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Year 2- CNS > Headache > Flashcards

Headache Flashcards

1
Q

What is meant by a primary headache?

A

A headache with no underlying medical cause

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2
Q

What is meant by a secondary headache?

A

A headache with an identifiable structural or biochemical cause

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3
Q

Name some types of primary headache

A

Migraine
Tension type headache
Cluster headache

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4
Q

Name some underlying causes of secondary headache.

A

Tumour
Meningitis
Vascular disorders
Systemic infection
Head injury
Drugs

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5
Q

What is the most common type of secondary headache?>

A

Medicine overdose headache

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6
Q

Describe the pathophysiology of primary headache.

A

Sensitisation of normal pain pathways

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7
Q

Which neuropeptide is released in headaches and can cause worsening of pain and increases headache length?

A

CGRP
(Calcitonin gene related peptide).

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8
Q

What are some of the factors to consider in management of primary headache?

A

Any modifiable lifestyle triggers
Abortive treatment
Transitional treatment
Preventative treatment

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9
Q

In which type of primary headache is modifying lifestyle changes particularly important?

A

Migraines

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10
Q

In which type of primary headache is transitional treatment particularly important?

A

Cluster headaches

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11
Q

If there is concern that a headache may be secondary cause, which investigation may be carried out?

A

MRI is more sensitive but more likely to show incidental findings

-> incidental findings are findings on investigation that were completely unexpected and potentially could lead to further unnecessary investigations

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12
Q

In secondary headaches, which type of investigations can be used to diagnose and guide treatment?

A

CT
CT angiogram

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13
Q

What is the most common type of primary headache?

A

Tension type headache

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14
Q

Describe the presentation of tension type headache.

A

Mild bilateral headache, often pressing or tight feeling.

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15
Q

Acute treatment for tension type headache?

A

Paracetamol, NSAIDs

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16
Q

Preventative treatment for tension type headache?

A

Tricyclic antidepressants e.g. amitriptyline

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17
Q

What are some of the symptoms of a migraine?

A

Headache
Nausea, vomiting
Photophobia
Phonophobia
Functional disability

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18
Q

What are some of the premonitory symptoms of a migraine?

A

Mood changes
Fatigue
Cognitive changes
Muscle pain
Food cravings

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19
Q

What are the symptoms of early headache in migraine and what is the treatment for this stage?

A

Symptoms- dull headache, nasal congestion, muscle pain
Treatment- acute treatment e.g. NSAIDs, paracetamol

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20
Q

What are the symptoms of advanced headache in migraine?

A

Symptoms- unilateral, throbbing, nausea, photophobia, phonophobia, osmophobia

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21
Q

What are the symptoms of the postdrome in migraine?

A

Fatigue
Muscle pain
Cognitive changes

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22
Q

A 44yo male presents with a migraine. He describes his symptoms as causing him to feel sick and needing to lie still in a dark room. What stage of migraine is he likely to be in?

A

Advanced headache

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23
Q

Aura?

A

Transient neurological symptoms resulting from cortical brainstem dysfunction

->affects a third of migraineurs

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24
Q

What may a migraine with aura affect?

A

Visual, sensory, motor or speech issues

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25
Q

What may a migraine with aura be confused with?

A

Transient ischaemic attack

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26
Q

What is the difference between a migraine with aura and a transient ischaemic attack?

A

TIA symptoms have a sudden onset
Aura has slow evolution of symptoms (15-60mins)

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27
Q

Define chronic migraine

A

Headache on 15 or more days/month, of which 8 or more days have to be a migraine for more than three months

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28
Q

What are chronic headaches commonly associated with?

A

Medication overuse

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29
Q

If a chronic migraine is caused by medication overuse, what is often the management?

A

Discontinue medication

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30
Q

Define a medication overuse headache.

A

Headache present on at least 15 days/month which has developed or worsened whilst taking regular symptomatic medication

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31
Q

Use of triptans, ergots, opioids and combination analgesics can cause a MOH. How much would cause a MOH?

A

Use of these drugs more than 10days/month

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32
Q

Use of simple analgesics can cause a MOH. How much would cause a MOH?

A

Use of these more than 15 days/month

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33
Q

Which other type of drug can cause a MOH?

A

Caffeine

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34
Q

What are some of the modifiable lifestyle triggers to try and prevent migraines?

A

Stress
Hunger
Dehydration
Sleep disturbance
Diet
Environment
Changes of oestrogen levels in women

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35
Q

Describe the acute treatment of migraines.

A

-Aspirin or NSAIDs
-Triptans
^(limit to 10 days/month, or two days a week to prevent MOH)

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36
Q

List some options for the prophylactic treatment of migraines.

A

-Propranolol, Candesartan
-Anti-epileptics (topiramate, valproate, but not in child bearing women).
-Tricyclic antidepressants
-Flunarizine
-Botox
-CGRP monoclonal antibodies

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37
Q

Treatment for MOH

A

Prevention better than cure so limit acute treatment to 2days/week

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38
Q

What can happen when there is abrupt withdrawal of overused symptomatic medication?

A

Headaches may get worse for 2-4 weeks.
Need to wait 2 months or longer before knowing if effective

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39
Q

If a women has a headache without aura, what happens in pregnancy?

A

Migraine gets better

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40
Q

If a women has a headache with aura, what happens in pregnancy?

A

Migraine does not change

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41
Q

If a women gets her first migraine during pregnancy, which type of headache is this likely to be?

A

Migraine with aura

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42
Q

Which drug is contraindicated in active migraines with aura in women and why?

A

Combined contraceptive pill as carries small risk of stroke

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43
Q

Which drug should be avoided in the treatment of migraines in women of child bearing age?

A

Anti-epileptics

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44
Q

Treatment of migraine can be more difficult in pregnancy. What are some of the acute options?

A

Paracetamol
NSAIDs- in first two trimesters
Triptans

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45
Q

Treatment of migraine can be more difficult in pregnancy. What are some of the preventative options?

A

Propranolol
Amitriptyline (tricyclic antidepressant)

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46
Q

What is new daily persisting headache?

A

Distinct onset of headache with pain becoming continuous and unremitting for 24hrs

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47
Q

What is a common complication of new daily persistent headache?

A

Medication overdose headache

48
Q

What is important about the diagnosis of new daily persistent headache?

A

It is a diagnosis of exclusion and secondary causes must be actively excluded

49
Q

Neuralgia?

A

An intense burning or stabbing pain, usually brief but severe

50
Q

What usually causes neuralgia?

A

Irritation or damage to a nerve

51
Q

Which type of cranial neuralgia is the most common?

A

Trigeminal neuralgia

52
Q

Which areas of the trigeminal nerve are usually irritated to cause trigeminal neuralgia?

A

Unilateral maxillary or mandibular division

53
Q

Describe the pain experienced in trigeminal neuralgia.

A

Triggered and spontaneous lancinating (stabbing) pain

54
Q

What are some of the cutaneous triggers of trigeminal neuralgia?

A

Wild/cold
Touch
Chewing/brushing teeth

55
Q

What is a common cause of trigeminal neuralgia (pathophysiology)?

A

Vascular compression of trigeminal nerve

-> if an artery is pulsing, every pulse may irritate trigeminal nerve

56
Q

What are some uncommon cause of trigeminal neuralgia (pathophysiology)?

A

MS
Intracranial arteriovenous malformation
Intracranial tumour
Brainstem lesion

57
Q

List some potential medical treatments for trigeminal neuralgia.

A

Carbamazepine
Oxcarbazepine
Lamotrigine
Pregabalin/ gabapentin/ lacosamide
Phenytoin for severe exacerbations

58
Q

List some potential surgical treatments for trigeminal neuralgia.

A

Glycerol ganglion injection
Stereotactic radiosurgery
Microvascular decompression

59
Q

List some trigeminal autonomic cephalalgias.

A

Cluster headache
Paroxysmal headache
SUNCT/ SUNA
Hemicrania Continua

60
Q

What are the similarities between all trigeminal autonomic cephalalgias?

A

Strictly unilateral head pain
Very severe pain
Cranial autonomic symptoms
Restless

61
Q

What are the differences between all trigeminal autonomic cephalalgias?

A

Attack frequency and duration differs

62
Q

List the cranial autonomic symptoms.

A

Conjunctival infection/ lacrimation
Nasal congestion/ rhinorrhoea
Eyelid oedema
Forehead and facial swelling
Miosis/ptosis (Horner’s)

63
Q

In which regions is pain from cluster headaches felt?

A

Mainly orbital and temporal regions

64
Q

Describe the onset of a cluster headache.

A

Strictly unilateral. rapid onset (maximum 9 mins)

65
Q

What is experienced in cluster headaches?

A

Excruciatingly severe pain so patients are restless and agitated during attack

->some have committed suicide as under so much intense pain

66
Q

What are some of the premonitory symptoms of cluster headaches?

A

Tiredness, yawning

67
Q

What are some of the associated symptoms of cluster headaches?

A

Nausea, vomiting, photophobia, phonophobia

68
Q

Describe the pattern of attacks in cluster headaches.

A

‘Cluster’ into bouts typically lasting 1-3 months with a period of remission after, usually a month.

Attacks may differ from 1 every other day to 8 per day.

There can be continuous background pain in remission.

Attacks occur at some time every day/ same time every year.

->loads of info but READ

69
Q

What can trigger a attack during a bout of attacks but not during remission?

A

Alcohol

70
Q

At which point of the day is it common to get a cluster headache?

A

Very early in the morning, during REM sleep

71
Q

List some of the abortive treatments used in cluster headaches.

A

Triptans- injections as oral unlikely to help
Oxygen

72
Q

In terms of triptans as an abortive treatment of cluster headaches, medication overdose cannot occur. However, why can only two doses a day be taken?

A

Any more increases risk of myocardial ischaemia

73
Q

What are some of the transitional treatment options for cluster headaches?

A

Oral prednisolone taper
Greater occipital nerve block

74
Q

What are some of the preventative treatment options for cluster headaches?

A

Verapamil
Lithium
Topiramate
Gabapentin
Pregabalin
Sodium Valproate
Levetiracetam
Melatonin

75
Q

Which drug type should verapamil not be given alongside to treat cluster headaches?

A

Never at same time as beta blocker as increased risk of heart block

Those taking verapamil require ECG monitoring

76
Q

The frequency of attack can help to differentiate between different trigeminal autonomic cephalgia’s.
How many times, per day, may a cluster headache occur?

A

1-8 x / day

77
Q

The frequency of attack can help to differentiate between different trigeminal autonomic cephalgia’s.
How many times, per day, may paroxysmal hemicrania occur?

A

1-40 x / day

78
Q

The frequency of attack can help to differentiate between different trigeminal autonomic cephalgia’s.
How many times, per day, may SUNCT occur?

A

3-200 x / day

so daily attack frequency SUNCT > Paroxysmal Hemicrania > Cluster Headache

79
Q

In which type of trigeminal autonomic cephalalgias is the duration of attack the-
1. Longest
2. Shortest

A
  1. Longest= cluster headache, 15-180 mins
  2. Shortest= SUNCT 2-240 secs
80
Q

Describe the pain felt in cluster headaches and paroxysmal hemicrania.

A

Sharp and throbbing

81
Q

Describe the pain felt in SUNCT.

A

Stabbing and burning

82
Q

What is the only NSAID which works for paroxysmal hemicrania and hemicrania continua?

A

Indometacin

83
Q

Indomethacin is a NSAID and works on COX-1 and COX-2 receptors, like other NSAIDs. However, it does not work through these receptors in paroxysmal hemicrania. What does it act on instead?

A

Nitric oxide

84
Q

Paroxysmal hemicrania is very similar to cluster headaches in terms of pain, rapid onset and offset. How does it differ?

A

More frequent and shorter than cluster headaches.
Pain still felt in unilateral orbital and temporal areas

85
Q

Describe pain felt in SUNCT.

A

Unilateral orbital, supraorbital or temporal region
Stabbing or pulsating pain

86
Q

What are some of the triggers of SUNCT?

A

Wind, cold
Touch
Chewing

87
Q

How long does SUNCT last?

A

10-240 second duration

88
Q

List some of the medical treatment options for SUNCT/SUNA.

A

Lamotrigine
Topiramate
Oxcarbazeprine
Carnazeprine
Duloxetine
pregabalin/gabapentin

89
Q

What is a transitional treatment for SUNCT/SUNA?

A

GON block (greater occipital nerve)

90
Q

What are some surgical options for treatment for SUNCT/SUNA?

A

Occipital nerve stimulation
Deep brain stimulation

91
Q

Which features would predict a more serious type of headache?

A

More likely to have a sinister cause:
-Head injury
-First or worst
-Sudden, thunderclap onset
-New daily persistent headache
-Change in headache pattern or type
-Returning patient

92
Q

List some red flags which should make us consider secondary headache.

A

New onset headache, without preceding history
New or change in headache
Aged over 50
Immunosuppression or cancer
Neck stiffness
Fever
High/LOW PRESSURE
GCA- giant cell arteritis

93
Q

What is a thunderclap headache?

A

A high intensity headache reaching maximum intensity in less than a minute

94
Q

What must be considered if a patient presents with a thunderclap headache?

A

Subarachnoid haemorrhage

95
Q

What is a subarachnoid haemorrhage?

A

Aneurysmal rupture and bleeding into subarachnoid space

96
Q

What are some complications of a subarachnoid haemorrhage?

A

Vasospasm
Hydrocephalus
Seizure
Infection
Re-bleeding

->those who rebleed have high mortality rate

97
Q

Which investigations should be done if subarachnoid is suspected?

A

CT Head asap
Lumbar puncture

98
Q

When should a lumbar puncture be carried out in someone with suspected subarachnoid haemorrhage?

A

12 hours after headache onset to allow blood breakdown products to develop

99
Q

Which investigation should be carried out after conformation of subarachnoid haemorrhage.

A

CT angiogram

100
Q

What is the treatment of a subarachnoid haemorrhage?

A

Early treatment essential, clipping of aneurysm

Nimodipine ( type of Ca channel blocker for vasospasm)

HHH treatment- hydration, hyperoxia, hypertension- keep high hydration, BP and oxygen levels

101
Q

What can cause high pressure in brain?

A

Tumour/ brain occupying lesion
Brain swelling

102
Q

What are some symptoms suggestive of a high pressure headache?

A

Headache wakes patient up
Cough
Visual obscurations/pulsatile tinnitus
Seizures
Progressive focal symptoms
Cognitive change or drowsiness

103
Q

What are some signs suggestive of a high pressure headache?

A

Papilledema
New abnormal neuro examination

104
Q

What is the clinical presentation of intracranial hypertension?

A

Progressive episodic or persistent headache
Visual obscuration’s and/or pulsatile tinnitus
Papilledema, often with enlarged blind spot

105
Q

What is the commonest cause of intracranial hypotension?

A

Lumbar puncture

106
Q

What name is given to a headache which develops or worsens soon after assuming an upright position and lessens shortly after lying down?

A

Postural headache

107
Q

What would be seen on MRI in someone with intracranial hypotension?

A

Less CSF, more blood so venous engorgement
Subdural hygromas (increased space between skull and brain)

108
Q

What is the treatment for intracranial hypotension?

A

Bed rest, fluids, analgesia, caffeine
IV caffeine
Epidural blood test

109
Q

When is a high pressure headache worse?

A

When lying flat

110
Q

When is a low pressure headache worse?

A

When standing upright

111
Q

What is giant cell arteritis?

A

Inflammation of large arteries

112
Q

Headache is a non-specific feature of giant cell arteritis. What are some specific features?

A

Scalp tenderness
Jaw claudication
Visual disturbances
Systemically unwell
Enlarged temporal arteries may be present

113
Q

What is the treatment of giant cell arteritis?

A

High dose prednisolone

114
Q

Which blood tests supports diagnosis of giant cell arteritis?

A

Elevated ESR

->Raised CRP and platelet count are other useful markers

115
Q
A

Year 2- CNS (49 decks)

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