CBL - Headache Flashcards
1
Q
What are the important components of the history in a patient with headache? [8]
A
- Aura
- typically reversible visual, sensory or language symptoms
- Location
- facial/retro-orbital/frontal/occipital/parietal; unilateral/bilateral, radiation/spread of pain
- Onset
- thunderclap or gradual onset
- Severity
- (can be scored out of 10)
- Associated symptoms
- nausea/vomiting
- photophobia
- phonophobia
- Periodicity
- frequency, duration; is the patient headache-free between attacks?
- Exacerbating/relieving factors
- Concerns, fears, anxieties about headaches and their underlying cause
2
Q
What are the ‘red flag’ features in a patient with a headache? [8]
A
- Age >50 years at onset of headache symptoms;
- Thunderclap headache (i.e. headache reaches maximal intensity in <5 minutes)
- Focal/non-focal neurological deficit;
- Worsening of symptoms with posture (high/low CSF pressure headache), valsalva (coughing, straining during defecation) or physical exertion
- Early morning headaches
- Previous history of cancer (higher risk of metastatic tumour deposit)
- Systemic symptoms:
- fever
- weight loss
- Temporal artery tenderness/jaw claudication specifically suggestive of temporal arteritis in >65 years age group
3
Q
What are the symptoms of visual aura and how long do they typically last? [9]
A
- “Positive” symptoms:
- flickering lights,
- spots,
- zig zag lines,
- tingling
- “Negative” symptoms:
- visual loss
- numbness
- Symptoms characteristically evolve over 25 minutes and resolve within 60 minutes
4
Q
What are the typical symptoms of migraines? [6]
A
- can be unilateral or bilateral
- associated nausea
- photophobia (sensitivity to light)
- phonophobia (sensitivity to sound)
- interference with daily activities
- can get clustering of headaches around menstrual periods
5
Q
What are the possible triggers for migraines? [5]
A
- stress
- alcohol
- caffeine
- hunger
- sleep deprivation
6
Q
What are the clinical signs of raised intracranial pressure? [4]
A
- Papilloedema on fundoscopy
- Constriction of visual fields
- Enlargement of the blind spots
- Unilateral or bilateral 6th nerve palsy may be a false localising sign of raised ICP
7
Q
What are the differential diagnoses for migraine? [3]
A
- Episodic headache without “red flag” features
- Tension-type headache
- Trigeminal autonomic cephalgia
8
Q
Describe the pathogenesis of migraine [7]
A
- Migraines are considered a neurovascular disorder
- Attacks probably result from dysfunction within sensory brainstem nuclei
- The pain results from interactions between components of the trigeminovascular system:
- the pain-sensitive cranial blood vessels,
- the trigeminal nerve fibres that innervate them and
- the cranial parasympathetic outflow
- The aura phase of migraine is associated with reduction blood flow in hemispheric regions contralateral to affected symptoms
9
Q
Describe the management of a migraine under the following headings:
- lifestyle factors? [3]
- acute management? [3]
- prophylaxis? [3]
A
- Lifestyle factors
- Advise patients to avoid triggers identified
- Reduce caffeine and alcohol intake
- Encourage regular meals and good sleep patterns
- Acute management
- Analgesia
- Paracetamol
- Aspirin
- Ibuprofen
- Triptans
- Highly selective 5-HT1 agonists
- Can be given orally, subcutaneously or by nasal spray
- Antiemetics
- Prochlorperazine
- Metoclopramide
- For nausea
- Analgesia
- Prophylaxis
- Beta-blockers (e.g. propranolol)
- Tricyclics (e.g. amitriptyline)
- Anti-epileptic drugs (e.g. topiramate, sodium valproate)
10
Q
What is a sudden-onset or thunderclap headache? [2]
A
- high-intensity headache in which the time from onset of symptoms to reaching its maximal intensity is minutes.
- in most cases of subarachnoid haemorrhage (SAH) this only takes a few seconds and patients often describe the pain as the “worst headache of life”
11
Q
What are the important components of the history of a patient with suspected thunderclap headache? [7]
A
- Location of pain;
- Severity of pain;
- Time to reach maximal intensity;
- What was patient doing at onset of pain?
- Associated features:
- nausea,
- vomiting,
- photophobia,
- neck stiffness
- Focal neurological deficit
- Exacerbating/relieving features
12
Q
What are the red flag features in a typical thunderclap headache description and what do they suggest? [4]
A
- Headache is of sudden-onset
- Neurological deficit:
- e.g. generalised seizure followed by diplopia
- Worsening of headache with coughing
- suggests raised intracranial pressure
- Neck stiffness and photophobia
- suggest meningism
13
Q
What are the differential diagnoses for a thunderclap headache? [6]
A
- SAH
- Intercerebral haemorrhage
- Cerebral venous sinus thrombosis
- Arterial dissection (vertebral or carotid)
- Bacterial meningitis
- Primary thunderclap or exertional headache
14
Q
What are the risk factors for subarachnoid haemorrhage?
- modifiable? [3]
- non-modifiable? [5]
A
- Modifiable:
- Cigarette smoking
- Hypertension
- Alcohol excess
- Non-modifiable:
- Previous SAH
- Polycystic kidney disease
- Connective tissue diseases e.g. Ehler’s Danlos, Marfan syndrome)
- Arteriovenous malformations
- Strong family history (>2 first-degree relatives)
15
Q
What is a positive Kernig’s sign and what is it suggestive of? [2]
A
- When the hip and knee are flexed at 90° and subsequent extension at the knee is painful
- Headache, photophobia, neck stiffness and a +ve Kernig’s sign suggests meningism (irritation of the meninges)
