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Year 3 > Case 4 - Headache > Flashcards

Case 4 - Headache Flashcards

1
Q

What are the 3 primary types of headaches?

A

Tension headache
Migraine (with or without aura)
Cluster headache

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2
Q

What are the contraindications for the use of triptans in headache relief?

A

History of transient ischaemic attack (TIA) and cerebrovascular accident
Ischaemic heart disease
Poorly controlled hypertension

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3
Q

What is the MOA of triptans?

A

5-HT agonist
Mediate vasoconstriction
Also act on receptors in midbrain and trigeminal nucleus caudalis (TNC) - thought to be an area involved in production of migraines

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4
Q

What is the 1st and 2nd line prophylactic drug treatment for migraine?

A

Propranolol 80mg OD or Topiramate
Amytriptyline (low dose) 10mg
Calcium channel blocker (amolodipine, verapamil)

2nd line: sodium valproate, gabapentin, topiramate

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5
Q

What percentage of migraine sufferers describe aura?

A

20-30%

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6
Q

What are the symptoms of aura?

A 
Visual symptoms - flickering lights, spots, lines
Partial loss of vision 
Numbness or tingling / pins and needles
Weakness on one side of the body 
Speech disturbance 
Vertigo
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7
Q

What are the common trigger factors for migraine?

A 
Menstruation 
Flickering lights 
Relaxing after stress
Contraceptive pills
Jet lag
Foods containing tyramine - cheese, red wine, chocolate, citrus fruit
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8
Q

What headache would be described as a recurrent, non disabling, bilateral headache, ‘tight band’

A

Tension headache

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9
Q

What type of headache would be describe as recurrent, severe headache which is unilateral and throbbing in nature. Associated with nausea and photosensitivity

A

Migraine

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10
Q

What type of headache can be described as intense pain around one eye. Attacks occur once each day, each episode lasting 1 hour for the past 8 weeks. Associated with red and watery eye and constricted pupil

A

Cluster headache

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11
Q

What drugs can cause headaches?

A 
Isosorbide mononitrate (GTN Spray)
Amlodipine 
Nicroandil 
Sulphasalazine 
Carbamazepine
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12
Q

Which drug is used in the prevention of cluster headaches?

A

Verapamil

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13
Q

What is the acute treatment for cluster headaches?

A

100% oxygen and subcutaneous triptan

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14
Q

What are the clinical features of a cluster headache

A 
Episode lasting 15 mins - hours 
Unilateral headache 
Intense sharp stabbing pain around one eye
Tearing and redness of the affected eye 
Runny nose
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15
Q

Why is soluble paracetamol preferred to oral tablets during a migraine attack?

A

Gastric motility is reduced during migraine attacks which can cause nausea and emesis. Therefore soluble paracetamol will be absorbed more quickly

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16
Q

What is the classical triad of symptoms associated with meningitis?

A

Headache, neck stiffness and photophobia

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17
Q

What are the main risk factors for meningitis?

A 
Extremities of age 
Living in close proximity - outbreaks in student halls
Vaccination history (lack of meningitis vaccine)
Immune suppression/deficiency
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18
Q

When would meningitis be considered an emergency and why?

A

In the presence of a pupuric rash (non blanching rash)
This is a sign of meningococcal meningitis - emergency
Start antibiotics immediately

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19
Q

How can you tell if a rash is non blanching?

A

Press a glass up against it, if it doesn’t disappear then it is non blanching

20
Q

What is kernigs sign and what does this suggest?

A

Severe stiffness of the hamstrings which causes an inability to straighten the leg when the hip is flexed to 90 degrees. This is suggestive of possible meningitis

21
Q

What are the major contraindications for doing a lumber puncture?

A

Any sign of raised intracranial pressure - papilloedema or focal neurological signs
Meningococcal septicaemia
Coagulation defects
Signs of infection where insertion of the needle

22
Q

What would the results of the CSF be if there was a bacterial infection present?

(Appearance, WCC count, glucose, protein)

A

Appearance - Turbid
WCC count - 500-10,000 polymorphs
Glucose - very low
Protein - high

23
Q

What would the results of the CSF be if there was a tuberculosis infection present?

(Appearance, WCC count, glucose, protein)

A

Appearance - Turbid, viscous
WCC count - <500 lymphocytes/polymorphs
Glucose - low
Protein - very high

24
Q

What would the results of the CSF be if there was a viral infection present?

(Appearance, WCC count, glucose, protein)

A

Appearance - Clear
WCC count - <1000 lymphocytes
Glucose - normal
Protein - raised

25
Q

What would the results of the CSF be if there was a fungal infection present?

(Appearance, WCC count, glucose, protein)

A

Appearance - Viscous, clear
WCC count - <500 lymphocytes/polymorphs
Glucose - low
Protein - very high

26
Q

What are the important investigations to do in suspected meningitis?

A

Lumbar puncture (unless contraindicated)
Blood cultures
Full Blood Count, urea, creatinine, electrolytes, LFTS, clotting screen
ProCalcitonin
Serology for viruses causing meningo-encephalitis
Throat swab for neisseria meningitides and streptococcus pneumonia
Urine pneumococcal antigen
Glucose

27
Q

What is the treatment for meningitis?

A 
IV cefotaxime (IV chloramphenicol if penicillin/cephalosporin allergy)
IV dexamethasone

Add amoxicillin IV (co-trimoxazole IV) if patient over 60 years

Add vancomycin or ciprofloxacin if penicillin resistance suspected

28
Q

What is the most common long term complication following meningitis?

A

Sensorineural hearing loss

29
Q

How would you treat a suspected meningitis differently if you were in a pre hospital setting (GP surgery)

A

Intramuscular benzylpenicillin (instead of IV ceftriaxone)

Transfer to hospital should not be delayed

30
Q

What is the most common meningitis causing organism in neonates?

A

Group B streptococcus

31
Q

What are the two most common meningitis causing organism in adults?

A 
Neisseria meningitis (meningococcus)
Streptococcus pneumoniae (pneumococcus)
32
Q

In the treatment of meningitis in neonates, in addition to cefotaxime, what other antibiotic should be given intravenously?

A

Amoxicillin

33
Q

What is the recommended prophylaxis treatment for those who have contact with patients with meningococcal meningitis?

A

Oral ciprofloxacin

34
Q

What are the symptoms of raised Intracranial pressure?

A 
Headache - often made worse by straining and bending over 
Vomiting
Activity wakes a patient up from sleep
Restricted visual fields 
Enlarged blind spots
Blurred or black vision when change in posture 
Deterioration of conscious level 
Any focal neurological signs
34
Q

What is pronator drift sign and why would it occur?

A

When patient is unable to keep arms outstretched with eyes closed. It is a sign of an upper motor neuron lesion or subtle pyramidal tract dysfunction

35
Q

What drug is given to help reduce oedema surrounding a space occupying lesion?

A

Dexamethasone (steroid)

36
Q

What are the symptoms of giant cell arteritis?

A

Headache
Temporal artery and scalp tenderness (e.g, when brushing hair)
Jaw claudication

37
Q

What treatment and investigations would you do if you suspect giant cell arteritis?

A

ESR investigation (raised in GCA)
Start prednisolone 60mg/d PO immediately
Get temporal artery biopsy within 7 days of starting steroids

38
Q

If a patient had a migraine and felt sick, what treatment can you offer them?

A

Anti emetics to treat sickness
Soluble paracetamol instead of oral to prevent further gastric status occurring which would exacerbate feelings of nausea further

39
Q

What are the differential diagnosis of meningitis?

A

Encephalitis (inflammation of the brain)
Trauma causing meningeal irritation
Subdural empyema (collection of pus between dura mater and arachnoid mater)

40
Q

What should you suspect in a new onset headache in a patient over the age of 50?

A

A secondary pathology causing the headache

41
Q

What investigation would you do if you suspected a space occupying lesion in the head?

A

Urgent CT scan
MRI if further imaging is required
Refer to neurology

42
Q

What is the difference between a CT scan and an MRI scan?

A

CT scan - X ray based imaging

MRI - uses magnetic waves, higher quality image, more expensive

43
Q

What is the most common cause of an extradural haematoma?

A

Trauma to the side of the head

Causes trauma to the middle meningeal artery which then bleeds

44
Q

What is the common presentation of a subdural haemotoma?

A

Venous in origin
Elderly patients, alcoholics and debilitated people are high risk
Venous ooze in brain so there might be some time between the injury and the clinical presentation (weeks/months)
Headache, drowsiness and confusion are common in late stages

45
Q

What are the differentials for a space occupying lesion in the brain?

A

Primary brain tumour (glioblastoma, astrocytoma, Meningioma)

Metastatic deposit

46
Q

When would you give prophylactic treatment for headaches?

A

If the frequency is more than 2 headaches per month

Year 3 (24 decks)

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