K D
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A 52-year-old man with ischaemic heart disease requires treatment
for an acute migraine attack that has not responded to paracetamol.
Aspirin and metoclopramide provide relief for the symptoms of pain and
nausea/vomiting associated with migraine. The use of serotonin 5HT 1
agonists such as sumatriptan are indicated if the patient fails to respond
to conventional analgesics. Remember that the 5HT 1 agonists are contraindicated
in patients with coronary artery disease, previous myocardial
infarction (MI) and uncontrolled hypertension.
A 75 year old has a headache and painful red congested eye with a
dilated non-responsive pupil.
This is a presentation of acute glaucoma and is a medical emergency
because there is a risk of blindness. The symptoms are often
precipitated/made worse by the dark. The severe pain can lead to nausea
and vomiting. Acetazolamide acts by decreasing the formation of
aqueous humour. After the intraocular pressure has been reduced,
surgical intervention in the form of peripheral iridectomy can prevent
recurrence.
A 65-year-old woman presents with a headache that has lasted a few
weeks. She gets pain in her mouth during meals and her scalp is tender
on palpation.
Her symptoms and signs are suggestive of temporal/giant cell arteritis
(GCA). The erythrocyte sedimentation rate (ESR) is characteristically very
high in this condition. Treatment of choice is high-dose oral prednisolone.
Skip lesions occur in temporal arteritis and so a negative temporal
artery biopsy is not an indication to stop treatment in the face of
high clinical suspicion of GCA.
A 70-year-old woman requiring treatment for troubling trigeminal
neuralgia.
Carbamazepine is commonly used to treat trigeminal neuralgia.
Phenytoin and gabapentin have also been used to treat this condition.
Cases refractory to medical treatment may be considered for surgery.
A 29-year-old man with a skull fracture is suffering from very severe
pain overlying the laceration to his head. He has been admitted for
overnight observation.
Morphine causes pupillary constriction and should not be given as
analgesia in this case of head injury because it will interfere with
neurological observations.