Headache Flashcards
What are possible causes of acute, single headaches?
- febrile illness, sinusitis
- first attack of migraine
- head trauma
- subarachnoid haemorrhage
- meningitis
- tumour
- drugs, toxins
- stroke
- thunderclap
- low pressure
What are the possible causes of a dull headache, increasing in severity?
- benign
- overuse of medication
- contraceptive pill
- HRT
- neck disease
- temporal arteritis
- benign intracranial hypertension
- cerebral tumour
- cerebral venous sinus thrombosis
What tends to cause a dull headache, unchanged for months?
- chronic tension headache
- depressive, atypical facial pain
What are different forms of recurrent headaches?
- migraine
- cluster headache
- episodic tension headache
- trigeminal/post-herpetic neuralgia
What are the red flags for a headache?
- onset
- meningism
- systemic symptoms
- neurological symptoms or focal signs
- orthostatic
- strictly unilateral
What types of onset are red flags?
- thunderclap
- acute
- subacute
What forms of meningism are red flags?
- photophobia
- phonophobia
- stiff neck
- vomiting
Which systemic symptoms are red flags?
- fever
- rash
- weight loss
Which neurological symptoms are red flags?
- visual loss
- confusion
- seizures
- hemiparesis
- papilloedema
What does orthostatic mean?
the headache is better when lying down
Which focal signs are red flags?
- double vision
- 3rd nerve palsy
- Horner syndrome
How are subarachnoid haemorrhages caused?
- ruptured aneurysm
- arteriovenous malformations
How do subarachnoid haemorrhages present?
- sudden, generalised head ache (‘blow to the head’)
- meningism (photophobia, stiff neck)
How do you diagnose a subarachnoid haemorrhage?
- 50% are instantly fatal
- early neurological assessment
- brain CT
- lumbar puncture (RBC and xanthochromia)
- MRA
- Angiogram
How do you treat a subarachnoid haemorrhage?
- vasospasm may stop the leak
- nimodipine
- blood pressure control
- high future risk of a bleed
- coiling an aneurysm
How do you manage aneurysm?
- clip or wrap
- filled with a platinum coil to prevent rupture
How are most haemorrhages fatal?
due to coning
What is coning?
- movement of the cerebellar tonsils down through the foramen magnum.
- It leads to compression of the lower brainstem - leading to cardiovascular and respiratory instability
What is papilloedema?
optic disc swelling
- due to raised inter-cranial pressure
What can cause a trigger headache?
- coughing, straining, exertion
- coitus
- food and drink
What are the symptoms of a carotid and vertebral artery dissection?
- headache
- neck pain
When are carotid and vertebral arterial dissections most common?
mean: 40yo
carotid is more common than vertebral
(cause of 20% of ischaemic strokes in those <45yo)
How do you diagnose a carotid/vertebral dissection?
- MRI/MRA
- Doppler
- Angiography
How do you treat a carotid/vertebral dissection?
aspirin or anticoagulation
How do chronic subdural haemorrhages present?
- right frontal headache
- unsteadiness
- left limb weakness
(dependent on side of the brain)
When is temporal arteritis most common?
- > 55yo
- 3 x more common in females
How does temporal arteritis present?
- constant unilateral headache
- scalp tenderness
- jaw claudication
- elevated ESR and CRP
- 25% polymyalgia Rheumatica-proximal muscle tenderness
- blindness (involvement of posterior ciliary arteries)
- inflamed and tortuous temporal artery
What investigations show temporal arteritis?
- biopsy shows inflammation and Giant cells
- visible on ultrasound
How do you treat temporal arteritis?
- high dose steroids
- aspirin
What is temporal arteritis?
the disruption of the internal elastic lamina
What is a cerebral venous thrombosis?
thrombosis in dural venous sinus or cerebral vein
How does a cerebral venous thrombosis present?
- unusual amount of headache due to raised ICP
- non-territorial ischaemia (venous infarcts)
- haemorrhage
What are risk factors for a cerebral venous thrombosis?
- thrombophilia
- pregnancy
- dehydration
- Behcets
What are the different types of causes of meningitis?
- viral
- bacterial
- tuberculous
- fungal
- granulomatous
- syphilis
- carcinomatous
What are the viral causes of meningitis?
- coxsackie
- ECHO
- Mumps
- EBV
What are the bacterial causes of meningitis?
- Meningococci
- Pneumococci
- Haemophilus
- Tuberulous
What are the fungal causes of meningitis?
cryptococci
What are the granulomatous causes of meningitis?
- Sarcoid
- Lyme
- Brucella
- Behcets
- Syphilis
What are the presenting symptoms of meningitis?
- malaise
- headache
- fever
- neck stiffness
- photophobia
- confusion
- alteration of consciousness
How does Herpes Simplex Encephalitis look like on a scan?
classic haemorrhagic changes in the temporal lobes
How do you manage meningitis?
treat then diagnose
How do you treat meningitis?
antibiotics
How do you diagnose meningitis?
Blood and urine culture Lumbar puncture - increased WCC - decreased glucose - antigens - cytology - bacterial culture CT/MRI
How does bacterial meningitis look on a scan?
cerebral oedema with effacement of ventricles and sulci and inflamed meninges
How does sinusitis present?
- malaise
- headache
- fever
- blocked nasal passages
- loss of vocal resonance
- anosmia
- nasal or postnasal catarrh
- local pain and tenderness
frontal pain starts 1-2 hours after rising and clears at noon
How does Idiopathic Intracranial Hypertension present?
- headache
- visual obstructions
- diplopia
- tinnitus
- papilloedema +/- visual field loss
When is Idiopathic Intracranial Hypertension common?
young, obese women
What is a risk factor of Idiopathic Intracranial Hypertension?
- hormones
- steroids
- antibiotics
- vitamin E
What is the treatment for Idiopathic Intracranial Hypertension?
- weight loss
- diuretics
- optic nerve sheath decompression
- lumboperitoneal shunt
- stenting of stenosed venous sinuses
How does raised intracranial pressure look on a scan?
cerebral oedema with effacement of ventricles and sulci but no mass lesion
What can cause a low pressure headache?
CSF leak due to a tear in dura
- traumatic post lumbar puncture
- spontaneous
What is the treatment for a low pressure headache?
- rehydration
- caffeine
- blood patch
How does a low pressure headache look like on a scan?
meningeal enhancement (bright white)
What is a Chiari malformation?
- brain that sits low in the skull
- cerebellar tonsils descend through the foramen magnum
- descends further when coughing and tug on the meninges, causing a cough headache
What are the characteristics of sleep apnoea?
- history of loud snoring
- apnoeic spells
- depression
- impotence
- poor work performance
- non-refreshing sleep
- CO2 retention
- hypoxia
How do you diagnose sleep apnoea?
sleep study
What is the treatment/management of sleep apnoea?
- nocturnal NIV
- surgery
What is trigeminal neuralgia?
- electric shock like pain in the distribution of a sensory nerve
- any division of trigeminal
- neurovascular conflict at point of entry of the nerve to the pons
What can trigger trigeminal neuralgia?
often innocous stimuli
What is the treatment for trigeminal neuralgia?
- carbamazepine
- lamotrigine
- gabapentin
- posterior fossa decompression
What is atypical facial pain?
daily, constant, poorly localised deep aching or burning
How does atypical facial pain present?
- in facial or jaw bones, may extend to the neck, ear or throat
- no lancinating
- no conformation to the anatomical distribution og any nerve
- no sensory nerve
What is needed to diagnose atypical facial pain?
- exclusion of pathology in teeth, temporomandibular joints, nasopharynx and sinuses
- unresponsive to analgesics, opiates and nerve blocks
How do you manage atypical facial pain?
tricyclics
What correlates with the incidence of a post-traumatic headache?
a previous history of headache
What does the incidence of post-traumatic headaches depend on?
the nature of the injury
- high in car accident victims
- low in car accident perpetrators
- low in sports injuries
What are the mechanisms of post-traumatic headaches?
- neck injury
- scalp injury
- vasodilation (autonomic damage)
- depression (delayed)
How do you manage a post-traumatic headache?
- clear education
- prevent analgesic abuse
- NSAIDS (ibuprofen, naproxen)
- Tricyclic antidepressants (amitriptyline)
(takes 3-4 years)
What is cervical spondylosis?
narrowing of joint space due to a worn disc
What is the presentation of cervical spondylosis?
- bilateral
- occipital pain, radiating forwards to the frontal region
- steady pain
- no nausea or vomiting
- worsened by neck movement
What is the management for cervical spondylosis?
- rest
- deep heat
- massage
- anti-inflammatory analgesics
- over-manipulation may be harmful
How does migraine disorder present?
- tendency of repeated attacks
- triggers
- easily hung over
- visual vertigo
- motion sickness
What are the different forms of migraine attacks?
- pain only
- pain and focal sings
- focal symptoms only
What are the 5 phases of a migraine?
- prodrome
- aura
- headache
- resolution
- recovery
What is the prodrome phase of a migraine?
changes in:
- mood
- urination
- fluid retention
- food craving
- yawning
What is the aura phase of a migraine?
- visual changes
- sensory numbness/paraesthesia
- weakness
- speech arrest
What is the headache phase of a migraine?
- head and body pain
- nausea
- photophobia
What is the resolution phase of a migraine?
- rest
- sleep
What is the recovery phase of a migraine?
- disturbed mood
- food intolerance
- hungover
What visual symptoms happen during the aura phase of a migraine?
positive and negative symptoms simulatenously:
- scintillations
- blindspots
- expanding C’s
- elemental visual disturbances
What is the treatment for an acute migraine attack?
- NSAIDS (aspirin, ibuprofen)
- Anti-emetic (paracetamol, metoclopramide)
- soluble preparations
- triptans-tablets, melts, nasal sprays, sc injections (vasoconstrictors)
- CAUTION: analgesic abuse
- TMS
- nap
How does TMS help treat acute migraine attacks?
interrupts complex networks that trigger and perpetuate migraines - caused by spreading electrical depression across the cerebral cortex
What are the long term treatments for migraines?
- lifestyle issues due to overstimulation
- identify and avoid triggers
- hydrate and avoid caffeine
- avoid ready meals and take-aways
- good sleep
What prophylaxis can be taken for migraines?
- over the counter
- tricyclic antidepressants
- beta-blockers
- serotonin antagonists
- calcium channel blockers
- anticonvulsants
- greater occipital nerve blocks
- botox
- suppress ovulation
- Erenumab
What are the over-the-counter options to prevent migraines?
- feverfew
- coenzyme Q10
- riboflavin
- magnesium
- EPO
- nicotinamide
Which Tricyclic antidepressants can be taken to prevent migraines?
amitriptyline 7pm
What beta-blockers can be taken to prevent migraines?
- propranolol
- atenolol
What serotonin antagonists can be taken to prevent migraines?
- Pisotifen
- Methysergide
What calcium channel blockers can be taken to prevent migraines?
- Flunarazine
- Verapamil
What anti-convulsants can be taken to prevent migraines?
- Valproate
- Topiramate
- Gabapentin
What is Erenumab?
- injectable drug
- monoclonal antibodies
- disables calcitonin gene-relates peptide or its receptor (CGRP mAbs)
- halved migraines
What can Erenumab treat?
- episodic migraines
- chronic migraines
- cluster headaches
What is a tension headache?
tight muscles around the head and neck bilaterally
What is the treatment for tension headaches?
- NSAIDS (ibuprofen, naproxen, diclofenac)
- Paracetamol
- Tricyclic antidepressants (amitriptyline 50-75mg daily)
What is a cluster headache?
severe unilateral pain lasting 15-180 minutes untreated
classified as: trigeminal autonomic cephalgia
How does a cluster headache present?
- forehead and facial sweating
- miosis and/or ptosis
- restlessness or agitation
- 1-8 daily
- (at least one) ipsilaterally:
conjunctival redness and/or lacrimation
nasal congestion and/or rhinorrhea
eyelid oedema
(most common site of pain is the eye)
What is the acute treatment of a cluster headache?
- inhaled oxygen (inhibits neuronal activation in the trigeminocervical complex)
- s/c or nasal sumatriptan
What can prevent a cluster headache?
- Verapamil
- Prednisolone
- Lithium
- Valproate
- Gabapentin
- Topiramate
- Pizotifen
What is the difference in distribution between migraines and cluster headaches?
migraines are more common in women, vice versa for cluster headaches
What is the difference in duration between migraines and cluster headaches?
migraines last 3-12 hours
cluster headaches last 45min-3 hours
What is the difference in frequency between migraines and cluster headaches?
migraines: 1-8 monthly
cluster headaches: 1-3 daily (often at night)
What is the difference in remission between migraines and cluster headaches?
remission is longer in cluster headaches
What is the difference in nausea between migraines and cluster headaches?
nausea and vomiting is common in migraines but rare in cluster headaches
What is the difference in symptoms between migraines and cluster headaches?
migraines: visual or sensory auras
cluster headaches: eye waters, blocked nose and ptosis
What is the difference in pain between migraines and cluster headaches?
migraines: pulsating hemicranial pain
cluster headaches: steady, severe, localised, unilateral)
What is the difference in activity between migraines and cluster headaches?
migraine: lie in dark
cluster headaches: pacing common
What are the most common primary headaches?
- migraine
- tension headaches
- cluster headaches
What should be given to treat migraine without aura?
- nasal sumatriptan
- oral, oro-dispersable wafers
What should be used to treat cluster headaches?
- s/c or nasal triptan
- home/ambulatory oxygen
- Verapamil (Ca channel blocker) for prophylaxis
What should NOT be given to treat cluster headaches according to NICE?
- paracetamol
- NSAIDS
- oral triptans
- ergots
- opiods
