Headache Flashcards
Meningism definition:
- Irritation of the meninges
Meningsm: clinical signs (3)
- Headaches
- Neck stiffness
- Photophobia
Kernig’s sign
- Test for?
- Positive test if???
- Test for meningism
- inability to straighten the leg where the hip is flexed to 90 degrees
Brudzinski’s sign:
- Tests for what?
- Positive test if?
- Meningism
- Patient’s hips and knees to flex when the neck is flexed
Encephalitis definition:
- Inflammation of the brain parenchyma
Encephalitis symptoms:
- Specific symptoms (3)
- General symptoms
- Personality/behavioural changes
- Seizures
- Focal neurological deficit (body function issues)
- Fever, headache, confusion
Causes of viral encephalitis: (3)
H
E
T
- HSV
- Enteroviruses
- travel related viruses
Meningitis definition:
- Inflammation of the meninges
Causes of meningitis: (2)
- Neissera meningitidis
- Streptococcus pneumoniae
Meningitis symptoms:
- Specific (4)
- General
- Rash
- Neck stiffness
- Vomiting
- Shock
- Fever, headache, confusion
Cerebral abscess definition:
- Focal collection within the brain parenchyma, which can arise as a complication of a variety of infections, trauma, or surgery
Cerebral abscess: symptoms
H
S
F
C
F N
- Headache
- Seizures
- Fever
- Confusion
- Focal neurology
Cerebral abscess: causes (2)
- Staphylococcus aureus
- Streptococcus spp
Cerebral malaria: definition
- Severe form of P.falciparum malaria that causes cerebral manifestations
Cerebral malaria: symptoms
F
H
G M
GI
R C
S
- Fever
- Headache
- General malaise
- GI symptoms in children
- Reduced consciousness
- Seizures
Cerebral malaria: causes
- P. falciparum (parasite) transmitted following bite from infected female anophele’s mosquito
Features of severe malaria:
H
A
S B
P O
S
- Hypoglycaemia
- Acidosis
- Spontaneous bleeding
- Pulmonary oedema
- Shock
Clinical features of headache due to sinusitis:
- Pain
- At least 2 of these N…. symptoms
- Frontal Headache
- At least two of these nasal symptoms:
1. Nasal blockage
2. Rhinorrhoea/discharge
3. Loss of smell
4. Facial pressure/tenderness
Imaging modalities for cranial infections: (2)
- CT scan for head
- MRI for brain
Microbiological investigations for diagnosis of cerebral infections: (3)
- Blood cultures (prior to antibiotics)
- Bacterial and viral throat swabs
- CSF (if safe)
Microbiological investigations for:
- Meningococcal
- Enterovirus
- Meningococcal: blood
- Enterovirus: pneumococcal PCR stool
What to do if meningococcal infection is suspected?: (3)
- MEDICAL EMERGENCY
- Treatment required before results of investigation
- Immediately administer benzylpenicillin or ceftriaxone
What to do if HSV Encephalitis is suspected?:
- Drug : IV A…
- NEUROLOGICAL EMERGENCY
- Requires treatment before results of investigation
- Administer IV Aciclovor 10mg/Kg TDS for 14-21 days
What factors enhance Antibiotic CSF entry?: (3)
- High lipid solubility
- Low molecular weight
- Low protein binding
Which antibiotics cannot pass the blood brain barrier?: (2)
T
A
- Tetracyclins
- Aminoglycosides
Arterial supply: what does the Internal carotid artery supply
- Anterior circulation of the brain
Arterial supply: What does the Vertibrobasilar artery supply?
- Posterior circulation of the brain
Arterial supply: what is the role of the circle of willis?
- Anastomosis of ICA and basilar artery
What is the basic venous drainage of the brain?
- Blood from veins drains into venous sinuses and eventually into the internal jugular vein
Munro-Kellie Doctrine’s Hypothesis:
- The skull is a rigid box containing blood, brain and CSF. If volume of any of these increases so does ICP
Causes of increased ICP: (4)
- Space occupying lesions
- Cerebral oedema
- Intracranial haematoma
- Obstruction of CSF drainage
Cerebral Perfusion Pressure (CPP):
- The net pressure gradient that drives oxygen to cerebral tissue
Relation of CPP, MAP, and ICP:
- CPP = MAP - ICP
What can cause a catastrophic decrease in Cerebral Perfusion Pressure?:
- A pathological increase in ICP and/or a pathological fall in MAP can lead to decreased CPP
How does hypoxia cause loss of consciousness and neuronal death?:
- A fall in CPP can result in cerebral ischaemia and eventually neuronal death
- Hypoxia = loss oxygen in blood, so decreased CPP
Effect of hypocapnia on cerebral resistance:
- Hypocapnia -> cerebral vasoconstriction -> increased cerebral resistance
Effect of hypercapnia on cerebral resistance:
- Hypercapnia -> cerebral vasodilation -> decreased cerebral resistance
Metabolic hyperaemia:
- Definition
- Relation to cerebral metabolic rate
- The process by which the body adjusts blood flow to meet the metabolic needs of different tissues
- Increased cerebral metabolic -> increased cerebral blood flow
Cerebral autoregulation in CPP maintenance
- Regular ranges of MAP
- CBF remains fairly constant
Sympathetic innervation in vascular headaches:
- Ascends from ..
- Innervates and causes
- Reason for this ???
- Ascend from superior cervical ganglion
- Innervation of arteries on brain surface, causing cerebral vasoconstriction in response to sudden increase in MAP
- Protects smaller downstream vessels from sudden surge in pressure
Sympathetic innervation and migraines:
- Decreasing neuronal activity in cerebral cortex
Blood Brain Barrier (BBB): descriotion
- A highly selective permeable barrier between capillary blood and ECF in the CNS
BBB structure:
- Endothelial
- Astrocytes
- Formed by tight junctions between capillary endothelial cells
- Astrocytes regulate permeability
BBB role:
- Protects brain against harmful molecules and organisms
Diseases that disrupt the BBB: Eclampsia
- Eclampsia:
Increase in BBB permeability -> cerebral oedema
Diseases that disrupt the BBB: Meningitis
- Meningitis
Makes BBB more permeable to toxins and some antibiotics
Diseases that disrupt the BBB: HIV virus
- Crosses barrier to hide in monocytes and causes encephalitis
Cerebral vein thrombosis:
- Presence of a blood clot in the dural venous sinuses or/ and the cerebral veins
Optic lesions: location and effect
- Optic nerve
- Optic nerve -> right/left anopsia (blind)
Optic lesions: location and effect
- Optic chiasm
- Optic chiasm -> bitemporal hemianopsia
Optic lesions: location and effect
- Optic tract
- Optic tract -> homonyous hemianopsia (same sided 1/2 blind)
Damage to optic radiation fibres: location and effect
- Temporal lobe -> upper quadrantanopia
Direct light reflex:
- Ipsilateral pupil constricts (same side of body as stimulus)
Consensual light reflex:
- Contralateral pupil constricts (opposite side of body as stimulus)
Pathway of light reflex:
- Stimulus causes optic nerve to send signal to occulomotor nerve
Cerebrospinal fluid (CSF) production:
- Choroid plexus mainly in the lateral ventricles
- 500 mls per day
Blood-CSF barrier structure:
- Capillary endothelial cells joined by tight junctions to form blood-CSF barrier
Metabolic function of CSF: (3)
- Helps maintain a constant environment for brain cell
- Drains unwanted metabolites in to venous blood
- Transports hormones around the brain
Intracranial idiopathic hypertension:
- Cause
- Exacerbating factors?
- Signs?
- Treatment
- Unknown
- Coughing, and sneezing
- Headache, Papilloedema
- Refer to neurologist, CT/MRI to exclude other ICP issues
Hydrocephalus:
- Accumulation of CSF in ventricles in the brain, resulting in increased ICP
Non-communicating hydrocephalus:
- A blockage within ventricles (between interventricular foramina and median aperture)
Communicating hydrocephalus:
- Failure to drain CSF via arachnoid granulations
Features of a headache due to raised ICP: (7)
H
V D
S
D L
A P
C R
- Headache, worse in morning
- Nausea and vomiting
- Visual disturbances
- Seizure
- Decreased level of consciousness
- Abnormal posturing
- Cushing response
Coup and contracoup pattern injuries:
- Coup: brain collides with part of skull that has collided with object
- Contracoup: bran rebounds and collides with side of skull opposite to trauma
How to spot papilloedema?:
- Retinal disc is much blurrier
Temporal lobe herniation:
- Herniates where?
- Causes (2)
- Herniation of part of the temporal lobe over the tentorium cerebelli
- Causes ipsilateral CN III palsy and blown pupil
Uncal herniation:
- Temporal lobe herbiates over the tentorium cerebelli
- Causing ipsilateral CN III palsy and blow pupil
Cerebellar tonsil herniation:
- Down through the foramen magnum, can be rapidly fatal (DO NOT LUMBAR PUNCTURE)
Decorticate positioning:
- indication
- What is it?
- GCS
- Damage to….
- Indicates severe brain injury
- Flexor response spontaneously or in response to pain
- GCS: M3
- Damage to upper pons
Decerebrate positioning:
- indication
- What is it?
- GCS
- Damage to….
- Severe brain injury
- Extensor response spontaneously or in response to pain
- GCS: M2
- Damage to upper pons
Cushing response/reflex:
- Attempts to raise MAP to increase CPP and CBF
- Triggered by brainstem ischaemia due to +ICP
- ## Indicates death may be imminent unless ICP reduced
Acute subdural haematoma:
- Location
- Mechanism
- Source
- Shape
- Presentation
- Between the dura and arachnoid
- Trauma
- Venous (bridging veins)
- Crescent, hyperdense
- May be insidious
Extradural haematoma:
- Location
- Mechanism
- Source
- Shape
- Between the dura and the bone
- Fracture
- Arterial, active bleeding
- Bi-convex
Contusion:
- Description
- Location
- Shape
- Bruising of parenchymal brain tissue
- Often frontal pole
- Wedge shaped, hyperdense
For CT scans of the brain:
- Dark structures
- Brighter structures
- Dark = hypodense
- Brighter = Hyperdense
Epidural definition:
- Bleed between skull and dura mater, expands rapidly
Subdural definition:
- Bleed between dura mater and arachnoid mater expands slowly
Incidentaloma:
- A radiological neologism to denote a lesion found incidentally and of dubious clinical significance
Sacular (berry) aneurysm:
- Weakness in the wall of a cerebral artery or vein causes a localised dilation of the blood vessel
Charcot-Bouchard aneurysm:
- Microaneurysms in the brain that occur in small penetrating blood vessels
- Cause hypertensive haemorrhages
- Diameter less than 300 micrometers
Intraparenchymal haemorrhage:
- definition
- Mechanism
- Presentations
- Source
- Appearance
- Bleeding inside the brain
- High BP, arteriovenous malformation, tumour trauma etc
- Acute (nausea, headaches, vomiting)
- Arterial or venous
- Typically rounded bleed
Subarachnoid haemorrhage:
- Mechanism
- Presentations
- Source
- Appearance
- bleeding between the arachnoid and pia mater
- Rupture of aneurysms, arteriovenous malformations or trauma
- Acute (worst headache of life)
- Predominantly arterial
- White area that tracks along sulci and fissures
Subdural Haemorrhage:
- Mechanism
- Cause
- Presentations
- Source
- Bleed between dura and pia mater
- Trauma
- Insidious (worsening headache)
- Bridging veins
Acute subdural haemorrhage:
- Time
- Imaging
- Developed over 72 hours
- Hyperdense crescent/banana shape
Chronic subdural haemorrhage:
- Time
- Imaging
- Develop over the course of weeks
- Hypodense crescent/banana shape
Epidural Haematoma:
- Mechanism
- Presentations
- Source
- Imaging
- Bleed between the dura mater and the skull
- Trauma or after surgery
- Skull fracture, altered mental status
- Arterial
- Convex/lemon shape collection of blood
Epidemiology of patients presenting with headache:
- Primary
- Secondary
- All headache presents to primary care
- Serious cases referred to secondary care, 2 week cancer referral
Benign thunderclap headache:
- Character
- Association
- Diagnosis
- Sudden onset headache (<1minute), Maximum intensity
- Associated with subarachnoid haemorrhage
- Diagnosis of exclusion
Migraine:
- Symptoms
- Duration
- Prevalence
- Bad headache, nausea, photophobia, phonophobia, osmophobia
- 3-72 hrs
- women>men
Cluster headache:
- Description
- Duration
- Unilateral …..
- Behaviour
- Timing
- Gender prevalence
- Severe side locked headache
- 30-90 mins
- Unilateral (red eye, tearing, nasal stuffiness)
- Pacing behaviour
- Circadian, circannual
- Men>women
Temporal (Giant cell) Arteritis:
- Age range
- Symptoms
- Signs
- Treatment
- Over 50 yrs
- Tender scalp, thick temporal arteries, fever, blindness
- Retinopathy, Raised inflammatory markers
- Steroids and biopsy ASAP
Acute glaucoma:
- Increased occular pressure
- Eye pain, rock hard eye, blurred vision, mid dilated pupil, vomiting
Sinusitis:
- Description
- Symptoms
- Risks
- Inflammated airway sinuses
- Nasal discharge, Facial pain/pressure, frontal headache
- Sphenoid sinusitis can be dangerous
Tension headache:
- Description
- Prevalence
- mild, featureless headache, Band around head
- most common
Analgesic headache:
- Cause
- How to avoid (2)
- Caused by pain killers, e.g. opiates can turn migraines into chronic dull headaches
- Avoid paracetamol/NSAIDS for 15 days/month
- Avoid opiates/compound analgesics/triptans more than 10 days/month
Trigeminal neuralgia:
- Cause
- Symptoms
- Duration
- Occurs in old people, skin sags, causing blood vessel to rub on the trigeminal nerve roots
- Severe, unilateral, electric pain. Cheek + jaw > forehead
- Usually less than 2 mins
High ICP causing headache:
- High ICP stretches the dura, causing pain
Low ICP causing headache:
- Low ICP stretches nerves and blood vessels causing pain
Carbon monoxide poisoning in headache:
- Symptoms
- Index of suspicion
- Consequence
- low level CO poisoning can cause headache, fatigue, confusion
- High index of suspicion, esp. when multiple people
- Multiple deaths can occur if missed
Subarachnoid Haemorrhage (SAH): symptoms (4)
- SUDDEN ONSET (thunderclap) that persists
- Neck stiffness
- Altered consciousness
- Photophobia
Subarachnoid haemorrhage (SAH): clinical features (2)
- Main cause
- Tests
- Aneurysm in 77%
- CT, LP after 12 hrs
SAH grading: grade 1
- State of consciousness
- Symptoms (2)
- Mistaken for ..,
- Alert
- mild headache
- stiff neck
- mistaken for benign thunderclap
SAH: grade 2
- State of consciousness
- Symptoms (3)
- Alert
- Vision problems
- Moderate to severe headache
- Stiff neck
SAH grades: grade 3
- Consciousness
- Symptom
- Lethargy/confusion
- Weakness or partial paralysis on one side of body
SAH grades: grade 4
- Consciousness
- Symptoms
- Stupor
- Moderate to severe paralysis on one side of body
SAH grades: grade 5
- Comatose
Acute meningitis: clinical signs
H
F
N
R
C
F N
- Headache
- FEVER
- Neck stiffness
- Rash
- Confusion
- Focal Neurological signs
Chronic meningitis clinical signs: (3)
C N …
R
I E
- Cranial nerve palsy
- Radiculopathy
- Ischaemic events
Chronic meningitis causes: (3)
I
M
A
- Infection: TB, lyme, fungal
- Malignant
- Autoimmune: sarcoidosis, behcet’s syndrome
Low pressure headaches: causes (3)
- Iatrogenic: post trauma, post LP
- Lesional
- Postural/diural
Low pressure headache: treatment
- Seal the leak of CSF
Harmless headaches:
- Duration
- Occurence
- Location
- Long duration
- Most are episodic
- Many lateralised
What is tested in a lumbar puncture?: (5)
O
M & C
V
P
G
- Opening pressure
- Microscopy and culture
- Viruses (PCR)
- Protein
- Glucose (paired serum)
Diagnostic use of lumbar puncture:
Used for suspected ……. (4)
- neurological infection
- Subarachnoid haemorrhage
- Neuroinflammatory disease
- CNS malignancy
Therapeutic use of lumbar puncture: (2)
- Lowers ICP in people with idiopathic intracranial hypertension
- Intrathecal administration of drugs e.g. methotrexate
Contraindications of lumbar puncture:
intracranial imaging (what may cause you to scan before LP?)
- Examples (5)
CT or MRI used prior to LP especially if:
* Altered mental state (reduced GCS or fluctuating conscious level)
* Papilloedema
* Headache (suggestive of raised ICP)
* Focal neurological signs
* Recent seizure
Complications of lumbar punctures and how to prevent them:
Headache
Pain
Bleeding
Infection
Spinal damage
Cerebral herniation
- Post LP headache (atraumatic needles)
- Pain (local anaesthesia)
- Bleeding (check clotting, anticoagulants/platelets)
- Infection (aseptic technique)
- Spinal damage
- Cerebral herniation (Avoid raised ICP)
Anatomical landmarks for a lumbar puncture:
- Key positioning
- Key layers
- Left lateral position, LP needle L3/4
- Ligamentum flavum (pop), subarachnoid space (CSF)
Visual appearance of CSF:
- Healthy
- Clear and colourless
Investigation of idiopathic intracranial hypertension:
- Diagnosis
- Diagnosis of exclusion - other causes need to be sought with history, imaging and CSF
Idiopathic intracranial hypertension: symptoms (4)
- Raised pressure headache
- Pulsatile tinnitus
- Visual loss
- Diplopia
Idiopathic intracranial hypertension: signs (3)
- Papilloedema
- VF defect and 6th palsy
- LP shows a raised opening pressure (>25cm H20)
LP as a therapeutic treatment for idiopathic intracranial hypertension:
- CSF drained to a closing pressure of less than 20 cm H20
- Aim is the preservation of vision/alleviation of symptoms
Multiple sclerosis:
- Damage to insulating cover of nerve cells of brain and spinal cord
Diagnosis of MS: (1 of 3)
- Clinical presentations alone (2 or more relapse/signs)
- Clinical presentations & MRI
- Clinical presentation and CSF (+/-MRI)
How to test for MS in CSF: (2)
- Electrophoresis
- CSF
- Oligoclonal bands of IgG on electrophoresis
- Posistive if proteins present in CSF not serum
Use of CSF in bacterial meningitis:
- Identification of pathogen allows for tailoring of antimicrobial therapy
Diagnostic sign of viral meningitis in CSF:
- CSF clear with high White cell count
CSF positive test for subarachnoid haemorrhage: (2)
- RBC must be high in all tubes to distinguish from trauma
- Xanthochromia (presence of bilirubin)
LP not performed in suspected SAH if: (2)
- CT Positive
- CT negative within 6hrs onset + low index of suspicion
Definition of domestic violence and abuse:
Any incidents or pattern of incidents of controlling, coercive, threatening behaviour, violence or abuse between those aged 16 or over who are or have been intimate partners or family members regardless of gender or sexuality
Types of headache associated with domestic violence: (3)
- Tension headache
- Migraine headache
- Traumatic brain injury
Response to headache and current domestic violence: (4)
- Enquire about immediate safety
- Refer to specialist domestic violence service
- Tackle underlying stress
- Follow up
Response to headache and past domestic violence:
- Enquire about safety
- Tackle underlying stress
- Follow up
Questions to identify domestic violence during history taking: (3)
- How are things at home?
- Is that something that might be affecting you?
- Could that be something that’s…..
Treatment of migraine - step1: over the counter analgesics (2)
- Paracetamol: inhibits central prostaglandin production
- NSAIDS: inhibition of prostaglandin synthesis on COX-1/2 enzymes
Treatment of migraines - step 2: Triptans (5-HT1B agonist)
- Stimulation of 5-HT1B receptors on smooth muscle cells causes cranial vasoconstriction, relieving migraine
Treatment of migraines - step 2: triptans (5-HT1D agonist)
- Stimulation of 5-HT1D receptors blocks the release of vasoactive peptides from
the trigeminal nerve, which convey nociceptive information to the thalamus
Triptan effectiveness:
- Tension
- Migraines
- Not effective for tension headaches
- Not a cure for migraines
Migraine treatment - Step 3:
- Triptans + NSAIDs
Prophylaxis of migraines: Tricyclic antidepressants (2)
- Inhibits reuptake of Noradrenaline and 5-HT (serotonin)
- NMDA receptor antagonist
Tricyclic antidepressants: examples (2)
Amit….
Desip….
- Amitriptyline
- Desipramine
Prophylaxis of migraines: topiramate
- Blocks ….
- Inhibits ….
- Enhances ….
- Inhibits …
- Blocks voltage-dependant na+ and K+
- Inhibits excitatory glutamate pathway
- Enhances inhibitory effects of GABA
- Inhibits carbonic anhydrase
Prophylaxis of migraines: Candesartan
- Role
- Action
- Angiotensin II type 1 receptor antagonist
- Inhibits vasoconstriction by blocking AT1 receptors in smooth muscle
Prophylaxis of migraines: propanolol
- Action
- Beta blocker
Treatment of tension type headaches: (2)
- Analgesics
-TCA’s
Acute treatment of cluster headaches: (2)
- Oxygen
- Triptans
Preventative treatment of cluster headaches:
- Ca
- C
- L C
- Calcium channel blockers
- Corticosteroids
- Lithium carbonate
Classification of rebound headache (med overuse): (3)
- Headache occurs 15 or more days a month
- Overuse for more than 3 months (10+ days a month)
- Marked worsening of headache during overuse
Pathophysiology of rebound headache: (3)
G
R & E
P
- Genetic disposition
- Receptor and enzyme physiology regulation
- Physical dependency
Incidence and significance of brain tumours:
- New cases per year
- Deaths per year
- Survival rate
- Preventable %
- Child population
- 12,000 +
- 5,000+
- 12% survive
- 3%
- 2nd most
Primary brain tumours:
- Defintion
- Examples of cells (5)
A
O
C P
E
N
- Intrinsic, originates from cell types native to the brain
- Astrocytes, oligodendrocytes, choroid plexus, ependymal cells, neurons
Secondary brain tumours:
- Metastatic, derived from cell that have spread from elsewhere in the body
Most common primary tumours in:
- Adults
- children (0-14) & (15-19)
- Meningioma
- Pilocytic astocytoma (0-14)
- Pituitary (15-19)
General brain cancer symptoms: (4)
- H
- S
- C
- N
- Headaches
- Seizures
- Cognitive decline
- Nausea
Symptoms for frontal brain mass: (3)
P
I
L
- Personality/behaviour/emotional changes
- Impaired judgement
- Loss of vision
Symptoms for temporal brain mass: (4)
P
A
C P S
M
- Personality changes
- Auditory hallucinations
- Complex partial seizures
- Memory difficulties
Symptoms for occipital brain mass: (2)
- Visual loss
- Visual hallucinations
Symptoms for parietal brain mass: (4)
- Receptive aphasia (L)
- Spatial disorientation (R)
- Impaired speech
- Lack of recognition
Symptoms of brainstem mass: (5)
- Difficulty speaking or swallowing
- Drowsiness
- Headache
- Hearing loss
- Unilateral facial muscle weakness
Brain biopsy:
- Removal of a small sample of brain tissue for neuropathological examination to establish a diagnosis
Common primary sources for secondary brain tumours: (6)
- Lungs
- Breasts
- Colon
- Melanoma
- Kidney
- Choriocarcinoma
Size classifications of pituitary tumours: Ring enhancements
- Ragged ring
- Smooth ring
- C shaped
Which brain cancers are?: ragged ring (2)
- Glioblastoma
- Metastasis
What brain cancer type is a smooth ring?:
- Abcess
Which brain cancer type is C shaped?:
- Demyelination in MS
Which brain cancer types have a cyst with a nodule?: (3)
p a
H
G
- pilocytic astrocytoma
- Haemangioblastoma
- Ganglioma
ALL IN CEREBELLUM
Brain cancer types with solid enhancements: (3)
M
S
C
- Meningioma
- Schwannoma
- CNS lymphoma
Infiltrative brain tumour:
- Astrocytoma
