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I don't know when that's gonna work. Ok. There we go. All right. Uh Mommy, can you hear me and see me? Yeah. K Yeah, that's quite the reason. Yeah, cool. All right, let's get started. So thanks for coming to this tutorial. My name is Rama AFA, a medical student at UCL. This is Mohamed. He's also a final year medical student at UCL in case we haven't come before just teaching things. We do weekly tutorials on all the core presentations that you need to know to pass your medical school exams. We make these tutorials ourselves and the vast majority of our, these tutorials are screened by um doctors to make sure we're not getting any information wrong. Um And we're here every Thursday at 6 p.m. on me and we will, all of our, all of our tutorials have recordings which you can watch um and give feedback for retrospectively. Um And we also might consider uploading all our videos to youtube just for ease of access as well. So today we're gonna focus on headaches just a quick poll to sort of get a gist of things. Um I haven't actually made the poll but if you guys just write in the chart 12345 for how much you feel like, you know about headaches so far, just so we can get a gauge for what your current level of understanding is. That would be great. OK. So same, but you do seem more or less confident with this. Uh But hopefully by the end of this, you know, everyone will have a better understanding and we can get up to like a four or five. So in terms of why you need to know about headaches in terms of your medical school exams, um it can be a common os history um as well as sort of a counseling or explaining the management to a patient. Um and in your, in your A KT, um you'll most likely have a few questions on the neurology section or the GP section on, on headaches and sort of figure out which headache a patient has and and knowing the management of that headache and then in terms of going past medical school and, and becoming an actual doctor, headaches are actually common in, in GP practice, but there also can be a sinister presentation in acute pre in acute settings such as A&E. Um So it's important that you're good at uh taking your history, figuring out any red flags, which we will cover later on in the tutorial and understanding what basic management principles you can apply to each situation. So just some quick five questions um that you can put in the chart, just name as many headaches and different types of headaches that you can. And I'll just give you about 30 seconds to do that just so we can know what you know, so far. Great. You guys do stuff, tensions, migraines, migraines with or without aura, neuralgia. Perfect. Yeah. So we've got a good, good range of knowledge already and we will try and cover all of these today. So these are the different types of headaches. There are a lot of them and we will try and cover most of them. But these are what you need to be aware of for your exams and also also for your clinical practice. So you've got migraines, tensions, clusters, temporal arthritis, trigeminal neuralgia, idiopathic intracranial hypertension medication, overuse headache, subarachnoid hemorrhage strokes, tumors, intracranial venous thrombosis and post lumbar puncture headache. It's all presentations you can get um in medicine. So start off with a case presentation. Um A 32 year old lady presents to the GP with recurrent episodes of severe throbbing headaches, primarily on one side of her head lasting several hours. She experiences associated nausea, vomiting and sensitivity to light and sound with occasional visual disturbances. Before the headache begins. The headaches have worsened recently and she has been traveling frequently. She also ex eats excessive amounts of cheese and has been struggling with sleep lately. So has been drinking alcohol as an aid what do you think the most likely differential is for her headache? Just write it in the chat and then we'll start going through the case together and I'll give you like 30 seconds or so to do that. Ok. So we've got some responses. Looks good. So the answer is migraines. So we'll go over this off cause of migraines and how we manage them and stuff. But there are a lot of triggers to migraines. Can you guys tell me any potential triggers that might cause a migraine? There were some in the slide before. So I'll just put that back up. But can you not notice any triggers for the migraine in this history? Um But also that you might know outside of what's what's presented to you here. So light alcohol. Yes, cheese. That's good. Travel. Caffeine smells as well. Good, really good. So there's a good pneumonic that we can remember to, to go to learn the um the triggers of migraines. Um And it's chocolate. So chocolate itself, hangovers, orgasms cheese or caffeine, the oral contraceptive lions, alcohol travel and exercise. So if you have a patient with symptoms, consistent with the migraine, it's important to screen for any of these um which might be triggering the migraine itself because then you can counsel the patient to reduce the use of any of these triggers. So in this case, the patient was having a lot of cheese also drinking a lot of alcohol and was traveling quite a lot and there are other triggers such as stress which he was under as well, which are important to be aware of going over the main facts of migraines themselves in terms of why they happen. The science isn't too sure but it what's most likely is is the cerebral artery uh or specifically the temporal arteries dilating. And I don't know if any of you guys get migraines, but if you do, you can actually feel, I mean, I get them and I can feel my my temporal arteries here just really dilated and very, very strong in their pulsations. Um And in terms of what happens during a migraine, it's sort of split into four different phases. So you've got your pro your aura, the actual headache itself and then the post room. So in terms of the prodrome that can have that can last hours to days and can just include simple things like yawning and craving and having some mood or sleep changes then just before the headache. So five minutes to 60 minutes beforehand, you can get an aura. I think someone did mention that in the chat, but those are normally sort of visual issues where you can get sort of, you can see sort of zig zags, you can lose vision itself. Um and those are sort of very strong programs for patients that you should be aware of. Then the actual headache itself specifically with migraines just going back to the case presentation. So they're painful, usually very painful, 6 to 10 out of 10 on the pain scale, they're throbbing. So it's not a constant pain. It like comes and goes, comes and goes, comes and goes and it just doesn't stop and they're normally unilateral. So on one side of the head, other symptoms you can get are photophobia. So not being able to tolerate light, also nausea and vomiting and also sensitivity to sound as well. Following the headache, patients can also have what we call a post drome, which can last up to two days. And that's just basically feeling tired, low mood, not feeling good and struggling with concentration. And we have sort of a diagnostic criteria, a screenshot of this from past me. Um But these are the sort of nice guideline criteria to diagnose headaches and you need at least five of the criteria which we basically are covered. So longlasting headaches that are on one side of the head, they're pulsating in quality, they're moderate to severe in pain, um and worsened by doing things like physical activity. Um And there's also symptoms of