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Week 13 - neurology > Headache > Flashcards

Headache Flashcards

1
Q

What are the primary headaches?

A
  • Migraine

* Trigeminal autonomic cephalgias

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2
Q

What are the secondary headaches?

A
  • Thunderclap - subarachnoid haemorrhage
  • High pressure headaches - SOL
  • Low pressure headache
  • Neuralgias - vascular compression
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3
Q

Describe what you should ask when taking history of the presenting complaint of headache

A

•Personal history of migraine or tendency
•How many different headache types
•For each headache type:
- age of onset
- chronic headache, episodic, constant or new type of headache
- premonitory symptoms
- onset, time to peak
- progression
•impact, personal concerns, expectations

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4
Q

What should you ask about regarding past medical history of someone presenting with headache?

A
  • Immunosuppression
  • Cancer
  • Foreign travel
  • Cardiac, cerebrovascular, renal, hepatic, psychiatric, gastric disease
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5
Q

Which medication classically causes headache?

A

Nitrates

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6
Q

What should you ask about in a social history of someone presenting with headache?

A
  • Sleep
  • Meals
  • Exercise
  • Caffeine
  • illicit drugs, alcohol
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7
Q

What examinations should you carry out in someone presenting with headache?

A
  • Blood pressure, urine dipstick, pregnancy test, temperature, weight
  • GCS and mental status examination
  • Palpation of the skull, neck, greater occipital nerves, TMJ, temporal arteries, nuchal rigidity?]
  • Eyes: acuity, visual fields, fund, papilloedema, presence or absence of horners/3rd/6th nerve palsy
  • Facial sensation
  • Autonomic features if during an attack
  • Cranial nerves, routine neurological examination
  • Skin exam
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8
Q

What investigations should you consider for a patient presenting with headache?

A
  • Blood pressure
  • ECG
  • Urinalysis
  • Bloods, ESR/CRP for temporal arteritis, UEs, thyroid function
  • CT Brain/MRI brain
  • Lumbar puncture
  • CT angiogram
  • CT venogram
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9
Q

When should you image someone?

A
  • Systemic symptoms
  • Secondary risk factors
  • Seizure
  • Neurological symptoms
  • Onset
  • Older than 50
  • Progression (including a change in attack frequency, nature)
  • Papilloedema
  • Precipitated by cough, exertion, sleep or valsalva
  • If you cannot diagnose a primary headache then image the
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10
Q

When should you lumbar puncture someone with headache?

A
  • Change in nature of headache
  • Systemic symptoms of signs
  • Focal neurological deficit
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11
Q

What is the diagnostic criteria for tension type headache?

A

•At least 10 episodes of headache occurring on <1 day per month on average and:
•Lasting 30 minutes to 7 days
•And at least 2 of the following:
- Bilateral
- mild or moderate intensity
- Not aggravated by routine physical activity such as walking or climbing stairs
- pressing or tightening (non-pulsating) quality
•No vomiting and no more than one of photophobia or phonophobia
•Not better accounted for by another ICHD-3 diagnosis

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12
Q

What is the pathophysiology of migraine?

A
  • Interaction between primary afferent nociceptive neurones, trigeminovascualr system, brainstem, thalamus, hypothalamus and cortex
  • Calcitonin gene related peptide
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13
Q

Describe the ICHD-3 criteria for a diagnosis of migraine

A

•At least 5 attacks and:
•Attacks lasting 4-72 hours
•Headache must have two of the following:
- unilateral
- pulsating
- moderate or severe pain
- aggravation by or causing avoidance of routine physical activity
•During the attack at least one of:
- nausea and/or vomiting
- photophobia and phonophobia
•Not better accounted for by another ICHD-3 diagnosis

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14
Q

What should be determined in the diagnosis of migraine?

A
  • high or low frequency?
  • Episodic or chronic
  • With or without aura
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15
Q

What are the phases of headache?

A
  • Prodrome: hours or days before
  • Aura: 5-60mins
  • Headache 4-72 hours
  • Postdrome 24-48 hours
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16
Q

Describe the prodromal phase of migriane

A
  • Yawning
  • Polyuria
  • Depression/irritability/poor concentration
  • Food cravings
  • Sensitivity to light
  • poor sleep
17
Q

Describe the postdrome phase of migraine

A
  • Depression
  • Euphoria
  • Poor concentration
  • Fatigue
18
Q

Describe the aura phase of migraine

A
  • Can be visual (99%), sensory, language or motor related
  • Evolves
  • Fully reversible
19
Q

What is the acute treatment of migraine?

A
  • Avoid opiates, restrict acute medication to 2 days a week
  • Simple analgesics: aspirin or ibuprofen
  • Triptans: sumatriptan is first choice (gastrically absorbed so won’t work if vomiting)
  • Add antiemetic if persistent vomiting: metoclopramide
  • If no response then try other triptans or triptan and NSAID combination
20
Q

What is the strategy for prophylactic therapy of migraines?

A
  • Lifestyle advice and triggers
  • Identify and treat medication overuse
  • Prophylaxis if 4-5+ disabling headaches per month
  • Use headache diaries
  • For each medication determine efficacy at 3 months, if ineffective went medication and try another
21
Q

What are the prophylaxis options for migraine you could try first?

A
  • Propranolol (beta blocker) start at 20mg bd, target 80mg bd
  • Topiramate (anti-epileptic) start at 15 or 25mg daily, target 50mg bd
  • Amitriptyline (tricyclic anti-depressant) start at 10mg, target 50mg
  • Candesartan (ARB) start at 4mg, target 16mg
  • Flunarazine (selective calcium try blocker)
22
Q

What are the second line prophylaxis options for migraine?

A
  • Onabotulinumtoxin A for chronic migraine >/15 headache days per month, 8 of which are migraine days, MOH previously addressed, failed on at least 3 prophylactics
  • CGRP inhibitors (monoclonal antibodies) once a month
23
Q

What is the diagnostic criteria for cluster headaches?

A

•At least 5 attacks
•Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15-180 minutes
•Either or both of the following:
1. At least one of:
- conjunctival injection and/or lacrimation
- nasal congestion and/or rhinorrhoea
- eyelid oedema
- forehead and facial sweating or flushing
- sensation of fullness in the ear
- miosis and/or ptosis
2. a sense of restlessness or agitation
•Occurring with a frequency between one every other day and 8 per day

24
Q

What is the classical presentation of trigeminal neuralgia?

A
  • Sharp shooting pain
  • Can be triggered by something e.g. chewing
  • MRI shows distorted/compressed trigeminal nerve (superior cerebellar artery)
25
Q

What is the typical history of someone with a raised pressure headache?

A
  • Worse on lying flat, improved on sitting or standing up
  • Worse in the morning
  • Persistent nausea/vomiting
  • Worse on valsalva
  • Worse with physical exertion
  • Transient visual obscurations with change in posture
26
Q

What are the typical examination findings in someone with raised pressure headaches?

A
  • Optic disc swelling - papilloedema
  • Impaired visual acuity/colour vision
  • Restricted visual fields
  • 3rd nerve palsy
  • 6th nerve palsy
  • Focal neurological signs
27
Q

What are the SIGN 107 guidelines for thunderclap headache?

A
  • Treat as a medical emergency
  • No contrast CT asap, preferably within 12 hours of onset
  • If CT is normal, lumbar puncture (oxybilirubin)
28
Q

In someone with a suspected thunderclap headache, with normal CT/lumbar puncture, what other investigations can you carry out?

A
  • MRI

* MRI/CT venogram or angiogram

29
Q

What are the causes of thunderclap headache?

A
  • Subarachnoid haemorrhage approx 15%
  • Intracerebral haemorrhage
  • Arterial dissection
  • Cerebral venous sinus thrombosis
  • Ischaemic stroke
  • Bacterial meningitis
  • Spontaneous intracranial hypotension
  • Pituitary apoplexy

Week 13 - neurology (12 decks)

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