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Year 3 - TCD > Case 4 - Headaches > Flashcards

Case 4 - Headaches Flashcards

1
Q

What are the 2 main types of headaches?

A
  • Primary

- Secondary

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2
Q

What are the 3 types of primary headaches?

A
  • Tension
  • Cluster
  • Migraine
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3
Q

What is the site of tension headache?

A

Band around the forehead (bilateral)

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4
Q

What is the site of cluster headache?

A

Peri-orbital pain (unilateral)

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5
Q

What is the site of migraine?

A

Variable (unilateral/bilateral- usually unilateral)

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6
Q

What is the onset of tension headache?

A

Worsens at the end of the day with stress

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7
Q

What is the onset of cluster headache?

A

Occurs at night during sleep

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8
Q

What is the onset of migraine?

A

In bright light / Related to periods - can be variable

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9
Q

What is the character of tension headache?

A

Dull, aching, persistent, tightening, pressing

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10
Q

What is the character of cluster headache?

A

Sharp, stabbing, excruciating

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11
Q

What is the character of migraine?

A

Pulsatile/throbbing,

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12
Q

What is the frequency/duration of tension headache?

A

30 min to 7 days

3 - 4 attack/week to 1 - 2 attacks/year

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13
Q

What is the frequency/duration of cluster headache?

A

15 - 180 mins/attack
1 - 8 attacks/day for 3 - 16 weeks
1 - 2 bouts/year

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14
Q

What is the frequency/duration of migraine?

A

2 - 72 hours/attack

1 attack/year to >8 per month

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15
Q

What are the associated symptoms with tension headache?

A
  • Mild photophobia
  • Mild phonophobia
  • Anorexia
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16
Q

What are the associated symptoms with cluster headache?

A
  • Sweating
  • Facial flushing
  • Nasal congestion
  • Ptosis
  • Lacrimation
  • Conjunctival injection
  • Pupillary changes
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17
Q

What are the associated symptoms with migraine?

A
  • Visual aura
  • Phonophobia
  • Photophobia
  • Pallor
  • Nausea/vomiting
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18
Q

What are the risk factors for tension headaches?

A
  • Mental tension
  • Stress
  • Missing meals
  • Fatigue
  • Female
  • Family history
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19
Q

What are the risk factors for cluster headaches?

A
  • Males
  • Heavy smoking
  • Heavy drinking
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20
Q

How to treat tension headache?

A

Acute - analgesics (paracetamol, ibuporfen)

Prophylactic - Amitriptyline

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21
Q

How to treat tension headache?

A

Acute - analgesics (paracetamol, ibuprofen)

Prophylactic - Amitriptyline

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22
Q

How to treat menstrual migraines?

A
  • Occur prior to menstruation due to fall in oestrogen levels.
  • May benefit from transdermal oestrogen patches 3 days before menstruation.
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23
Q

What is needed for diagnosis of cluster headaches?

A

At least 1 autonomic pain feature:

  • conjunctival injection
  • Facial sweating
  • Lacrimation
  • Redness
  • Nasal stuffiness
  • Eyelid and facial swelling
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24
Q

How to treat mild/moderate migraines?

A
  • NSAIDs (paracetamol, ibuprofen)

- Don’t give opiates as it increases N+V

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25
Q

How to treat severe attacks of migraine and cluster headaches?

A
  • Triptans (sumatriptan)

- 5HT1 receptor agonist, leads to vasoconstriction of cranial and basilar arteries.

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26
Q

How to treat severe attacks of migraine and cluster headaches?

A
  • Triptans (sumatriptan)

- 5HT1 receptor agonist, leads to vasoconstriction of cranial and basilar arteries.

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27
Q

What are the side effects of triptans?

A
  • Temporary blood pressure increase
  • Paraesthesia and sensation of cold in the extremities
  • Dizziness, malaise, flashes
  • Frequent intake (≥ 10x/month) can lead to headaches
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28
Q

What are the contraindications for triptans?

A
  • Coronary artery disease (MI, stroke)
  • Peripheral artery disease
  • Uncontrolled hypertension
  • Pregnancy and breastfeeding
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29
Q

What is the treatment for acute cluster headaches?

A
  • 100% oxygen with 12L/min non rebreathe mask for 15 mins
  • Arrange home and ambulatory oxygen
  • Sumatriptan nasal spray or SC injections
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30
Q

What is the prophylactic treatment for cluster headaches?

A
  • Verapamil - CCB
  • Lithium: neurotransmitter stabiliser
  • Take at onset of cluster headache.
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31
Q

What are the different causes of secondary headaches?

A
  • Meningitis
  • Brain tumour
  • Haemorrhage
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32
Q

What are the different causes of primary headaches?

A
  • Tension headaches
  • Cluster headaches
  • Migraines
  • Giant cell arteritis
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33
Q

What is meningitis?

A

Inflammation of the meninges.

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34
Q

What is route of infection and the incubation time?

A
  • Pathogens colonise in nasopharynx and then enter CNS
  • Bacterial: 3-7 days
  • Viral: 2-14 days
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35
Q

What are the symptoms of meningitis?

A
  • Headache
  • N+V
  • Neck stiffness: nuchal rigidity, check for sore throat
  • Fever
  • Altered mental state and seizures: bacterial meningitis only
  • Photophobia
  • Flu like symptoms: viral
  • Non blanching rash/purpura
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36
Q

What is the triad of symptoms in meningitis?

A

Headache, neck stiffness, photophobia

37
Q

Which bacteria are more likely to lead to bacterial meningitis?

A
  • Neisseria meningitidis (meningococcal meningitis)
  • Streptococcus pneumoniae,
  • Haemophilus influenzae type b (Hib)
38
Q

How to treat TB meningitis?

A
  • Same medications for TB

- Isoniazid, rifampin, pyrazinamide and ethambutol

39
Q

Who is more likely to have fungal TB?

A
  • Immunocompromised such as HIV
40
Q

What are the risk factors for meningitis?

A
  • Extremes of age - young children, young adults (since they live in close quarters) and elderly.
  • Crowding
  • Immunodeficiency and absence of vaccination
  • Patients with leukaemia and lymphoma
  • Asplenia
41
Q

What is encephalitis?

A
  • Encephalitis is inflammation of the brain.
  • Common cause is herpes simplex virus (HSV).
  • Unlike meningitis it causes confusion or disorientation, drowsiness, seizures and changes in personality and behaviour, such as feeling very agitated and aggressive.
42
Q

What can be seen on examination for meningitis?

A
  • Purpuric (non-blanching) rash: press glass against rash and it it might not disappear
  • Neck stiffness: chin might not be able to touch chest
  • Kernig’s sign: Inability to straighten leg when hip is flexed to 90 degrees
  • Brudzinski’s Signs - Flexion of the neck will cause flexion of the hips and knees
43
Q

How is lumbar puncture performed?

A
  • L3/L4 or L4/L5
  • Use iliac crest as it lines up with the spinous process of L4
  • Patient in lateral recumbent position.
44
Q

What are the contraindications of lumbar puncture?

A
  • Not done if signs of raised ICP as it can cause brainstem to move down foramen magnum
  • Signs of ICP = seizures, focal neurological sign, papilledema
45
Q

What are the results of bacterial lumbar puncture?

A 
Colour - Cloudy
WBC - High
Type of WBC - Neutrophils
Glucose - Very low 
Protein - High
46
Q

What are the results of viral lumbar puncture?

A 
Colour - Clear
WBC - High
Type of WBC - Lymphocytes
Glucose - Normal 
Protein - High
47
Q

What are the results of tuberculosis and fungal lumbar puncture?

A 
Colour - Clear (fungal), turbid (TB)
WBC - High
Type of WBC - Lymphocytes + neutrophils 
Glucose - Low 
Protein - Very high
48
Q

What does blood in LP suggest?

A
  • Needle used to perform the LP probably punctured a vessel
  • Subarachnoid haemorrhage.
  • CSF will be yellow (xanthochromia) due to breakdown of haemoglobin.
49
Q

How to manage encephalitis?

A
  • CT or MRI

- Treatment: IV antivirals

50
Q

How to treat viral meningitis?

A

Symptomatic therpay

51
Q

How to treat bacterial meningitis?

A

1st - Cefotaxime or ceftriaxone because they can travel through the BBB and Dexamethasone.
2nd - Add amoxicillin if the patient is over 60
3rd - Add vancomycin if penicillin resistance is a possibility
- In GP: IM benzylpenicillin

52
Q

What is giant cell arteritis?

A

Autoimmune vasculitis that causes chronic inflammation of large and medium-sized arteries in particular the carotid arteries, its major branches and the aorta.

53
Q

What are the risk factors of GCA?

A
  • Over 50 years

- Female

54
Q

What are the symptoms of GCA?

A
  • New onset headache – throbbing, dull, unilateral, temporal
  • A tender, hardened temporal artery (weak/absent pulses)
  • Jaw claudication – painful when chewing
  • Scalp tenderness – painful to brush hair
  • Sudden Vision loss:(amaeurosis fugax)
55
Q

What can be a differential to GCA?

A
  • Polymyalgia rheumatica (PMR), an inflammatory condition that classically causes morning pain and stiffness is the neck, shoulders, and hips – the pain gets better with exercise.
56
Q

What are the investigations for GCA?

A
  • Raised ESR/CRP
  • Temporal Artery Biopsy:
    negative results do not rule out GCA as it happens in skip lesions
57
Q

What is the treatment for GCA?

A
  • High dose steroids: oral prednisolone to prevent loss of vision
  • Refer to neurology/rheumatology/ophthalmology
58
Q

What is aura?

A
  • Neurological features which precede headache.
  • Around 20-30% people experience aura.
  • Visual disturbance: Scintillating scotoma
  • Sensory symptoms: unilateral paraesthesia and numbness affecting the hand and arm before involving the face, lips and tongue.
59
Q

What are the causes of raised ICP?

A
  • Increase in tissue: SOLs, cerebral oedema
  • Increase in CSF
  • Hypertension
60
Q

What are the symptoms of raised ICP?

A
  • Headache – persisting headaches, could be worse in the morning, made worse on bending over
  • Vomiting
  • Focal neurology – cranial nerve palsy. CN VI – longest running nerve.
  • Blurring of vision - enlarged blind spots, peripheral visual field loss.
  • Bradycardia
  • Hypertension
  • Papilledema
  • Decreased level of consciousness – change in memory, change in personality
  • Respiratory depression
61
Q

How to treat raised ICP?

A
  • Mannitol: osmotic diuretic
  • Hyperventilation: reducing pCO2
  • Barbiturate coma
  • Remove SOLs: craniotomy
62
Q

What are the different causes of space occupying lesion?

A
  • Tumours
  • Infection
  • Vascular: haemorrhages, AVM
  • Hydrocephalus: build up of CSF due to blockage, increased production, reduced absorption
63
Q

Where does epidural haemorrhage occur?

A

Periosteal dura and skull

64
Q

Where does subdural haemorrhage occur?

A

Meningeal dura and subarachnoid

65
Q

Where does subarachnoid haemorrhage occur?

A

Subarachnoid and pia matter

66
Q

Which artery bleed causes epidural haemorrhage?

A

Middle Meningeal artery

67
Q

Which artery bleed causes subdural haemorrhage?

A

Bridging Veins

68
Q

Which artery bleed causes subarachnoid haemorrhage?

A

Cerebral artery

69
Q

How does epidural haemorrhage present on CT?

A
  • Convex/Lens + swelling around skull

- Doesn’t cross suture line

70
Q

How does subdural haemorrhage present on CT?

A
  • Crescent

- Crosses suture line

71
Q

How does subarachnoid haemorrhage present on CT?

A
  • Blood in the sulcus
72
Q

What are the causes of epidural haemorrhage?

A
  • Trauma to head
  • Fall in elderly
  • Fight
73
Q

What are the causes of subdural haemorrhage?

A
  • Fall in elderly

- Alcoholic patients

74
Q

What are the risk factors of subarachnoid haemorrhage?

A
  • Hypertension
  • Polycystic kidney disease
  • Arteriovenous malformations
75
Q

How does epidural haemorrhage present?

A

Collapse at time of injury followed by lucid interval followed by sudden loss of consciousness

76
Q

How does subdural haemorrhage present?

A

Slowly progressive deterioration in abilities after injury (days to weeks)

77
Q

How does subarachnoid haemorrhage present?

A

Severe, sudden, thunderclasp headache

78
Q

What is cerebral venous sinus thrombosis?

A
  • Thrombi in central venous sinus causing venous congestion.

- Leads to raised ICP and its symptoms.

79
Q

What is idiopathic intracranial hypertension?

A
  • This is a diagnosis of exclusion and usually occurs in obese women in the range of 20-40 years.
80
Q

What are the signs of idiopathic intracranial hypertension?

A
  • Papilledema
  • Headaches
  • Signs of raised ICP
81
Q

How to treat idiopathic intracranial hypertension?

A

Acetazolamide, diuretics and losing weight

82
Q

What type of brain tumours are there?

A
  • Primary: arise from intracranial structures

- Secondary: Metastasis from breast, stomach, prostate, thyroid

83
Q

What are the different types of primary brain tumours?

A
  • Meningioma: most common, slow growing and benign
    • Commonly caused by radiation for other cancers
    • Treat using dexamethasone
  • Gliomas
84
Q

Which childhood cancer causes a “white reflex” on ophthalmoscopy instead of a red one?

A

Meningioma

85
Q
  • What is the prophylactic treatment for migraines?

- What should be remembered with each treatment?

A

Propranolol – should be avoided in asthmatics

Topiramate – less likely given to women of childbearing age

86
Q

What is the causes of meningitis in 0-3 months?

A
  • Group B Streptococcus (most common cause in neonates)

- E. coli

87
Q

What is the causes of meningitis in 3 months - 60 years?

A
  • Neisseria meningitidis
  • Streptococcus pneumoniae
  • Haemophilus influenzae
88
Q

What is the causes of meningitis in immunocompromised patients?

A

Listeria monocytogenes

89
Q
  • What is likely to develop after LP?
  • How long does it last?
  • How to treat it?
A
  • Infection at site and low pressure headache
  • Develops within 24-28 hours
  • May last several days
  • Worsens with upright position
  • Manage using analgesia, fluids, caffeine
  • If persists: use blood patch

Year 3 - TCD (17 decks)

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