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Year 3 > Headache > Flashcards

Headache Flashcards

1
Q

Aetiology/RF tension headache

A
  • Unknown- muscle contraction? Psychological stress?
  • F>M
  • Young
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2
Q

How can tension headache be divided?

A

Episodic - occurs on < 15 days per month

Chronic - occurs on > 15 days per month

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3
Q

SOCRATES tension headache

A 
S: Generalised, Bilateral.
O: Gradual or acute onset
C: Dull – “tight band”
R: Neck/shoulders
A- insomnia, stress
T: Lasts 3-4 hours
E: Analgesics help
S: Moderate
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4
Q

Ix/Mx for tension headache

A

CLINICAL DIAGNOSIS

Conservative: Headache diaries (avoid triggers, relaxation)

Medical: Simple analgesia (paracetamol, ibuprofen)

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5
Q

What must you be wary of when prescribing analgesics for headache?

A

Medication Overuse Headaches-

analgesics cease to provide pain relief and actually perpetuate and intensify the headaches.

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6
Q

Define migraine

A

chronic condition that causes

attacks of headaches

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7
Q

What is believed to be the pathophysiology of migraine?

A

Inflammation of the trigeminal nerve changes
the way that the brain process stimuli

So things like the pulsations of the meningeal arteries which are normally ignored by the brain are perceived as painful.

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8
Q

RF migraine

A

F>M

Younger 30-40

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9
Q

Migraine triggers (chocolates)

A 
Chocolate/cheese
HTN/hypothyroid
Obesity
Caffiene
Oral contraceptive/hormone changes
Lack of sleep/sleep disorder
Alcohol
Travel
Exercise
Stress
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10
Q

SOCRATES migraine

A 
S: Unilateral
O: Paroxysmal, comes on gradually
C: Pulsating/throbbing
R: neck stiffness/pain
A: aura, photophobia, N+V, parasthesia
T: 4 – 72h 
E: Physical activity/stress, noise, light;  lying in a quiet, dark room
S: Moderate to severe
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11
Q

What are the associated symptoms of migraine?

A 
Aura: flashing lights, tingling
Photophobia, phonophobia
Nausea, vomiting
Visual changes
Tingling
Numbness

INTERFERES WITH ADLs

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12
Q

Briefly describe the phases of migraine

A

PRODROME
- few hours-days
changes in mood, behaviour and sleep.

AURA

  • 5-60 mins before
  • visual changes, flashing lights
  • pathognomonic but only present in 15-20%
MIGRAINE ATTACK
-throbbing, drilling
- icepick in head
- N+V
- sensitivity to light/sound/smell
and then a postdrome which is characterised by weakness and fatigue

POSTDROME

  • fatigue
  • depressed/euphoric
  • lack of concentration
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13
Q

Ix for migraine

A

Migraine is a CLINICAL diagnosis

Investigations only to exclude sinister causes

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14
Q

Mx of acute migraine

A

Conservative: Headache diary, avoid triggers

MEDICAL

  • Paracetamol, NSAIDs
  • Triptans- if above is ineffective (cause vasoconstriction of MMA + inhibit nociceptive transmission)
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15
Q

Prophylaxis of migraines

A
  • Propranolol (BB)
  • Topiramate (antiepileptic)

If ineffective:
- Amitriptyline (antidepressant

NOTE- only give prophylaxis if triptans ineffective

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16
Q

A 40-year-old man comes in with a headache. The headache started yesterday and he feels it more over one side of his head. He is also quite nauseous and the only thing that helps him is to seat in the dark. He says that he has had similar headaches in the past for which the GP advised ibuprofen and NSAIDs but these did not help him. What’s the next most appropriate step in his management?

A

Sumatriptan

Codeine → opioids should be avoided in migraine as they can cause dependence
Diclofenac → NSAIDs haven’t worked so need to step up
Sumatriptan
Topiramate → first-line for prevention but doesn’t manage headache acutely
Amitriptyline → second-line for prevention

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17
Q

Define cluster headache

A

A neurological disorder characterized by
recurrent, severe headaches on one side of the head, which
occur at a cyclical pattern

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18
Q

Epidemiology cluster headaches

A

M>F

20-40 yrs

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19
Q

Pathophysiology cluster headache

A

hypothalamic activation with secondary trigeminal and autonomic activation

  • Hypothalamus regulates body clock
  • Autonomic activation > autonomic features
  • Trigeminal activation > pai
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20
Q

Cluster headache presentation

A 
S: UNILATERAL, behind the eye
O: Acute onset, CYCLICAL PATTERN, (same time each day, usually at night)
C: intense, sharp, penetrating
A: autonomic symptoms 
T:  15 minutes – 3 hours
E: triggered by alcohol & strong smells
S: Severe – Can be disabling
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21
Q

What is the pattern of cluster headache attacks?

A

come in clusters following a cyclical pattern

eg every few months will wake you up at 1am every night for a week

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22
Q

Describe the associated symptoms of a cluster headache

A

ANS symptoms:

  • Watery, red eye
  • Facial flushing
  • Nasal congestion

O/E:
- Partial Horner’s (Ptosis, miosis)

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23
Q

RFs cluster headache

A

smoking

alcohol

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24
Q

Define trigeminal neuralgia

A

Facial pain syndrome in

the distribution a division of the trigeminal nerve.

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25
Q

What is thought to be the cause of trigeminal neuralgia?

A

Compression of the trigeminal nerve by a loop of artery or vein

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26
Q

what is trigeminal neuralgia associated with?

A

MS (plaque deposition)

HTN

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27
Q

What are the triggers for trigeminal neuralgia?

A

Things that compress the affected area:

washing your face, eating, brushing teeth

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28
Q

Typical trigeminal neuralgia presentation

A

Unilateral pain, along the trigeminal division
Paroxysmal, lasting for seconds
Stabbing, shooting
Numbness/parasthesia

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29
Q

Commonest causes of meningitis in neonates

A

E. coli

Group B Strep

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30
Q

Commonest causes of meningitis in children

A

H. influenzae

Strep. pneumoniae

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31
Q

Commonest cause of meningitis in young adults

A

Nesseria meningitidis

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32
Q

Commonest causes of meningitis in elderly

A

Strep pneumoniae,

Listeria monocytogenes

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33
Q

What is the typical presentation of meningitis?

A

Acute onset, severe headache + fever = early signs

  • Meningism- headache, neck stiffness, andphotophobia
  • N+V
  • Seizures
  • Altered Mental status
  • Shock (tachycardia, hypotension)
  • non-blanching rash
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34
Q

RF for meningitis

A
  • Closed communities/Crowding (spread via resp droplets)
  • Extremes of age <5, >65
  • Infections (head/face, mastoiditis, sinusitis)
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35
Q

2 signs of meningitis

A

Kernig’s Sign - with the hips flexed, there is pain/resistance on passive knee extension - this is due to severe stiffness in the hasmstrings

Brudzinski’s Sign - flexion of the hips and knees when the neck is flexed - this is due to severe neck stiffness

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36
Q

Ix for meningitis

A

CT head-PRIMARY:
if neurological deficit or ↓ consciousness (check for raised ICP)

DIAGNOSTIC: LP + CSF analysis

2 sets of blood cultures

37
Q

Compare the appearance of CSF in bacterial, viral and TB meningitis

A

APPEARANCE

  • bacterial = turbid
  • viral = clear
  • TB = fibrin web
38
Q

Compare the cells of CSF in bacterial, viral and TB meningitis

A 
CELLS
- bacterial = ↑ neutrophils (polymorphs)
- viral = ↑ lymphocytes
(mononuclear)
- TB = ↑ lymphocytes
(mononuclear)
39
Q

Compare the glucose of CSF in bacterial, viral and TB meningitis

A

GLUCOSE

  • bacterial = ↓
  • viral = normal
  • TB = ↓
40
Q

Compare the protein of CSF in bacterial, viral and TB meningitis

A

PROTEIN

  • bacterial = ↑
  • viral = normal / ↑
  • TB = ↑
41
Q

GP management of suspected meningitis

A

benzylpenicillin IM

& URGENT REFERAL TO THE HOSPITAL

42
Q

A+E management of suspected meningitis

A

Broad spectrum antibiotics

  • ceftriaxone IV
  • benzylpenicillin IM
  • acyclovir if viral

IV dexamethasone (prevent hearing loss, cerebral oedema + improve mortality)

43
Q

Complications of meningitis

A

Hearing loss (most common)
Sepsis
Impaired mental status

44
Q

Define encephalitis

A

Acute onset febrile illness with behavioural, cognitive, psychiatric manifestations due to inflammation of the brain parenchyma.

45
Q

aetiological causes of encephalitis

A

USUALLY VIRAL:

  • HSV1-2
  • CMV
  • EBV
  • HIV
  • measles

NON-VIRAL

  • bacterial meningitis
  • TB
  • malaria, listeria, Lyme disease, legionella
46
Q

Epidemiology of encephalitis

A

Affects mostly the extremes of age

  • <1
  • > 65
47
Q

How does encephalitis present?

A

Viral prodrome
Fever
Headache

ALTERED MENTAL STATE

  • Memory disturbances
  • Personality changes
  • Psychiatric manifestations
  • Impaired consciousness
48
Q

Ix for encephalitis

A
  • LP- CSF analysis for same as meningitis
  • Bloods
  • EEG
  • CT/MRI (bitemporal oedema/hyperintense lesions)
49
Q

A 19-year old medical student presents to A & E with
headache, fever, and neck stiffness. Once raised ICP is
excluded a lumbar puncture is performed and CSF
analysis reveals the following:
High polymorphs, low glucose and high protein
Given the most likely diagnosis, which is the most likely
causative organism?
Listeria monocytogenes
HIV
HSV
Neisseria meningitidis
VZV

A

Neisseria meningitidis

50
Q

Causes of raised ICP

A

SOL- tumour, abscess, haemorrhage

Hydrocephalus

51
Q

Symptoms of raised ICP

A

HEADACHE

  • Bilateral
  • Gradual
  • throbbing/bursting
  • worse in the morning
  • coughing, sneezing

ASSOCIATED:

  • Vomiting
  • Altered GCS
  • Seizures
52
Q

Signs of raised ICP

A
  • Focal neurological symptoms
  • Papilloedema

Cushing’s reflex → Cushing’s triad:

  • ↑SBP
  • Irregular breathing
  • Bradycardia
  • Cheyne-stokes respiration
53
Q

What reflex is a physiological response to raised ICP?

A

Response to ↑ICP that results in Cushing’s trial of

  • ↑BP
  • irregular breathing
  • bradycardia
54
Q

Cheyne - stokes respiration

A

Abnormal pattern of breathing characterised by progressively deeper and sometimes faster breathing followed by a gradual decrease that results in apnoea

55
Q

Which conditions may show cheyne - stokes respiration?

A 
HF
stroke
hyponatraemia
TBI
brain tumours
56
Q

Ix for raised ICP

A
  • URGENT CT-head
  • ↑ICP is a CONTRAINDICATION to LP
  • Causes brainstem herniation
57
Q

Define EDH

A

A collection of blood in the potential space between the dura and the bone

58
Q

Causes of EDH

A

Head trauma
- Skull fracture causing laceration of the MMA

  • can also result from tears in dural venous sinus
59
Q

Epidemiology of EDH

A

YOUNG (20-30 years old males)

60
Q

How does EDH present?

A
  1. Trauma (major)
  2. LOC
  3. Lucid interval
  4. Increasingly severe headache, drop in GCS, signs of raised ICP

Ipsilateral pupil dilation (compression of PSNS fibre in CNIII)

61
Q

Ix for EDH- what would you see?

A

Urgent Non-contrast CT head
MRI

Fluid collection shows LENTICULAR (lemon) shape that does not cross suture lines

62
Q

Define SDH

A

A collection of blood between the dural and arachnoid covering of the brain.

63
Q

Causes of SDH

A

Rupture of the bridging veins
- elderly
- alcoholics
due to brain atrophy

64
Q

SDH presentation

A
  • Gradual onset, continuous headache
  • Fluctuating consciousness
  • Confusion
  • Personality changes
  • Symptoms of ↑ ICP
65
Q

How can SDHs be classified?

A

ACUTE: Within 72 hours (younger patients, trauma)

SUBACUTE: 3-20 days (worsening headache, elderly)

CHRONIC: After 3 weeks (headache, confusion)

66
Q

RF for SDH

A
  • Head trauma & falls (often following minor trauma up to 9 weeks before which patients have forgotten)
  • Old age
  • Alcoholics
  • Anticoagulation
67
Q

Ix for SDH- what would you see?

A

Urgent Non-contrast CT head
MRI

The subdural fluid collection is usually CRESCENTIC (banana) in shape and can cross suture lines.

68
Q

Different histories for different categories of SDH?

A

ACUTE: history of trauma with head injury, patient has reduced conscious level

SUBACUTE: worsening headache 7-14 days after injury, altered mental status

CHRONIC: can present with headache, confusion, cognitive impairment, psychiatric symptoms, gait deterioaration, focal weakness, sezures

69
Q

SDH conservative management + indications

A

CONSERVATIVE- <10mm, no midline shift, non neuro deficit

  • Admit, observe and monitor
  • Do a follow-up CT in 2-3 weeks.
  • Prophylactic antiepileptics
  • ICP monitoring if GCS < 9
  • Correct coagulopathies
70
Q

SDH surgical management + indications

A

Burr hole surgery

May leave drain in place

71
Q

Most common cause of SAH

A

Berry (saccular) aneurysm rupture

Blood flows into the SAH, sometimes seeping into brain parenchyma and/or ventricles.

72
Q

What causes symptoms in SAH?

A
  • Sudden increase in ICP

- Toxic effects of blood on brain parenchyma and cerebral vessels

73
Q

SAH symptoms

A

HEADACHE

  • Occipital (or diffuse)
  • Sudden (“Thunderclap”)
  • Continuous
  • Very severe, maximum intensity within MINUTES

OTHER:

  • meningism
  • symptoms of ↑ ICP
74
Q

RF for SAH

A

Polycystic kidney disease
Alcohol
Smoking
HTN

75
Q

CT sensitivity over time

A

< 12 hours- 98%
< 1 week- 50%
> 3 weeks - 0%

76
Q

What would you see in lumbar puncture in SAH? When is it indicated?

A
  • Indicated if CT is normal
  • Xanthochromia & oxyhaemoglobin
  • From 12 hours after symptom onset
77
Q 
An older man with a longstanding history of AF on anticoagulation with warfarin is brought into A & E by his carer, who is concerned about the patient's confusion at home. The carer describes frequent falls over the last several months. On examination, he has a right-sided pronator drift and is weaker on his right side. His mental status testing reveals poor concentration. What is the most likely cause of his symptoms?
Stroke
Subdural haemorrhage
Alzheimer’s disease
Encephalitis
Parkinson’s disease
A

Subdural haemorrhage

Pronator drift is a sign of an upper motor neuron problem, and subdural is an UMN problem

Stroke → UMN (can have pronator drift but more acute presentation)
Subdural haemorrhage
Alzheimer’s disease → wouldn’t present with one-sided weakness and pronator drift
Encephalitis → has changes in behaviour and mental state but here the patient does not have any features suggestive of infection, and the anticoagulation is a stronger RF for bleeding
Parkinson’s disease → would present more with resting tremor, bradykinesia and tremor

78
Q

Most common type of primary brain tumour

A

Most brain tumours arise from glial cells (the supportive cells of the NS)

79
Q

How can primary brain tumours be classified?

A

Intra-axial tumours: within the brain substance

Extra-axial tumours are outside the brain parenchyma (they originate from meninges or CNS)

80
Q

What is the most common type of brain tumour in children?

A

Medulloblastoma

81
Q

CNS tumour presentation

A

raised ICP headache:

  • Bilateral
  • Gradual
  • Throbbing/bursting
  • Worse in the morning
  • Coughing, sneezing

Others:

  • FLAWS
  • Focal neurological signs
  • Weakness
  • Difficulty walking
  • Seizures
  • Personality changes
82
Q

RF for brain tumours

A

Ionising radiation
Immunosuppression (HIV)
Inherited syndromes (eg neurofibromatosis)

83
Q

What in general causes the symptoms of CNS tumours?

A
  • By direct effect: brain is infiltrated and local function impaired
  • By secondary effects of raised ICP and shift of intracranial contents (papilloedema, vomiting, headache)
  • By provoking generalised or partial seizures
84
Q

How do frontal lobe tumours present?

A

personality disturbance,
apathy
impaired intellect

85
Q

How do R parietal lobe tumours present?

A

L homonymous Hemianopia
L sided hemiparesis
Left sensory loss

86
Q

How do vestibular schwannoma’s present?

A

progressive deafness

87
Q

Ix for CNS tumours

A

CT (quicker)
MRI (better resolution)
CXR, CT thorax, abdo & pelvis to check for metastases
Biopsy (definitive)

88
Q

A 33-year-old woman attends her six-month follow-up appointment for headache. They are migrainous in nature but whereas she used to have them every few months, over the last three months she has experienced a chronic daily headache. She takes co-codamol qds and ibuprofen
tds. What is the best medical management?
A. Stop all medication
B. Start paracetamol
C. Start sumatriptan
D. Start propranolol
E. Continue current medication

A

The treatment is to withdraw analgesics which initially will worsen the headache (the patient should be prepared for this) but in the long run will alleviate it.

It is not advisable for headache patients to take simple analgesia more than 2 days a week.

Once she is off the analgesia, it will be easier to discern the
effect of her migraines

Year 3 (38 decks)

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