Case 4- Headache Flashcards
Migraine headache
Unilateral pulsating headache
Last between hours-days
May be visual aura (scotoma)
Photophobia, nausea, phonophobia
Sufferers don’t want to move
Children- GI disturbance
NB- can get slight paralysis
Management of migraines
Limit stimuli, supportive management (diet, exercise etc.)
Acute- oral triptan (not in pregnancy) and NSAID (or paracetamol)
Prophylaxis (2 or more attacks per month)- topiramate or propranolol (use the latter in pregnancy and women of child-bearing age)
NB- antiemetic in migraine: metoclopramide (no more than 5 days- risk of extra-pyramidal side effects)
Cluster headache
Short painful attacks around one eye
Last between 30mins-3 hours
Occur once/twice a day for 1-3 months
May be lacrimation/ flushing
Can see partial Horner syndrome
Tend to be pacing around in agony (unlike migraine sufferers)
NB- can also get aura, photophobia, hyperacusis, swollen red eye
Management- 100% oxygen, s/c triptan
verapamil (or lithium/Prednisolone) for prophylaxis
Tension headaches
Bilateral tight band sensation
Recurrent
Occurs late in the day
Associations with stress
Tightness in muscles of the neck
Use paracetamol or NSAID
Supportive- lifestyle modifications (esp. stress)
Acupuncture as prophylaxis
Investigations for GCA
Bloods- ESR, CRP, LFTS (raises ALP)
Temporal artery biopsy- gold standard (if biopsy negative and still clinically suspicious- treat anyway)
Management of GCA
Steroids (PPI and bone protection)
Aspirin
Referral to vascular surgeons, ophthalmology (same day if vision loss), and rheumatology
Trigeminal neuralgia
2 second paroxysms of stabbing pain in unilateral trigeminal nerve distribution (electric shock)
Face screws up with pain (tic doloroux)
Carbamazepine is first line
If doesn’t respond or atypical features/red flags- refer to neurology
NB- could be a tumour pressing on the trigeminal ganglion. MRI head may be me necessary
Investigations for meningitis
Bedside- pneumococcal urinary antigen, lumbar puncture with viral PCR, throat swabs for n. Meningitidis and s. Pneumoniae
Bloods- FBC (WCC, anaemia), UE, cultures at different sites, clotting profile (DIC), LFT (derangement), serology for common meningitis viruses
CT head- when neurological symptoms predominate
Involve microbiology early
Management of meningitis
Supportive- IV fluids, notify PHE
Medical- IV cefotaxime (add IV amoxicillin if younger than 3 months or older than 50 years), IV steroids if older than 3 months, one dose PEP for any contacts within 7 days of onset (oral rifampicin or ciprofloxacin)
NB- in community IM benzylpenicillin should be used
Contraindications to steroids;
-Septic shock
-Meningococcal septicaemia
-Meningitis post-surgery
-Immunocompromised
-<3months
Kernigs test
Lie patient on back- flex one hip and knee to 90 degrees and slowly straighten the knee whilst keeping the knee flexed
Positive test- spinal pain/ resistance to movement
Brudzinskis test
Lie patient flat on back and use hands to lift their head and neck off the bed to touch their chest with their chin
Positive- patient involuntarily flexes hips and knees
Subarachnoid Haemorrhage
Usually the result of a cerebral aneurysm
Very sudden onset severe headache
Meningismus
Deviation of central sulcus on a CT and blood present in the sulci
Meningitis Features
Triad- fever, headache, nuchal rigidity
Altered mental state, photophobia, nausea and vomiting, malaise, seizures, purpuric rash, Kernigs and Brudzinskis
In neonates triad is typically absent, so may show lethargy, hypotonia, irritability, n and v, dyspnoea, fontanelle bulge, high pitched cry, seizures (all latter symptoms)
Encephalitis
May be similar to meningitis but more focal neurological deficits eg. Seizures, behavioural changes, altered consciousness
Notifiable diseases PHE
Encephalitis
Hepatitis
Meningitis
Food poisoning
Legionnaires
Malaria
TB
Encephalitis investigations
Lumbar puncture with PCR for HSV
Throat swab
Bloods- FBC UE cultures at different sites
CT head- oedema frontal lobes
EEG
Migraine risk factors
Stress, chocolate, red wine, cheese, hormonal changes in women, analgesia overuse
Cluster headache management
Triptans
High flow oxygen
Prednisone as prophylactic treatment
Contraindications to a lumbar puncture
Raised ICP- papilloedema, focal neurology
Coagulation defect
Sign of infection at site of needle insertion
Encephalitis risk factors
Animal or insect bite
Freshwater swimming
Epidural haematoma
Middle meninges artery rupture (or dural venous sinus)
Lucid interval very typical
Fusiform shape on CT- doesn’t cross the suture lines
Subdural haematoma
Venous in origin- bridging veins
Elderly (anticoagulation), alcoholics, debilitated people at risk
Fluctuating levels of consciousness- injury can be weeks ago
Crescent shaped haematoma- crosses the suture lines, mass effect (midline shift)
Chronic (old subdurals) are hypodense (dark) on imaging
Surgical decompression with burr holes if symptomatic
Raised ICP Sx
Headache, vomiting, blurred vision, reduced GCS, bradycardia, HTN, paiploedema
Medication overuse headache features
Present for 15 or more days a month
Developed or worse whilst taking meds
Opioids and Triptans- most at risk
Management of MOH
Withdraw analgesia (analgesics and Triptans- abruptly)
Opioids- gradual
NB+0- may get withdrawal symptoms eg. Vomiting, hypotension, tachycardia, restlessness, sleep disturbance, anxiety
What is the most common complication post-meningitis
Sensory neural hearing loss
Common migraine triggers
Tiredness, stress
Alcohol
Combined OCP
Lack of food or dehydration
Cheese chocolate red wine
Menstruation
Bright lights
Migraines in pregnancy
Paracetamol
NSAIDs (1st and 2nd trimester)
Avoid aspirin
Migraine with aura- COC pill contraindicated (stroke)
Thoracic outlet syndrome
Compression of brachial plexus, subclavian artery or vein at site of thoracic outlet (NB can have neurogenic or vascular presentation, or both)
Painless muscle wasting of hand muscles, hand weakness, altered sensation, cold hands, swollen hands, painful arm claudication, distended veins
How do triptans work
5 HT1B and D agonists
Tuberous sclerosis features
Autosomal dominant
Depigmented ash leaf spots that fluoresce under UV light
Roughened patches of skin over the lumbar spine (Shagreen patches)
Angiofibromas
Cafe au lait spots may be seen
Fibromata beneath nails
Developmental delay and intellectual impairment
Epilepsy
Retinal harmatomas
Triptans and ergotamine’s
Don’t take within 24 hours of one another- coronary artery spasm
Features of GCA
Constitutional- fever, weight loss, night sweats
Temporal artery inflammation- temporaL headache, tender temporal artery, jaw claudication, scalp tenderness
Vistula defecits- scotoma (curtain), amaurosis fugax (complete vision loss)
Diplopia
Poly myalgia rheumatica Sx (aching, morning stiffness in proximal limb muscles)
Meningitis bacterium 0-3mnths
Group B Streptococcus (most common cause in neonates)
E. coli
Listeria monocytogenes
Meningitis bacterium 3mnths-6years
Neisseria meningitidis
Streptococcus pneumoniae
Haemophilus influenzae
Meningitis bacterium in 6-60 years
Neisseria meningitidis
Streptococcus pneumoniae
Meningitis bacterium >60 years
Streptococcus pneumoniae
Neisseria meningitidis
Listeria monocytogenes
Nausea and migraine
metoclopramide
Paroxysmal Hemicrania
Paroxysmal hemicrania (PH) is defined by attacks of severe, unilateral headache, usually in the orbital, supraorbital or temporal region. These attacks are often associated with autonomic features, usually last less than 30 minutes and can occur multiple times a day.
Shares many features with cluster headaches
Management- indomethacin.
Metronidazole and alcohol
disulfiram-like reaction with alcohol (find what disulfiram does)
Mumps
fever
malaise, muscular pain
parotitis (‘earache’, ‘pain on eating’): unilateral initially then becomes bilateral in 70%
Management;
rest
paracetamol for high fever/discomfort
notifiable disease
Prevention- MMR vaccine (80% effective)
Complications
-orchitis (more common in post-pubertal males)
-hearing loss - usually unilateral and transient
-meningoencephalitis
-pancreatitis
Necrotising Fasciitis
type 1 is caused by mixed anaerobes and aerobes (often occurs post-surgery in diabetics). This is the most common type
type 2 is caused by Streptococcus pyogenes
Risk factors;
skin factors: recent trauma, burns or soft tissue infections
diabetes mellitus (the most common preexisting medical condition, particularly if the patient is treated with SGLT-2 inhibitors)
intravenous drug use
immunosuppression
Features and management of necrotising fasciitis
The most commonly affected site is the perineum (Fournier’s gangrene).
Features;
acute onset
pain, swelling, erythema at the affected site
often presents as rapidly worsening cellulitis with pain out of keeping with physical features
extremely tender over infected tissue with hypoaesthesia to light touch
skin necrosis and crepitus/gas gangrene are late signs
fever and tachycardia may be absent or occur late in the presentation
Management;
urgent surgical referral debridement
intravenous antibiotics
Norovirus
also known as the winter vomiting bug, is one of the most common causes of gastroenteritis in the UK
Features;
Develop within 15 - 50 hours of infection
patients experience nausea, vomiting, and diarrhoea, which may be accompanied by headaches, low-grade fevers, and myalgia.
Transmission- Faecal-oral route, with the virus becoming aerosolized
Investigations- stool culture viral PCR (polymerase chain reaction).
Management of norovirus
Limit transmission- isolate patients, handwashing (not hand gel)
Ensure adequate hydration (D+V)
Pnuemococcal pneumonia
Streptococcus pneumoniae (pneumococcus) is the most common cause of community-acquired pneumonia
Characteristic features of pneumococcal pneumonia
-rapid onset
-high fever
-pleuritic chest pain
-herpes labialis (cold sores)
Pseudomonas aeruginosa
an aerobic Gram-negative rod. It causes a number of clinically important infections in humans:
chest infections (especially in cystic fibrosis)
skin: burns, wound infections, ‘hot tub’ folliculitis
otitis externa (especially in diabetics who may develop malignant otitis externa)
urinary tract infections
Microcephaly
an occipital-frontal circumference < 2nd centile
Causes include
-normal variation e.g. small child with small head
-familial e.g. parents with small head
-congenital infection (Zika)
-perinatal brain injury e.g. hypoxic ischaemic encephalopathy
-fetal alcohol syndrome
-syndromes: Patau
-craniosynostosis
Mitochondrial diseases
Mitochondrial inheritance has the following characteristics:
-inheritance is only via the maternal line as the sperm contributes no cytoplasm to the zygote
-none of the children of an affected male will inherit the disease
-all of the children of an affected female will inherit the disease
-generally, encode rare neurological diseases
poor genotype:phenotype correlation - within a tissue or cell there can be different mitochondrial populations - this is known as heteroplasmy
Histology
-muscle biopsy classically shows ‘red, ragged fibres’ due to increased number of mitochondria
Causes and management of nappy (napkin) rashes
Irritant dermatitis- the most common cause, due to irritant effect of urinary ammonia and faeces
Creases are characteristically spared
Candida dermatitis- typically an erythematous rash which involve the flexures/creases and has characteristic satellite lesions
Seborrhoeic dermatitis- erythematous rash with flakes. May be coexistent scalp rash
Psoriasis- a less common cause characterised by an erythematous scaly rash also present elsewhere on the skin
Atopic eczema- other areas of the skin will also be affected
General management points;
-disposable nappies are preferable to towel nappies
-expose napkin area to air when possible
-apply barrier cream (e.g. Zinc and castor oil)
-mild steroid cream (e.g. 1% hydrocortisone) in severe cases
-management of suspected candidal nappy rash is with a topical imidazole. Cease the use of a barrier cream until the candida has settled
NB- candida/creases (C for C)
Neck masses in children
pass medicine
Necrotising enterocolitis
Necrotising enterocolitis is one of the leading causes of death among premature infants. Initial symptoms can include feeding intolerance, abdominal distension and bloody stools, which can quickly progress to abdominal discolouration, perforation and peritonitis.
Abdominal x-rays are useful when diagnosing necrotising enterocolitis, as they can show:
-dilated bowel loops (often asymmetrical in distribution)
-bowel wall oedema
-pneumatosis intestinalis (intramural gas)
-portal venous gas
-pneumoperitoneum resulting from perforation
-air both inside and outside of the bowel wall (Rigler sign)
-air outlining the falciform ligament (football sign)
Management;
Neonates with suspected NEC need to be nil by mouth with IV fluids, total parenteral nutrition (TPN) and antibiotics to stabilise them. A nasogastric tube can be inserted to drain fluid and gas from the stomach and intestines.
NEC is a surgical emergency and requires immediate referral to the neonatal surgical team. Some neonates will recover with medical treatment. In others, surgery may be required to remove the dead bowel tissue. Babies may be left with a temporary stoma if significant bowel is removed.
Neonatal blood spot screening
Performed at 5-9 days of life
The following conditions are currently screened for:
-congenital hypothyroidism
-cystic fibrosis
-sickle cell disease
-phenylketonuria
-medium chain acyl-CoA dehydrogenase deficiency (MCADD)
-maple syrup urine disease (MSUD)
-isovaleric acidaemia (IVA)
-glutaric aciduria type 1 (GA1)
-homocystinuria (pyridoxine unresponsive) (HCU)
Neonatal hypoglycaemia
Transient hypoglycaemia in the first hours after birth is common.
Persistent/severe hypoglycaemia may be caused by:
-preterm birth (< 37 weeks)
-maternal diabetes mellitus
-IUGR
-hypothermia
-neonatal sepsis
-inborn errors of metabolism
-nesidioblastosis
-Beckwith-Wiedemann syndrome
Features
may be asymptomatic
autonomic
-‘jitteriness’
-irritable
-tachypnoea
-pallor
neuroglycopenic
-poor feeding/sucking
-weak cry
-drowsy
-hypotonia
-seizures
other features may include
-apnoea
-hypothermia
Management;
asymptomatic
-encourage normal feeding (breast or bottle)
-monitor blood glucose
symptomatic or very low blood glucose
-admit to the neonatal unit
-intravenous infusion of 10% dextrose
Neonatal sepsis
Early-onset sepsis in the UK is primarily caused by group B strep infection (75%)
Risk factors
-Mother who has had a previous baby with GBS infection, who has current GBS colonisation from prenatal screening, current bacteruria, intrapartum temperature ≥38ºC, membrane rupture ≥18 hours, or current infection throughout pregnancy
-Premature (<37 weeks): approximately 85% of neonatal sepsis cases are in premature neonates
-Low birth weight (<2.5kg): approximately 80% are low birth weight
-Evidence of maternal chorioamnionitis
Patients typically present with a subacute onset of;
Respiratory distress (85%)
Grunting (grunting neonate, think sepsis)
Nasal flaring
Use of accessory respiratory muscles
Tachypnoea
Tachycardia: common, but non-specific
Apnoea (40%)
Apparent change in mental status/lethargy
Jaundice (35%)
Seizures (35%): if cause of sepsis is meningitis
Poor/reduced feeding (30%)
Abdominal distention (20%)
Vomiting (25%)
Temperature
The clinical presentation can vary from very subtle signs of illness to clear septic shock
Frequently, the symptoms will be related to the source of infection (e.g. pneumonia + respiratory symptoms, meningitis + neurological symptoms)
NB- all the usual tests eg. urine, LP, 2x blood cultures etc.
NB- sepsis 6 (oxygen, fluids and ABX in etc.)
The NICE guidelines recommend use of intravenous benzylpenicillin with gentamicin as a first-line regimen for suspected or confirmed neonatal sepsis
Nephrotic syndrome in children
In children the peak incidence is between 2 and 5 years of age. Around 80% of cases in children are due to a condition called minimal change glomerulonephritis. The condition generally carries a good prognosis with around 90% of cases responding to high-dose oral steroids.
Newborn resuscitation
- Dry baby and maintain temperature
- Assess tone, respiratory rate, heart rate
- If gasping or not breathing give 5 inflation breaths*
- Reassess (chest movements)
- If the heart rate is not improving and <60bpm start compressions and ventilation breaths at a rate of 3:1
Nocturnal enuresis
The majority of children achieve day and night time continence by 3 or 4 years of age. Enuresis may be defined as the ‘involuntary discharge of urine by day or night or both, in a child aged 5 years or older, in the absence of congenital or acquired defects of the nervous system or urinary tract’
NB- before 5, reassurance and follow up given
Nocturnal enuresis can be defined as either primary (the child has never achieved continence) or secondary (the child has been dry for at least 6 months before)
Management;
look for possible underlying causes/triggers
-constipation
-diabetes mellitus
-UTI if recent onset
general advice
-fluid intake
-toileting patterns: encourage to empty bladder -regularly during the day and before sleep
-lifting and waking
reward systems (e.g. Star charts)
-NICE recommend these ‘should be given for agreed behaviour rather than dry nights’ e.g. Using the toilet to pass urine before sleep
enuresis alarm
-generally first-line for children
-have sensor pads that sense wetness
-high success rate
desmopressin
-particularly if short-term control is needed (e.g. for sleepovers) or an enuresis alarm has been ineffective/is not acceptable to the family
Noon Syndrome
An autosomal dominant condition associated with a normal karyotype. It is thought to be caused by a defect in a gene on chromosome 12
As well as features similar to Turner’s syndrome (webbed neck, widely-spaced nipples, short stature, pectus carinatum and excavatum), a number of characteristic clinical signs may also be seen:
-cardiac: pulmonary valve stenosis
-ptosis
-triangular-shaped face
-low-set ears
-coagulation problems: factor XI deficiency
Normal lower limb variants in children
pass medicine
Obesity in children
Cause of obesity in children
-growth hormone deficiency
-hypothyroidism
-Down’s syndrome
-Cushing’s syndrome
-Prader-Willi syndrome
Consequences of obesity in children
-orthopaedic problems: slipped upper femoral epiphyses, Blount’s disease (a development abnormality of the tibia resulting in bowing of the legs), musculoskeletal pains
-psychological consequences: poor self-esteem, bullying
-sleep apnoea
-benign intracranial hypertension
-long-term consequences: increased incidence of type 2 diabetes mellitus, hypertension and ischaemic heart disease
