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Medicine year 3 ANNA > Headache > Flashcards

Headache Flashcards

1
Q

What is the triad of symptoms of meningitis?

A
  1. Headache
  2. Nuchal stiffness (neck)
  3. Photophobia
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2
Q

What is a red, purpuric rash indicative of?

A

Meningococcal meningitis

=

Medical emergency!

(when accompanied by fever in children it is meningitis until proven otherwise)

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3
Q

What signs will a meningitis patient have on examination?

A
  • Kernig’s sign = hamstring spasm in response to extension
  • Nuchal stiffness
  • Pupuric rash → does not blanch on applying pressure to it; glass test
  • Signs of sepsis
    • tachycardia
    • increased RR
    • temperature
  • Signs of shock
  • Decreased GCS
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4
Q

When would a lumbar puncture for meningitis be contraindicated?

A
  1. Coagulation defects
  2. Raised ICP (→coning)
  3. Infection at site
  4. Severe sepsis / rapidly evolving rash
  5. Respiratory or cardiac compromise
  6. Continuous or uncontrolled seizures
  7. GCS <12
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5
Q

What are the characteristics of a tension headache?

A
  • S - Bilateral
  • O -
  • C - Pressing, tightening, non-pulsating, feeling of pressure behind the eyes
  • R -
  • A - neck muscles tighten
  • T - 30 minutes
  • E - Not aggravated by routine
  • S - Mild-moderate
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6
Q

What are the characteristics of a migraine?

A
  • S - Unilateral OR bilateral
  • O - Brought on by stress/screens/other triggers
  • C - Pulsating
  • A - Nausea +/- vomiting
    • Aura as a warning (flickering lights, spots, lines, partial loss of vision, numbness in limbs), usually lasts only 20 minutes. For first experience of aura consult with neuro to check it’s not a stroke or TIA.
  • T - Lasts 4-72 hours in adults
  • E - Aggravated by/ causes avoidance of AoDL
    • Unusual sensitivity to light / sound
  • S - Moderate - severe
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7
Q

What are the characteristics of a cluster headache?

A
  • S - Unilateral, around eye / side of face
  • O - Same time each day
  • C - Variable: sharp, boring, burning, throbbing, tightnening
  • A - Restlessness / agitation
    • Red/watery eye
    • Nasal congestion / runny nose
    • Swollen eyelid
    • Forhead / facial sweating
    • Constricted pupil and/or drooping eyelid
  • T - 15 minutes - 3 hours
    • usually occur every day, in bouts lasting several weeks or months at a time (typically 4-12 weeks)
  • S - Severe - very severe
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8
Q

How do you treat a tension headache?

A
  • Paracetamol
  • NSAIDs e.g. ibruprofen
  • Aspirin sometimes also recommended
  • → medication overuse headache /“painkiller headache” may occur with 10 + days continuous use - you get a headache when you stop taking the medication
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9
Q

How do you treat a migraine:

  1. Acutely
  2. Prophylactically
A
  1. Combination therapy with:
  • an oral triptan and an NSAID,
  • or an oral triptan and paracetamol
  1. Preventative with:
  • Propanolol
  • Anticonvulsant e.g. Topiramate (warning: can cause foetal malformaitons and can interfer with oral contraception)
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10
Q

How do you treat a cluster headache?

A
  • NSAIDs / paracetamol are often not helpful
  • Treat in hospital with:
  1. Oxygen
    • use 100% oxygen
    • at a flow rate of at least 12 litres per minute
    • with a non‑rebreathing mask and a reservoir bag
    • Remember to arrange home oxygen
  2. Triptan
    • subcutaneous
    • or nasal spray
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11
Q

When would you suspect medication overuse headache?

A
  • headache developed or worsened while they were taking the following drugs:
    • triptans, opioids, ergots or combination analgesic medications on 10 days per month or more
    • paracetamol, aspirin or an NSAID, either alone or any combination, on 15 days per month or more
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12
Q

Name 4 primary causes of headache

A
  1. Tension
  2. Migraine
  3. Cluster
  4. Trigeminal Neuralgia (the only one that needs MRI to find cause)
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13
Q

Name 6 intracranial secondary causes of headache

A
  1. Meningitis
  2. Temporal arteritis
  3. Raised ICP
    • tumour
    • beinign intercranial HTN
    • acute hydrocephalus
  4. Venous sinus thrombosis
  5. Intercerebral haemorrhage
  6. Subarachnoid haemorrhage
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14
Q

Name 5 extracranial secondary causes of headache

A
  1. Acute closed-angle glaucoma
  2. Sinusitis
  3. Hypertensive encephalopathy
  4. Pre-eclampsia
  5. Carotid / vertebral artery dissection
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15
Q

What are the 4 risk factors for meningitis?

A
  1. Extremes of age
  2. Living in close proximity - outbreaks can occur in student halls of residence and boarding schools
  3. Vaccination history (absence of)
  4. Immune suppression/deficiency
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16
Q

What is the difference between meningitis and encephalitis?

A

Meningitis:

  • = inflammation of the meninges
  • Often bacterial
  • Causes photophobia, neck stiffness, rash, fever, headache

Encephalitis:

  • Most common cause is herpes simplex virus (HSV).
  • Inflammation of the brain
  • Causes confusion or disorientation, drowsiness, seizures and changes in personality and behaviour
17
Q

What are the common organisms that cause meningitis?

A

Bacterial:

  • Strep pneumoniae
  • Neisseria meningitidis (meningococcal meningitis)
  • Haemophilus influenzae - type b

Viral:

  • Enterovirus
  • Herpes simplex
  • Varicella Zoster

Fungal:

  • crytococcus neoformans
18
Q

What tests are especially important for meningitis?

A
  • Blood cultures
  • CSF testing
  • Serology for viruses causing meningo-encephalitis
  • Throat swab for Neisseria meningitides & Streptococcus pneumonie
  • Urine pneumococcal antigen
19
Q

What tests are important for encephalitis?

A
  • CT or MRI brain- in encephalitis this may show oedema of the temporal lobes. It can also be used to rule out other causes of intracranial pathology.
  • Electroencephalogram EEG- to show characteristic slow waves.
20
Q

What are the signs and symptoms of raised ICP?

A

Symptoms:

  • New onset headache (no prev. history of headache) in patient >50
  • Worse in the morning
  • Wose with coughing / bending / sneezing
  • Vomiting
  • +/- seizures if due to tumour
  • Visual disturbances:
    • transient visual obscurations; vision becomes blurred or black when there is a change of posture ​
  • May have nerological symptoms on examination
    • papilloedema
    • restricted visual fields
    • enlarged blind spots
    • reduced GCS

Signs:

  • Bradycardia
  • Hypertension
  • Papilloedema
21
Q

How would you treat viral meningitis?

A
  • Confirm viral over bacterial meningitis with CSF, then stop antibiotics
  • Commence antiviral therapy
    • Aciclovir or valaciclovir is typically given first line for HSV and varicella zoster
  • Don’t forget A→E medications e.g. fluids and anti-emetics
22
Q

How would you treat bacterial meningitis?

A

Start antibiotics without delay, adjuct once CSF results are back:

  • IV 3rd generation cephlosporin e.g. cefotaxime or ceftriaxone plus vancomycin
  • adjunct dexamethasone
  • If 60+ add amoxycillin
  • If penecillin resistance is a possibliliy add vancomycin or rifampicin

In the community, IM benzylpenicillin is used

23
Q

What are the signs / history of temporal / giant cell arteritis?

A

History:

  • Unilateral
  • Throbbing pain
  • Scalp tenderness
  • Jaw claudication (pain on chewing)
  • >55 years old
  • May have visual problems
  • malaise
  • sweats
  • proximal muscle aching

Signs:

  • Ispilateral blindness
  • Temporal tenderness
  • Optic nerve oedema on fundoscopy
24
Q

How do you treat giant cell / temporal arteritis?

A

Initially, give oral prednisolone:

  • with visual symptoms — 60 mg as a one-off dose (they should be seen by an ophthalmologist the same day).
  • without visual symptoms — 40 to 60 mg daily (minimum 0.75 mg/kg)
25
Q

What are the red flag symptoms (requiring 2WW) for secondary headaches?

A
  • Symptoms of raised ICP
    • dsf
  • unexplained vomiting
  • new onset seizures
  • new or progressive neurological deficit
  • PMH of malignancy
  • headaches triggered by exertion
  • increase in severity or frequency despite treatment
26
Q

What is “thunder-clap headache” a sign of?

A

Subarachnoid haemorrhage (SAH)

  • May also present with a ‘sentinel’ (a mild headache preceding the severe one, seen in <10%), usually in women aged 40 to 60 years.
  • Sudden onset, worst headache of life
  • Immediate CT or MRI.
27
Q

Describe the CSF changes

A
28
Q

Is meningitis a notifiable disease?

A

Yes!

Contacts need prophylaxis e.g. rifampicin

29
Q

What is the commonest type of brain tumour?

A

Glioblastoma multiforme (GBM), a type of glioma

30
Q

What is the normal ICP?

When is it pathologically high?

A

Normally <15 mmHg in adults

Pathological ICP is persistent pressures >20mmHg

31
Q

What are the headache red flags?

A
  • A headache of sudden onset, reaching maximum intensity by five minutes (suggestive of subarachnoid haemorrhage)
  • Fever with a worsening headache, meningeal irritation and change in mental status (viral/bacterial meningitis)
  • New-onset focal neurological deficit, personality change or cognitive dysfunction (intracranial haemorrhage/ischaemic stroke/space occupying lesion)
  • Decreased level of consciousness
  • Head trauma (more significant if within the last three months)
  • Headache which is posture dependent (e.g. worse on lying down and coughing with raised ICP).
  • Headache associated with tenderness in the temporal region (unilateral or bilateral) and jaw claudication (temporal arteritis)
  • Headache associated with severe eye pain/blurred vision/nausea/vomiting/red eye (acute angle closure glaucoma)
32
Q

What investigations are essential if you suspect temporal / GC arteritis?

A
  • CRP and ESR (both raised)
  • FBC and LFTs
  • temporal artery biopsy
    • ultrasound if unavailable, but this is not diagnostic

Medicine year 3 ANNA (30 decks)

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