Case 4 - Headache Flashcards by Rosemarie Stringfellow

What are the 3 primary types of headaches?

Tension headache
Migraine (with or without aura)
Cluster headache

How well did you know this?

Not at all

Perfectly

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

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

How well did you know this?

Not at all

Perfectly

What is the MOA of triptans?

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

How well did you know this?

Not at all

Perfectly

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

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

2nd line: sodium valproate, gabapentin, topiramate

How well did you know this?

Not at all

Perfectly

What percentage of migraine sufferers describe aura?

20-30%

How well did you know this?

Not at all

Perfectly

What are the symptoms of aura?

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

How well did you know this?

Not at all

Perfectly

What are the common trigger factors for migraine?

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

How well did you know this?

Not at all

Perfectly

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

Tension headache

How well did you know this?

Not at all

Perfectly

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

Migraine

How well did you know this?

Not at all

Perfectly

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

Cluster headache

How well did you know this?

Not at all

Perfectly

What drugs can cause headaches?

Isosorbide mononitrate (GTN Spray)
Amlodipine 
Nicroandil 
Sulphasalazine 
Carbamazepine

How well did you know this?

Not at all

Perfectly

Which drug is used in the prevention of cluster headaches?

Verapamil

How well did you know this?

Not at all

Perfectly

What is the acute treatment for cluster headaches?

100% oxygen and subcutaneous triptan

How well did you know this?

Not at all

Perfectly

What are the clinical features of a cluster headache

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

How well did you know this?

Not at all

Perfectly

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

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

How well did you know this?

Not at all

Perfectly

What is the classical triad of symptoms associated with meningitis?

Headache, neck stiffness and photophobia

How well did you know this?

Not at all

Perfectly

What are the main risk factors for meningitis?

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

How well did you know this?

Not at all

Perfectly

When would meningitis be considered an emergency and why?

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

How well did you know this?

Not at all

Perfectly

How can you tell if a rash is non blanching?

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

What is kernigs sign and what does this suggest?

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

What are the major contraindications for doing a lumber puncture?

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

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

(Appearance, WCC count, glucose, protein)

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

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

(Appearance, WCC count, glucose, protein)

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

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

(Appearance, WCC count, glucose, protein)

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

What would the results of the CSF be if there was a fungal infection present? (Appearance, WCC count, glucose, protein)

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

What are the important investigations to do in suspected meningitis?

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

What is the treatment for meningitis?

``` 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

What is the most common long term complication following meningitis?

Sensorineural hearing loss

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

Intramuscular benzylpenicillin (instead of IV ceftriaxone) Transfer to hospital should not be delayed

What is the most common meningitis causing organism in neonates?

Group B streptococcus

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

``` Neisseria meningitis (meningococcus) Streptococcus pneumoniae (pneumococcus) ```

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

Amoxicillin

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

Oral ciprofloxacin

What are the symptoms of raised Intracranial pressure?

``` 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 ```

What is pronator drift sign and why would it occur?

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

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

Dexamethasone (steroid)

What are the symptoms of giant cell arteritis?

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

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

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

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

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

What are the differential diagnosis of meningitis?

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

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

A secondary pathology causing the headache

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

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

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

CT scan - X ray based imaging | MRI - uses magnetic waves, higher quality image, more expensive

What is the most common cause of an extradural haematoma?

Trauma to the side of the head | Causes trauma to the middle meningeal artery which then bleeds

What is the common presentation of a subdural haemotoma?

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

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

Primary brain tumour (glioblastoma, astrocytoma, Meningioma) | Metastatic deposit

When would you give prophylactic treatment for headaches?

If the frequency is more than 2 headaches per month