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NEUROLOGY AND NEUROSCIENCE 2 > HEADACHE > Flashcards

HEADACHE Flashcards

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1
Q

What are the main categories of causes for headaches?

A

Structural
Pharmacological
Psychological e.g. stress

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2
Q

What are the patterns and causes associated with an acute single headache?

A 
Febrile illness, sinusitis
First attack of migraine
Following head injury
Subarachnoid haemorrhage
Meningitis, tumours, drugs, toxins, stroke
Thunderclap
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3
Q

What are the patterns associated with a dull headache, increasing in severity?

A 
Usually benign
Overuse of medication
Contraceptive pill, HRT
Neck disease
Temporal arteritis
Benign intracranial hypertension
Cerebral tumour
Cerebral venous sinus thrombosis
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4
Q

What types of headaches can be recurrent?

A

Migraine
Cluster headache
Episodic tension headache
Trigeminal/post-herpetic neuralgia

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5
Q

What can cause a dull headache, unchanged over months?

A

Chronic tension headache

Depressive, atypical facial pain

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6
Q

What triggers can cause headaches?

A

Coughing
Straining
Coitus
Food and drink e.g. wine

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7
Q

What are the red flags of headaches?

A

Thunderclap, acute, subacute onset

Photophobia, phonophobia, stiff neck, vomiting (associated with meningism)

Fever, rash, weight loss

Visual loss, confusion, seizures, hemiparesis, 3rd nerve palsy, Horner syndrome, papilloedema

Orthostatic (better lying down)

Unilateral (pain in same spot all the time)

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8
Q

What causes double vision?

A

Oculomotor muscle(s)/nerve(s) not working

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9
Q

What is 3rd nerve palsy?

A

Disruption of 3rd CN (oculomotor) causing ptosis and the eye to point outwards since no innervation to most of the muscles behind eye

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10
Q

What can a rupture of the posterior communicating artery sometimes cause?

A

3rd nerve palsy

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11
Q

What is Horner syndrome and its symptoms?

A

Sympathetic supply to eye is affected causing droopy eye, enopthalmos and a smaller pupil

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12
Q

What type of headache would a subarachnoid haemorrhage cause?

A

Sudden generalised headache (thunderclap)

Meningism

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13
Q

Why could a subarachnoid haemorrhage cause meningism?

A

Blood is flowing around subarachnoid space and irritating the meninges

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14
Q

What are the 3 causes of subarachnoid haemorrhage?

A

Ruptured aneurysm (main cause)
Arteriovenous malformations
Ideopathic

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15
Q

What percentage of subarachnoid heamorrhages are instantly fatal?

A

50%

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16
Q

What is a vasopasm?

A

When the smooth muscle of a blood vessel spasms to prevent leaking

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17
Q

What are the exams you can do to confirm and investigate a subarachnoid haemorrhage?

A

CT scan
Lumbar puncture (when you can’t see blood on CT as CSF will be slightly pink due to blood)
MRA
Angiogram to see location of aneurysm

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18
Q

How are aneurysms fixed?

A

Now filled with platinum coils via catheter causing aneurysm to sclerose and seal itself

Used to be clipped or wrapped

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19
Q

Describe the mechanism of coning

A

Tumour/bleed present in brain causing raised intracranial pressure (ICP). The brain has a certain amount of compliance but after that herniation of the brain occurs

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20
Q

List 3 different brain herniations

A

Subfalcine herniation
Tentorial herniation
Herniation through foramen magnum

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21
Q

What does a herniation through the foramen magnum cause?

A

Squashing and loss of blood supply leading to brainstem death and death

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22
Q

What is a cause of an acute intracerebral bleed?

A

Coning

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23
Q

What is papilloedema?

A

Optic disc swelling due to raised ICP

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24
Q

How can pathology in the larger arteries of the neck cause headache?

A

Basilar artery dissection: occipital headache

Carotid artery dissection: pain in phantom of opera mask distribution around eye and forehead

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25
What is an artery dissection?
Tear in the wall of artery causing blood to pool in split and turbulent flow in the lumen
26
Dissection in which neck artery is more common?
Carotid > vertebral/basilar
27
What is the treatment for a dissection?
Aspirin | Anticoagulant as turbulent flow can cause sticky blood leading to clotting which can dislodge and cause stroke
28
What diagnostics can be done if a dissection is suspected?
MRI/MRA Doppler Angiography
29
In which age population do chronic subdural haemorrhages occur in often?
Elderly due to falls and veins are easily traumatised due to thin walls. Also elderly are often on anticoagulants
30
How can you tell the age of a haemorrhage on a CT scan?
In older haemorrhage, hypotense blood darker as it has begun to degrade
31
What are the symptoms of temporal arteritis?
Constant unilateral headache Scalp tenderness Jaw claudication If posterior ciliary muscles involved causes blindness Elevated ESR and CRP (inflammation) Temple artery usually inflamed and tortuous Visible on ultrasound
32
What drugs can be used to treat temporal arteritis and for how long?
High dose steroids (anti-inflammatory) and aspirin (prevent stroke) for 3-4 years until disease runs its course
33
What should you see in a biopsy of temporal arteritis?
Disruption of internal elastic lamina (hallmark of vasculitis) Giant cells Inflammation
34
What is cerebral venous thrombosis (CVT)?
Similar to DVT but in brain Thrombosis in dural venous sinus or cerebral vein meaning blood can't leave
35
What are the symptoms of cerebral venous thrombosis?
Increased amount of headache due to raised ICP Haemorrhage Non-territorial ischaemia Sticky blood causing e.g. thrombophilia
36
List the different possible causes of meningitis
``` Viral Bacterial Fungal Granulomatous Carcinomatous (seeding of cancer cells in meninges causing a meningeal reaction) ```
37
What are the symptoms of meningitis?
``` Fever Malaise Headache Neck stiffness Photophobia Confusion Alteration of consciousness ```
38
Which lobes are usually seen affected by herpes simplex encephalitis?
Temporal lobes
39
What is the important rule when managing a patient with meningitis?
Treat then diagnose as meningitis can kill
40
How can meningitis be diagnosed/investigated
Blood and urine culture Lumbar puncture: increased WBC, decreased glucose, antigens, cytology, bacterial culture CT/MRI scan
41
Why should you do CT/MRI scan before a lumbar puncture in a patient with meningitis?
You need to assess how much ICP with the scan. If you LP'd without knowing, brain could hurtle through foramen magnum due to pressure change
42
What would a CT scan of a patient with bacterial meningitis look like?
Cerebral oedema with effacement of ventricles and sulci and inflamed meninges
43
What are the symptoms of sinusitis?
``` Malaise, headache, fever Blocked nasal passages Loss of vocal resonance Anosmia Nasal or postnasal catarrh Local pain and tenderness ``` Frontal pain usually 1-2 hours after waking up but the clears up during afternoon
44
What would a CT scan of a patient with sinusitis show?
Opacification of sinuses as full of infection
45
What is a pseudotumor?
Might think patient has tumour due to rise in ICP but none seen in CT. Completely idiopathic
46
What are the symptoms of pseudotumor cerebri?
``` Headache Visual obscurations Diplopia Tinnitus Papilloedema +/- visual field loss ```
47
What demographic is pseudotumor cerebri most commonly seen in?
Young obese women
48
What are the treatments for pseudotumor cerebri?
weight loss, diuretics, optic nerve sheath decompression, lumboperitoneal shunt, stenting of stenosed venous sinuses
49
What is a hallmark of a low pressure headache?
Orthostatic symptoms because when standing CSF leaks causing pressure drop thus headache
50
What occurs in a low pressure headache and its causes?
CSF leak due to tear in dura Due to traumatic post lumbar puncture or spontaneous
51
What is the treatment for low pressure headaches?
Rehydration, caffeine, blood patch (inject blood into epidural space as it acts like a natural glue to patch up tear)
52
How are low pressure headaches diagnosed?
MRI scan with contrast injection of gadolinium
53
What is Chiari malformation?
Normal brain which sits very low in the skull | The cerebellar tonsils descend through the foramen magnum
54
What type of headache does a chiari malformation cause and why?
Cough headache because cerebellar tonsils descend further into foramen magnum when patient coughs which tugs on the meninges
55
What is trigeminal neuralgia?
Electric shock like pain in the distribution of the trigeminal nerve and is often triggered by innocuous stimuli. Due to neurovascular conflict at point of entry of the trigeminal nerve into the pons Can be symptom of MS
56
What are the treatments for trigeminal neuralgia?
Anticonvulsants which dampen pain e.g. carbamazepine, lamotrigine Posterior fossa decompression
57
Describe the features of atypical facial pain
Daily, constant, poorly localised deep aching/burning Facial/jaw bones, sometimes neck, ear or throat No sensory loss and other pathologies must be excluded Unresponsive to conventional analgesics, opiates and nerve blocks
58
Which population is atypical facial pain most common in?
Middle aged women
59
What is a post traumatic headache and its mechanisms?
A headache which appears after head injury ``` Multiple mechanisms: Neck injury Scalp injury Vasodilation due to autonomic damage Depression ```
60
What treatment can be given to patients with post traumatic headaches?
Non-steroidal anti-inflammatories - ibuprofen Tricyclic antidepressants These drugs are the least addictive
61
What are the symptoms cervical spondylosis?
Usually bilateral Occipital pain can radiate to frontal region Steady pain No nausea/vomiting Worsened by moving the neck Worse during morning but gets better after stretch
62
How can cervical spondylosis be managed?
Rest, deep heat, massage Anti-inflammatory analgesics Over-manipulation may be harmful
63
What is the most common cause of new headaches in older patients and why?
Cervical spondylosis due to arthritis wearing out joints
64
What are some of the features of a migraine?
``` Tendency go repeated attacks Triggers Easily hung-over Visual vertigo Motion sickness ```
65
What are the 5 phases of a migraine?
Prodrome - mood to changes, urination, fluid retention... Aura - visual, sensory, weakness, speech arrest Headache - nausea, photophobia Resolution - rest and sleep Recovery - mood disturbed, food intolerance, hung-over
66
What are some visual changes seen in aura of a migraine?
Positive and negative symptoms together: - scintillations - blindspot - expanding Cs
67
Describe the expanding Cs seen in the aura of a migraine and why they occur
Cs which grow and grow whilst moving out to periphery until they disappear Occurs because migraines caused by spreading electrical depression across cerebral and visual cortex
68
What treatments can be given to a patient suffering from an acute migraine attack?
Non-steroidal painkillers e.g. ibuprofen, aspirin Antiemetics e.g. metoclopramide Triptans (headache painkillers) + NSAIDS Transcranial magnetic stimulation (TMS) interrupts complex network that causes the migraine Treat as early as possible Look for triggers and avoid them
69
What is erenumab?
Injectable drug against migraines. Reduces frequency of migraines Monoclonal antibody which disables calcitonin gene related peptide or its receptor (CGRP mAbs)
70
What are tension type headaches?
Headaches caused by tight muscles around head and neck
71
What drugs can be given for tension type headaches?
NSAIDs e.g. ibuprofen Paracetamol Tricyclic antidepressants e.g. amitriptyline
72
What are cluster headaches?
Severe unilateral pain lasting 15-180 minutes | Acute headache and then more and more (cluster)
73
What are cluster headaches classified as?
Trigeminal autonomic cephalgia as the pain mainly in 1st division of trigeminal nerve
74
What are the symptoms of a cluster headache?
At least one of the following, ipsilaterally: - Conjunctival redness/inflammation - Nasal congestion/rhinorrhoea - Eyelid oedema Facial sweating Miosis/ptosis Restlessness/agitation Frequency from 1 on alternate days to 8 per day
75
How do you treat the acute headache of a cluster headache?
Inhaled oxygen to inhibit neuronal activation in trigeminocervical complex S/C or nasal Sumatriptan
76
How do you prevent future headaches (the cluster)?
Steroids e.g. prednisolone, verapamil Anti-epileptics/seizures e.g. valproate, gabapentin, topiramate Pizotifen
77
Highlight the differences between migraine and cluster headaches
Distribution: Migraine - 33% men, 67% women Cluster - 90% men, 10% women Duration: Migraine - 3-12 hours Cluster - 45min - 3 hours Frequency: Migraine - 1-8 monthly Cluster - 1-3 daily Remission: Migraine - not usually long Cluster - usually long Nausea: Migraine - frequent Cluster - rare Pain: Migraine - pulsating hemicranial Cluster - steady, unilateral in each cluster, well localised Symptoms: Migraine - visual/sensory auras Cluster - eye waters, nose blocked, ptosis... Actvity: Migraine - patients lies in dark Cluster - patients pace about

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