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NEUROLOGY AND NEUROSCIENCE 2 > HEADACHE > Flashcards

HEADACHE Flashcards

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
Q

What is an artery dissection?

A

Tear in the wall of artery causing blood to pool in split and turbulent flow in the lumen

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26
Q

Dissection in which neck artery is more common?

A

Carotid > vertebral/basilar

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27
Q

What is the treatment for a dissection?

A

Aspirin

Anticoagulant as turbulent flow can cause sticky blood leading to clotting which can dislodge and cause stroke

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28
Q

What diagnostics can be done if a dissection is suspected?

A

MRI/MRA
Doppler
Angiography

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29
Q

In which age population do chronic subdural haemorrhages occur in often?

A

Elderly due to falls and veins are easily traumatised due to thin walls.

Also elderly are often on anticoagulants

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30
Q

How can you tell the age of a haemorrhage on a CT scan?

A

In older haemorrhage, hypotense blood darker as it has begun to degrade

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31
Q

What are the symptoms of temporal arteritis?

A

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
Q

What drugs can be used to treat temporal arteritis and for how long?

A

High dose steroids (anti-inflammatory) and aspirin (prevent stroke) for 3-4 years until disease runs its course

33
Q

What should you see in a biopsy of temporal arteritis?

A

Disruption of internal elastic lamina (hallmark of vasculitis)
Giant cells
Inflammation

34
Q

What is cerebral venous thrombosis (CVT)?

A

Similar to DVT but in brain

Thrombosis in dural venous sinus or cerebral vein meaning blood can’t leave

35
Q

What are the symptoms of cerebral venous thrombosis?

A

Increased amount of headache due to raised ICP
Haemorrhage
Non-territorial ischaemia
Sticky blood causing e.g. thrombophilia

36
Q

List the different possible causes of meningitis

A 
Viral
Bacterial
Fungal
Granulomatous
Carcinomatous (seeding of cancer cells in meninges causing a meningeal reaction)
37
Q

What are the symptoms of meningitis?

A 
Fever 
Malaise
Headache
Neck stiffness
Photophobia
Confusion
Alteration of consciousness
38
Q

Which lobes are usually seen affected by herpes simplex encephalitis?

A

Temporal lobes

39
Q

What is the important rule when managing a patient with meningitis?

A

Treat then diagnose as meningitis can kill

40
Q

How can meningitis be diagnosed/investigated

A

Blood and urine culture

Lumbar puncture: increased WBC, decreased glucose, antigens, cytology, bacterial culture

CT/MRI scan

41
Q

Why should you do CT/MRI scan before a lumbar puncture in a patient with meningitis?

A

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
Q

What would a CT scan of a patient with bacterial meningitis look like?

A

Cerebral oedema with effacement of ventricles and sulci and inflamed meninges

43
Q

What are the symptoms of sinusitis?

A 
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
Q

What would a CT scan of a patient with sinusitis show?

A

Opacification of sinuses as full of infection

45
Q

What is a pseudotumor?

A

Might think patient has tumour due to rise in ICP but none seen in CT.
Completely idiopathic

46
Q

What are the symptoms of pseudotumor cerebri?

A 
Headache
Visual obscurations
Diplopia
Tinnitus
Papilloedema +/- visual field loss
47
Q

What demographic is pseudotumor cerebri most commonly seen in?

A

Young obese women

48
Q

What are the treatments for pseudotumor cerebri?

A

weight loss, diuretics, optic nerve sheath decompression, lumboperitoneal shunt, stenting of stenosed venous sinuses

49
Q

What is a hallmark of a low pressure headache?

A

Orthostatic symptoms because when standing CSF leaks causing pressure drop thus headache

50
Q

What occurs in a low pressure headache and its causes?

A

CSF leak due to tear in dura

Due to traumatic post lumbar puncture or spontaneous

51
Q

What is the treatment for low pressure headaches?

A

Rehydration, caffeine, blood patch (inject blood into epidural space as it acts like a natural glue to patch up tear)

52
Q

How are low pressure headaches diagnosed?

A

MRI scan with contrast injection of gadolinium

53
Q

What is Chiari malformation?

A

Normal brain which sits very low in the skull

The cerebellar tonsils descend through the foramen magnum

54
Q

What type of headache does a chiari malformation cause and why?

A

Cough headache because cerebellar tonsils descend further into foramen magnum when patient coughs which tugs on the meninges

55
Q

What is trigeminal neuralgia?

A

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
Q

What are the treatments for trigeminal neuralgia?

A

Anticonvulsants which dampen pain e.g. carbamazepine, lamotrigine

Posterior fossa decompression

57
Q

Describe the features of atypical facial pain

A

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
Q

Which population is atypical facial pain most common in?

A

Middle aged women

59
Q

What is a post traumatic headache and its mechanisms?

A

A headache which appears after head injury

Multiple mechanisms:
Neck injury
Scalp injury
Vasodilation due to autonomic damage
Depression
60
Q

What treatment can be given to patients with post traumatic headaches?

A

Non-steroidal anti-inflammatories - ibuprofen
Tricyclic antidepressants

These drugs are the least addictive

61
Q

What are the symptoms cervical spondylosis?

A

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
Q

How can cervical spondylosis be managed?

A

Rest, deep heat, massage
Anti-inflammatory analgesics

Over-manipulation may be harmful

63
Q

What is the most common cause of new headaches in older patients and why?

A

Cervical spondylosis due to arthritis wearing out joints

64
Q

What are some of the features of a migraine?

A 
Tendency go repeated attacks
Triggers
Easily hung-over
Visual vertigo
Motion sickness
65
Q

What are the 5 phases of a migraine?

A

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
Q

What are some visual changes seen in aura of a migraine?

A

Positive and negative symptoms together:

  • scintillations
  • blindspot
  • expanding Cs
67
Q

Describe the expanding Cs seen in the aura of a migraine and why they occur

A

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
Q

What treatments can be given to a patient suffering from an acute migraine attack?

A

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
Q

What is erenumab?

A

Injectable drug against migraines.
Reduces frequency of migraines
Monoclonal antibody which disables calcitonin gene related peptide or its receptor (CGRP mAbs)

70
Q

What are tension type headaches?

A

Headaches caused by tight muscles around head and neck

71
Q

What drugs can be given for tension type headaches?

A

NSAIDs e.g. ibuprofen
Paracetamol
Tricyclic antidepressants e.g. amitriptyline

72
Q

What are cluster headaches?

A

Severe unilateral pain lasting 15-180 minutes

Acute headache and then more and more (cluster)

73
Q

What are cluster headaches classified as?

A

Trigeminal autonomic cephalgia as the pain mainly in 1st division of trigeminal nerve

74
Q

What are the symptoms of a cluster headache?

A

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
Q

How do you treat the acute headache of a cluster headache?

A

Inhaled oxygen to inhibit neuronal activation in trigeminocervical complex

S/C or nasal Sumatriptan

76
Q

How do you prevent future headaches (the cluster)?

A

Steroids e.g. prednisolone, verapamil
Anti-epileptics/seizures e.g. valproate, gabapentin, topiramate
Pizotifen

77
Q

Highlight the differences between migraine and cluster headaches

A

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

NEUROLOGY AND NEUROSCIENCE 2 (9 decks)

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