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Neurology > Headache > Flashcards

Headache Flashcards

1
Q

Headache preceding subarachnoid haemorrage?

A

Sentinel headache.

May be due to small bleed from aneurysm

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2
Q

What is the concern with carotid artery dissection?

A

Inflammatory response to heal -> thrombus formation -> thromboembolism -> stroke.

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3
Q

DDx of sudden onset headache?

A 
SAH
Meningitis
Intracerebral haemorrage
Migraine
Primary Sex Related Headache
Reversible cerebral vasospasm
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4
Q

How is SAH distinguished from primary sex related headache?

A

Duration.

SAH ongoing, PSRH 15-20min before diminishing.

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5
Q

What are the important headaches not to miss?

A 
SAH
Meningitis/encephalitis
Subdural haematoma
Space occupying lesion
Giant cell arteritis
Glaucoma
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6
Q

What are the characteristics of subdural haematoma?

A

Slow: hours - day.
Elderley
Anticoagulants
Alcoholics

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7
Q

What are the features of headache due to giant cell arteritis?

A 
Unilateral
Over 50yo
Visual disturbance - amaurosis fugax
Jaw claudication
Temporal tenderness
\+/- general malaise/fatigue
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8
Q

An aneurysm of which is artery is most likely to cause surgical 3rd nerve palsy?

A

Posterior communicating artery

Will generally involve the pupil (diplopia, ptosis, pupil dilation)

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9
Q

What is the commonest cause of 3rd nerve palsy?

A

Microvascular pathology
E.g. smoking, DM, HTN
Decreased blood flow to nerve -> ischaemia.

Often pupil sparing (diplopia, ptosis)

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10
Q

What investigations in suspected SAH?

A

Non-contrast CT

Bloods: FBE, UEC, LFT; coags

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11
Q

Causes SAH?

A

Ruptured cerebral aneurysm (70%)
Ruptured AV malformation (10%)
Undiscovered (!5%)
Rare (5%): spinal av malformation, arterial dissection, tumour, bleeding diathesis).

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12
Q

If CT normal but SAH expected, what is follow up?

A

LP: look for bloodstained CSF that does not clear on 3 consecutive collection tubes.

Looking for xanthochromia (yellow staining due to breakdown of Hb 6-8 h after SAH).

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13
Q

What are overall management priorities in SAH?

A

Monitor: GCS, BP
Symptomatic: pain, nausea, vomiting, raised ICP and hydrocephalus.
Prevent re bleeding: dx and manage cause SAH.

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14
Q

What are the considerations in SAH analgesia?

A

Don’t want to impair conscious state.
Mild opiates
Paracetamol
Simple NSAIDs (although often avoided as decrease platelet clotting).

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15
Q

What BP parameters post SAH?

A

Normotension

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16
Q

What follow up investigations post SAH?

A

CT angiogram

Coag studies

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17
Q

What is normal ICP?

A

10 - 15mmHg

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18
Q

What is ICP directly related to?

A

Volume of the intracranial contents: brain, CSF, blood. (Monro-Kellie doctrine).

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19
Q

What are the causes of raised ICP?

A

Space occupying lesion: tumour, blood clot, abscess
Increased volume normal contents:
-brain e.g. cerebral oedema
-CSF e.g. hydrocephalus
-blood e.g. vasodilation due to hypercapnia from hypoventilation

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20
Q

What are the symptoms of raised ICP?

A 
Headache
Nausea and vomiting
Drowsiness, eventual coma
Papilloedema
Signs of transtentorial herniation
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21
Q

What are the signs of transtentorial herniation?

A

Unilateral dilated pupil (3rd nerve palsy)
Contralateral hemiparesis (midbrain)
Hypertension/bradycardia (Cushing response)
Respiratory failure

22
Q

What is raised ICP treatment?

A
  • Elevation of head to encourage venous return
  • Diuresis to reduce cerebral oedema/extracellular fluid
  • Hyperventilate/avoid hypoventilation (intubate if necessary)
  • Sedate/paralyse
  • Remove mass
  • Drain hydrocephalus
23
Q

Headaches causing meningitic pain?

A
  • SAH

- Meningitis / encephalitis

24
Q

Intracerebral mass causing headache?

A
  • Tumour/abscess

- SDH/ SDE(empyema)

25
Q

What is idiopathic intracranial hypertension?

A
  • Young women
  • Usually overweight
  • ?problem in CSF production / resorption
  • Chronic disorder
  • CNI and CNVI d/o
26
Q

Important features to exclude in idiopathic intracranial hypertension?

A
  • Exclude mass lesion

- Exclude CVST

27
Q

Serious headaches to exclude?

A
  • Meningitic: SAH, meningitis encephalitis
  • Mass: tumour, SDH, SDE
  • Other raised ICP
  • GCA
28
Q

Common non serious headaches?

A
  • Migraine
  • Tension
  • Trigeminal autonomic cephalgias (inc cluster HA)
  • Low CSF pressure HA
  • Cough cephalalgia
  • Primary orgasm HA
  • Trigeminal neuralgia
29
Q

Cluster HA AFx?

A
  • Watery eye
  • Conjunctival haemorrhage
  • Stuffy nose
  • Ptosis
30
Q

Rx cluster HA?

A
  • High flow O2
  • IV Sumatriptan
  • Indomethacin (NSAID)
  • Verapamil (post ECG)
31
Q

Most sensitive test for SAH several weeks post occurrence?

A

MRI

32
Q

Describe pain of trigeminal neuralgia?

A
  • Stimulus sensitivity
  • Agonising stab of electric shock type pain
  • Usually V2/3 (rarely V1)
33
Q

Rx trigeminal neuralgia?

A
  • Carbemazepine

- Pregabalin (less effective)

34
Q

Ix for SAH

A
  • CT

- If Hx suggestive and CT Normal then ==> LP for bilirubin + oxyhaemoglobin >12h from ictus

35
Q

Why is LP deferred 12h post ictus?

A

Allows differentiation of old blood or new (i.e. exclude traumatic tap)

36
Q

CFx of meningitis?

A

-Neck stiffness
-Subacute/acute HA
-Photo/phonophobia
+/-
-Fever
-Rash
-Kernig’s sign
-Confusion/dec GCS / seizures focal signs
TREAT FIRST WHILE Ix DONE

37
Q

Rx meningitis?

A
  • Benzyl penicillin + ceftriaxone

- Often + acyclovir (for herpes encephalitis)

38
Q

Rx tuberculous meningitis?

A
  • Rifampicin
  • Isoniazid
  • Pyrazinamide
  • Ethambutol
39
Q

When should steroids be added to meningitis treatment?

A

Add dexamethasone for:

  • pneumococcal
  • Meningococcal
  • Tuberculous
40
Q

When is brain imaging necessary?

A

Mandatory if: focal signs or decreased GCS, to exclude mass lesions / obstructive hydrocephalus / diffuse brain swelling

41
Q

What are the parameters required pre LP?

A
  • Imaging ok
  • Plt >100
  • INR
42
Q

Ix on LP CSF?

A
  • Measure pressure, cell counts, protein, glucose, blood glucose, culture
  • HSV PCR
43
Q

CFx of mass lesion HA?

A
  • Worse in AM / lying down
  • AM n/v
  • Focal neuro signs
  • Seizure
  • Systemic 1’
  • Prodromal sinusitis / otitis media
44
Q

Ix GCA?

A

-ESR
-CRP
(both)
-Superficial temporal artery Bx (at least 1cm in length)

45
Q

What is malignant HTN with MRI correlate termed?

A

Posterior reversible encephalopathy syndrome (PRES)

46
Q

Dx for consideration in all pts with raised pressure HAs?

A

Cerebral venous sinus thrombosis

47
Q

Mx cerebral venous sinus thrombosis?

A

Treat as for DVT with anticoagulation

48
Q

Ix in CVST?

A
  • MRV or CTV

- Ix for local infection, thrombophilia, malignancy

49
Q

Acute migraine treatments?

A
  • Aspirin / paracetamol / ibuprofen
  • +/- anti emetic
  • strong NSAID
  • Avoid codeine
  • Triptan 5HT1 agonists
  • Parenteral triptan (rizatriptan, sumatriptan,)
50
Q

Consideration in migraine treatments?

A

Overuse of opiates or triptans can cause medication overuse HA (constant HA of varying severity)

51
Q

Migraine prophylaxis? Which in pregnancy?

A
  • B-blocker (not in pregnancy)
  • Pizotifen (not pregnancy)
  • Amitryptylline (safest in pregnancy)
  • Valproate (not pregnancy)
  • Topiramate (slightly safer but only lose doses)

Neurology (38 decks)

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