Secondary headache and raised intracranial pressure — formative SAQs

SAQ 1 — Eight-year-old with a progressive morning headache (10 marks, 15 minutes)

An eight-year-old boy is brought to your clinic with a six-week history of daily headache. The headache is present when he wakes in the morning, eases through the morning, and is made worse by coughing and bending. His mother describes early-morning vomiting two to three times a week, and his teacher has noticed he is quieter and less engaged at school. His general and neurological examination, including fundoscopy, is normal. [11]

a) Identify the red flags in this history, and explain why a normal examination does not make this headache safe. State the single most important examination finding that would convert this from a watchful-waiting scenario to an imaging-today scenario. (4 marks) [3] [12]

b) State your investigation of choice, the timing, and the reason this modality is preferred over computed tomography for this child. Explain why a lumbar puncture is not your first investigation. (3 marks) [1] [11]

c) Outline your disposition and safety-netting. Discuss the role of the HeadSmart symptom cluster in your reasoning, and explain how you would communicate the urgency to the family without causing disproportionate alarm. (3 marks) [11] [10]

SAQ 2 — Fourteen-year-old girl with papilloedema (10 marks, 15 minutes)

A fourteen-year-old girl with obesity presents to the emergency department with a three-month history of daily headache, episodes of greying of her vision on standing, a whooshing sound in her ears, and new horizontal double vision. Her body mass index is well above the ninety-fifth centile. Fundoscopy shows bilateral optic-disc swelling. Her blood pressure and the rest of her neurological examination are normal apart from a bilateral sixth-nerve palsy. [8]

a) Give the most likely diagnosis and list the Friedman 2013 revised diagnostic criteria you must satisfy to confirm it, including the specific imaging required to exclude a secondary cause. (4 marks) [5] [6]

b) A magnetic resonance imaging of the brain with venography is normal, and the lumbar puncture shows an opening pressure of 330 millimetres of cerebrospinal fluid with normal cells, protein and glucose. Outline the stepwise definitive management, including the drug, the dose, and the one outcome that governs escalation. (4 marks) [7] [9]

c) The girl asks whether the condition will damage her eyesight permanently. Outline your counselling on prognosis and follow-up, and name the circumstance that would make this a neuro-ophthalmological emergency needing surgery on the same admission. (2 marks) [8] [6]