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Neuro > Headache > Flashcards

Headache Flashcards

1
Q

Primary headache

A

Headache and its assocaited features that is the disorder (no underlying disorder) - tension headache, migraine, cluster headache

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2
Q

Secondary headache

A

Secondary to underlying cause e.g subarachnoid haemorrhage, space-occupying lesion, meningitis, temporal arteritis

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3
Q

Red flags from headache history (SNOOP)

A

Systemic symptoms: fever, weight loss

Neurological symptoms

Older age of onset

Onset is acute ( sudden, abrupt)

Previous headache history (worsening, increasing in frequency)

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4
Q

Headache history

A
    1. Age of onset
  2. Prodrome features
  3. .Pain scale
  4. Location and radiation
  5. onset (time to maximum)
  6. periodicity (duration and frequency)
  7. Associated features
  8. Triggers/ relieving factors
  9. FH in 90%
  10. Medication history
  11. Depression
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5
Q

General/systemic features on clinical examination

A
  • reuced conscious level
  • BP/pulse

Pyrexia

meningism

Skin rash

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6
Q

Cranial nerve features on clinical exam

A
  • Pupillary responses, visual fields +/- blind spot, eye movements,
  • fundoscopy
    • III nerve palsy - down and out (drooping eyelid)
    • VI nerve palsy - pulled in (raised ICP)
    • Horners syndrome - small pupil and drooping eyelid
  • Fundoscopy signs
    • optic disc swelling - raised ICP (disc looks like a doughnut)
    • Snuhyloid haemorrhafe (in 20% of SAH)- bleeding into lens
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7
Q

Neurological examination feaures

A

Upper motor neurone signs:

  • Power - Decreased
  • Tone- Increased
  • Reflex- Brisk
  • Fasciculations- absent
  • Muscle wasting- Nil or subtle

LMN

  • Power- Decreased
  • Tone- Decreased
  • Reflex- absent or reduced
  • Fasciculations- Present
  • Muscle wasting- Significant
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8
Q

Features of migrane

A

Females>males -

Most common in 25-55y/o -

Pulsatile/throbbing,

gradual onset, 4h-72hours long. -

60% are unilateral, 20% consistenyly one side

-Pain can change sides, radiate to neck

Scalp tenderness/allodynia.

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9
Q

Associated triggers of migraine

A
  • nausea - 90% -vomitting - 30% - anorexia - food craving
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10
Q

Symptoms of migraine

A

photophobia- fear of bright lights

phonophobia - fear of loud noises

osmophobia - fear of odours

mood changes blurred vision, nasal stuffiness, sweating

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11
Q

Triggers of migraine (CHOCOLATE)

A

Chocolate hangovers orgasms cheese oral contraceptives lie-ins tumult exercise

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12
Q

The four phases of migraine

A
  1. prodrome 2. aura 3. Headache 4. postdrome
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13
Q

Prodrome phase

A
  • 50% have
  • 48hrs before headache
  • variable symptoms
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14
Q

Aura phase

A

-recurrent reversible symptoms (visual, sensory, motor) -

develops 5-20 mins lasts for 60 -

visual aura most common (scotoma, visual field loss, flashing lights)

  • sensory- starts in arms and radiates up arm
  • motor–> rarer weakness most common
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15
Q

Scotoma definition

A

partial loss of vision or blind sopt in an otherwise normal visual field

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16
Q

Headache phase

A
  • character commmonly throbbing/pulsatile -moderate to severe -gradual onset and can last from 4-72 hours -unilateral in 60% radiates to the neck
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17
Q

Postdrome phase

A

depressant effects: impaired concentration, lethargy

elevant effects: euphoria, heightened energy, heightened state of alertnesss

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18
Q

Diagnosis/ Invesitagations of migraine

A

Good history and normal clinical exam does not require further investigations cranial imaging advised if “red flag” symptoms are presnt or aura .24 hours

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19
Q

Complications of migriaine

A
  • Medication overuse headache (MOH): headache 15+ days per month associated with frequent use of acute relief medication e.g. NSAIDs, paracetamol, opoids, triptants -

Patients advised to take acute treatments no more than 2-3 months times per week to prevent MoH

-Chronic miraine: headache on 15 days+ per month

20
Q

Management of migraine

A

Lifestyle: avoid triggers, reduce caffeine and alcohol, encourage regular meals and sleeping patterns

Acute management: simple analgesia –paracetamol, aspirin and NSAIDs. Triptans (sumatriptan)- serotonin agonists which dilate intracranial vessels. +/- antiemetic-domperidone and metoclopramide

Prophylaxis: Beta-blocker, Tricyclic antidepressants, Anti-epilepsy drugs- topiramae and sodium valproate

21
Q

Pathophysiology of migraine

A
  1. Neurovascular disorder- spreading cortical depression leads to increased sensitivity vascular changes. Overallvascular changes secondary to neural activation.
  2. Primary dysfunction in brainstem sensory nuclei (V, VII-X)

3, Pain results from pain sensitive cranial blood vessels and trigeminal fibres that innervate them

22
Q

Features of thunderclap headache

A
  • Abrupt onset of severe headache - reaches maximal intensity within 5 minutes, probably less than a minute. -Feels like being hit over the head). Assumed to be Subarachnoid Haemorrhage until proven otherwise
23
Q

Differential diagnosis of thunderclap headache

A

Venous sinus thrombosis, stroke non-vascular - Spontaneous intracranial hypotension, encephalopathy, meningitis

24
Q

Investigations of thunderclap headache

A

Primary aim is to identifif Subarachnoid haemorrhage

  • Bloods: U&Es, LFTs, glucose, FBC, coagulation screen and CRP
  • Blood cultures if pyrexial
  • 12-lead ECG -

Urgent CT brain: Blood visible in 90% of SAH within 24 hours

-Lumbar puncture: Performed after 12 hours to look for xanthochromia- change in CSF (blood breakdown)

25
Q

Treatment of SAH

A
  • Calcium anatagonists (to reduce vasospasm)
  • colining/clipping of aneurysms
26
Q

Normal ICP

A
  • Contents of skull= Brain, Blood and CSF
  • ICP normally is 7-15mmHg

Monroe-Killie doctrine: any increase in one component results in reduction of the other two

Above 25mmHg, small increases in component volume can cause very marked elevations of ICP

27
Q

Raised ICP problem

A

Cerebral perfusion pressure= the net pressure gradient causing blood to flow into the brain CPP = MAP-ICP

Global brain perfusion is reduced when ICP elevated- hypoxia

Cerebral metabolism is reduced-damage ensues

28
Q

History of raised pressure headaches

A
  • worse in the morning and with cough and bending
  • Vomitting
  • reduced GCS
  • visual disturbance
  • may be neurological symptoms and seizures if tumour
29
Q

Examination findings with Raised ICP

A
  • Optic disc swelling- papilledema on Fundoscopy
  • Impaired visual acuity/ colour vision
  • Restricted visual fields and enlarged blind spot
  • 3rd nerve palsy, 6th nerve palsy or Focal neurological sings

Cushings reflex that leads to cushings response (increased blood pressure, irregular breathing, and a reduction of the heart rate)

30
Q

Causes of raised ICP

A

Mass Effect: Tumour, infarction with oedema, subdural/extradural/intracerebral haematoma, abscess

  • Increased venous pressure: cerebral venous sinus thrombosis, obstruction of jugular venous system
  • Obstruction to CSF flow/absorption: hydrocephalus/meningitis

– Idiopathic: -intracranial hypertension-lose weight

31
Q

Treatment of raised ICP

A
  • mannitol + hyperventilation
  • treat the cause
32
Q

Tension headache History

A
  • \bilateral tight band sensation
  • reccurrent
  • occurs late in day
  • association with stress
33
Q

Examination findings with tension headache

A
  • tension and tenderness in neck and scalp muscles
34
Q

Investigations for tension headache

A
  • Clinical diagnosis and good history
35
Q

Management of tension headaches

A

Simple analgesiacs, avoid triggers

36
Q

Cluster headache history

A
  • short painful attacks around one eye
  • last between 30 minutes - 3 hours
  • occur once/twice a day for 1-3 months
  • may be lacrimation and flushing
37
Q

TCluster headache examination

A
  • conjunctival injection
  • lacrimation
  • swollen eye lid
  • horners syndrome during attack
38
Q

Cluster headache investigations

A

Clinical history enough

39
Q

Definitive management of cluster headache

A

100% oxygen, triptan verapamil may prevent

40
Q

Trigeminal neuralgia history

A
  • 2 second paroxysms of stabbing pain in unilatera trigeminal nerve distribution
  • face screws up with pain
  • triggers (washing, shaving)
  • symptoms of underlying disease (aneurysm, tumour)
41
Q

Examination findings in trigeminal neuralgia

A
  • normal
42
Q

Investigation findings with trigeminal neuralgia

A
  • MRI to find cause
43
Q

Trigeminal neuralgia management

A
  • anti-epileptics - carbamazepine
  • treat cause
44
Q

Temporal arteritis history

A
  • Unilateral throbbing pain
  • scalp tenderness and jaw pain
  • >55 years
  • may be visual problems
45
Q

Temporal arteritis examination

A
  • ipsilateral blindness
  • temporal tenderness
  • optic nerve oedema
46
Q

Temporal artertieis investigations

A
  • ESR raised
  • temporal artery biopsy
  • doppler temporal artery
  • decreased flow
47
Q

Management of temporal arterteritis

A

High dose steroids

Neuro (16 decks)

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