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Case 4: Headache Flashcards

1
Q

what is a primary headache? Give an example

A

Disorder where there is no secondary underlying pathology

E.g. migraine, cluster headache

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2
Q

What is a secondary headache? Give an example

A

Often potentially serious underlying mechanism

E.g. space occupying lesion, intracranial hypertension, vasculitis, arteritis

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3
Q

Signs of raised intracranial pressure

A

Papilloedema on fundoscopy
(blurred, swollen looking optic discs. haemorrhagic changes round the optic disc)

Peripheral visual field loss / enlarged blind spots

Pain on eye movements (nerve stretch due to RIP)

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4
Q

What is the cause of oral hairy leukoplakia?

A

EBV

Severe immunodeficiency

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5
Q

Cause of a purpuric rash

A

Meningococcal sepsis

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6
Q

Cause of livedo reticularis

A

Antiphospholipid Ab syndrome

Vasculitis

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7
Q

1st line Tx for acute migraine

A 
Oral triptan ((5-HT1 receptor agonist - constricts cerebral blood vessels) (or another triptan) + NSAID
OR oral triptan + paracetamol

Can prescribe antiemetics (e.g. domperidone, prochlorperazine, metoclopramide) because nausea/vomiting is a Sx in >50% of migraine sufferers

NOT codeine / other opiates - can increase nausea because of gut stasis

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8
Q

At what age do we consider giant cell arteritis

A

> 50

More common in women

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9
Q

Most common serious SE of GCA

A

blindness due to optic nerve ischaemia

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10
Q

What drugs must you consider overuse of causing a headache?

A

For 3 months or more:
Triptans / opioids / ergots or combination analgesic medications for 10 days or more per month
Paracetamol, aspirin, or NSAIDs alone or in combination for 15 days or more per month

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11
Q

Acute treatment for a cluster headache

A

Nasal triptan +/- oxygen (100% at 12L/min via non-rebreath mask)
Arrange home and ambulatory oxygen

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12
Q

When to diagnose migraine with aura

A

if they have neurological symptoms that:

  • are fully reversible
  • develop gradually, either alone or in succession over at least 5 minutes
  • last for 5-60 minutes
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13
Q

Is this likely to be a tension, migraine or cluster headache?

  • Can be unilateral or bilateral
  • pulsating pain
  • moderate-severe pain
  • causes avoidance of daily activities
  • sensitivity to light, nausea, vomiting, aura
  • 4-72 hours adults, 1-72 hours young people aged 12-17
A

Migraine (can be with or without aura)

(Episodic migraine - <15 days per month)
(Chronic migraine - > 15 days per month for more than 3 months)

Note, aura only occurs in 20-30% of pts

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14
Q

Is this likely to be a tension, migraine or cluster headache?

  • Unilateral (usually around eye, or one side of face)
  • Variable types of pain
  • Severe-very severe
  • Makes pt restless and agitated
  • on same side as pain can get a watery/red eye, nasal congestion, runny nose, swollen eyelid, sweating, drooping eyelid
  • 15-180 minutes
A

Cluster headache

(Episodic cluster - 1 every other day to 8 per day with remission for >1 month)
(Chronic cluster - 1 every other day to 8 per day with remission for <1 month

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15
Q

Is this likely to be a tension, migraine or cluster headache?

  • Bilateral
  • pressing/tightening - non pulsatile
  • mild-moderate severity
  • doesn’t really affect activities of daily living
  • no other symptoms really
  • 30 minutes - continuous
A

Tension headache

Episodic tension - <15 days per month
Chronic tension - >15 days per month for >3 months

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16
Q

Sensory symptoms associated with a migraine aura

A

Visual disturbance (e.g. scintillating scotoma)
Paraesthesia
Numbness affecting hand and progressing up the arm before involving the face/lips/tongue. Leg can be affected

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17
Q

Recognised triggers for migraine (with aura)

A

Contraceptive pills (particularly withdrawal period between cycles) (contraindicated in women with migraines with aura, or all women with migraine >35 - increased risk of CV events)
Jet lag
Cheese (tyramine - red wine, cheese, chocolate, citrus fruits)
Relaxing after stress
Menstruation (fall in oestrogen)
Flickering lights on TV

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18
Q

Contraindications to prescribing triptans in migraine

A

history of TIA or cerebrovascular accident

History of IHD / MI / poorly controlled HTN (because triptans have vasoconstricting actions)

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19
Q

Criteria for consideration of preventative Tx for migraines: any 1:

A

QoL / business duties / school attendance severely affected
2 or more attacks per month
Migraine attacks do not respond well to acute Tx
Frequent, very long, uncomfortable auras

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20
Q

Prophylactic Tx of migraines

A

1st line: propranolol or low dose amitriptyline

Women who get migraines prior to menstruation can be given transdermal oestrogen patches 3 days before onset of menstruation

2nd line: antiepileptics (e.g. sodium valproate, topiramate)
(Topiramate has a risk of fetal malformations) (Also used for epilepsy)
Or antihypertensives (ACEi, AngII receptor blockers, CCBs)

Remember to use propranolol over topiramate in pts of childbearing age

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21
Q

when would you prescribe topiramate over propranolol?

A

If the pt is asthmatic

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22
Q

Meningitis: triad of classical symptoms

A

Headache
Neck stiffness
Photophobia

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23
Q

Most common pathogen causing encephalitis

A

herpes simplex virus (HSV)

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24
Q

Symptoms of encephalitis that distinguish it from meningitis

A 
confusion
disorientation
drowsiness
seizures
changes in personality / behaviour e.g. agitation
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25
RFs for meningitis
<5yo or >65yo living in close proximity Lack of vaccinations Immune suppression / deficiency
26
What are you looking for on examination for meningitis?
``` Purpuric (non-blanching) rash Signs of sepsis/shock Assess nick stiffness(chin to chest) Kernig's sign (positive when the thigh is flexed at the hip and knee at 90 degree angles, and subsequent extension in the knee is painful/resistance) Perform a full neurological examination ```
27
Investigations for meningitis
CSF sample Blood culture Urine cultures Serology for viruses causing meningo-encephalitis Throat swab for Neisseria meningitides and strep pneumoniae Urine pneumococcal Ag
28
At what level does the spinal cord end and become the conus medullaris
L2
29
Where do we go for a lumbar puncture? Why?
``` Between L3 and L4, or L4 and L5 More space between bones Pt can arch back here to make more space Lumbar cistern here (cauda equina covered by dura) Cauda equina here ```
30
Side effects of a lumbar puncture / spinal anaesthetic
CSF can leak through the dura mater --> headache | This does not happen with an epidural because you aren't puncturing the dura
31
Tx for bacterial meningitis
Empirical Abx therapy with IV 3rd generation cephalosporin e.g. cefotaxime, ceftriaxone + Dexamethasone 10mg If >60, + amoxicillin If penicillin / cephalosporin allergic/contraindicated: Chloramphenicol Dexamethasone if >60, +co-trimoxazole If Listeria bacterium suspected, ampicillin
32
Symptoms of GCA
>55 malaise sweats proximal muscle aching
33
Tx for tension headache
10-25mg amitriptyline at night
34
If someone has a right sided pronator drift, what is this a sign of
Left hemisphere raised intracranial pressure e.g. space occupying lesion
35
Investigations if pt has a pronator drift
Urgent cranial imaging - CT, then consider MRI depending on results Refer to neuroscience centre If presence of oedema /swelling in brain, give dexamethasone
36
Examples of space occupying lesions
Tumour (primary, secondary, benign, malignant) Infection (brain abscess, subdural empyema, granuloma, parasitic) Vascular - acute haemorrhages, chronic (carvernoma/vascular malformation, brain infarction) Hydrocephalus - build up of CSF in brain
37
What type of haemorrhage would a trauma cause
Extradural or subdural haemorrhages
38
What haemorrhages are due to HTN or are spontaneous
Subarachnoid or parenchymal
39
Describe the 3 causes of hydrocephalus (build up of CSF in brain)
Non-communicating/obstructive: obstruction in the normal flow of CSF e.g. due to tumours, cysts, intraventricular haemorrhage Communicating: no obstruction in the pathway, but problem with absorption due to meningitis, subarachnoid haemorrhage) OVerproduction of CSF: rare, due to benign tumour - choroid plexus papilloma
40
What is the structure that produces CSF
choroid plexus
41
Signs/symptoms of primary brain tumour
Symptoms are due to the raised ICP: headache (1-2weeks, can be worse in morning), vomiting, blurred vision, deterioration of conscious level Signs: bradycardia, HTN, papilloedema Symptoms of compression of nearby structures Symptoms of cortical/meningeal irritation Hormonal effects if affecting pituitary or hypothalamus Systemic effects
42
Symptoms of tumour affecting frontal lobe
personality changes dementia weakness dysphasia
43
Symptoms of tumour affecting parietal lobe
``` sensory symptoms dressing apraxia (inability to correctly get self dressed) visual field defects ```
44
Symptoms of tumour affecting temporal lobe
dysphasia | visual field defects
45
Symptoms of tumour affecting occipital lobe
visual field defects
46
Symptoms of tumour affecting posterior fossa
``` dysmetria (lack of coordination) gait ataxia cranial nerve palsies tremor nystagmus ```
47
Most common primary malignant brain tumour
GBM - glioblastoma multiforme (IV)
48
Most common primary benign brain tumour
meningioma
49
What signs on scan would make you think something is a met and not the primary tumour
Mets are more uniformly enhancing Lots of swelling/oedema normally multiple of them
50
Grading of Gliomas
Grade I: pilocytic astrocytoma (most benign) Grade II: low grade astrocytoma Grade III: anaplastic astrocytoma Grade IV: glioblastoma multiforme (most malignant)
51
Tx of gliomas:
Surgery not useful because high grades are widespread RAdio/chemotherapy Steroids Tx of associated problems
52
Tx of meningioma (benign)
surgical excision small tumours can be observed Radiotherapy, stereo-radiosurgery, hormonal therapies
53
Typical presentation of a vestibular schwannoma
(benign tumour arising from nerve sheath of vestibular nerve) - ipsilateral hearing problems - ipsilateral tinnitus Can also affect the 5th and 7th and lower CNs
54
Tx of vestibular schwannoma
Surgical excision | RAdiosurgery
55
Most important investigation for a brain tumour
CT, MRI
56
what cures GMB (glioblastoma multiforme)
nothing - is about management
57
Where does a meningioma arise from
arachnoid cap cells
58
What is pathological raised ICP?
>20mmHg | normal ICP is 15mmHg - lower in children and can be negative in newborns
59
Symptoms of acute raised ICP
decreased consciousness high BP bradycardia respiratory depression
60
Symptoms of slowly raised ICP
headaches nausea vomiting problems with eyesight
61
Routine measures to control ICP
- head up tilt - 30-45degrees - improves venous drainage and CSF movement - keep neck straight and avoid tight tapes - prevent jugular venous obstruction - avoid hypotension - maintain adequate sedation to reduce metabolic demands - maintain euvolaemia - maintain normal PCO2 (raised pCO2 causes cerebral vasodilation and increases cerebral blood volume)
62
Management of sustained acute rise in ICP
Ensure routine measures have been attempted Rescan - is there a surgically correctable cause? Osmotic diuretic - mannitol Hyperventilation - reduces paCO2 Barbiturate therapy - barbiturate coma reduces function of brain cells - reduced metabolism/blood flow to lower ICP Removal of space occupying lesion Decompressive craniectomy (bone alone reduces ICP by 15%, opening dura reduces ICP by 70% but brain can start herniating through defect and infarct)
63
Typical presentation of a extradural/epidural haematoma
Often due to trauma Patients can lose consciousness very briefly and then regain it Level of consciousness then begins to deteriorate as a haematoma develops This lucid interval frequently leads to delayed or missed diagnoses which can be fatal
64
Are extradural/epidural haematomas arterial or venous
arterial
65
Are subdural haematomas arterial or venous
venous
66
Typical presentation of a subdural haematoma
Is chronic ARe venous in origin so may occur even after a trivial injury in vulnerable pts (elderly, alcoholics, debilitated people) Haematoma develops slowly so clinical presentation can be weeks/months after injury Headache/Drowsiness/Confusion common in late stages Fluctuating levels of consciousness over time as haematoma contracts and expands due to osmotic effects
67
Can primary brain tumours metastasize out of the brain?
No
68
What drug is used to reduce oedema and provide symptomatic relief in brain tumours
dexamethasone
69
Commonest source of brain mets
``` Bronchus (lung) Breast Stomach Prostate Thyroid Kidneys ```
70
Most common cause of headache?
Tension
71
What do we give as prophylaxis to people who have been in close proximity with someone with meningitis
Ciprofloxacin | Or rifampicin

TCD (7 decks)

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