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Neurology > Headache > Flashcards

Headache Flashcards

1
Q

What are primary headaches?

A

Headaches with no underlying medical cause

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2
Q

What are the three main forms of primary headache?

A

Tension Type Headache
Migraine
Cluster Headache

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3
Q

What are secondary headaches?

A

Headaches with an identifiable structural or biochemical cause

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4
Q

What are some secondary headache causes?

A 
Tumour
Meningitis
Vascular disorders
System Infection
head injury
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5
Q

Describe Tension-Type headache

A

Mild, bilateral headache often described as pressing or tightening
No significant associated factors
Not aggravated by routine physical activity
Almost 50% lifetime prevalence in men and women
Not disabling

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6
Q

What is the abortive treatment for tension-type headache?

A

Aspirin/Paracetamol
NSAIDs
Limit to 10 days per month

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7
Q

What is the preventative treatment for tension-type headache?

A

This is rurally required but can consist of tricyclic antidepressants - amitriptyline, dothiepin, nortriptyline

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8
Q

What WHO classification underlines the high impact of migraine?

A

It is listed at number seven of the twenty most disabling conditions

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9
Q

What is the lifetime UK prevalence of migraine?

A

Men - 10%

Women - 22%

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10
Q

What are features of a migraine attack?

A

Headache

Nausea, photophobia, phonophobia, functional disability

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11
Q

What is the generally held principle of migraine?

A

That it arises from a primary brain dysfunction that leads to activation and sensitisation of the trigeminal system

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12
Q

Outline some triggers of migraine

A 
Changes in oestrogen levels
Stress
Hunger
Sleep disturbance
Dehydration
Diet

The brain of a migraine sufferer is said to be hypersensitive to normal stimuli

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13
Q

Describe the phases of onset of migraine

A

The premonitory phase - predictors of the attack that may include mod changes, muscle cramps, yawning

The Aura phase - This inclines focal, reversible neurological symptoms that may precede headache
They are thought to arise from an electrical disturbance known as cortical spreading depression (CSD) - 15-30% of migraines

The headache phase - This can progress through early headache that features mild pain and associated symptoms, to advanced headache which features moderate to severe pain with the more disabling symptoms of migraine

The postdrome phase - the phase of migraine associated symptoms which may continue after the headache phase has resolved for 1 to 2 days

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14
Q

Approximately how many migraine sufferers are affected by aura?

A

One third

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15
Q

What features of aura mean that they can be confused with an ischaemic attack?

A

Loss of function

Sudden onset

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16
Q

What are the criteria for migraine to classified as chronic?

A

Headache on 15 or more days of the month, of which 8 or more must be migraine, for more than 3 months

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17
Q

What can medicine used to combat acute migraine on a regular basis cause?

A

Medicine overuse-induced migraine. Often dramatically improved by cessation of medication

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18
Q

Outline the causes of medication overuse headache

A

Headache present for 15 or more days of the month which has developed or worsened whilst taking a regular symptomatic medication

Particularly in use of triptans, ergots, opiods and combination analgesics >10days/month
Can be in use of simple analgesics for more than 15days per month and in caffeine overuse such as coffee, tea, cola and irn bru

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19
Q

What is the abortive treatment for migraine?

A

Aspirin or NSAIDs
Triptans
Limit to 10 days per month

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20
Q

What is the preventative treatment for migraine?

A

Propranolol, candesartan

Anti-epileptics such as topiramate, valproate and gabapentin

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21
Q

What is often the affect of pregnancy on migraine without aura?

A

It gets better

22
Q

What are some trigeminal autonomic cephalagias?

A

Cluster headache

Paroxysmal hemicrania

SUNCT - short-lasting unilateral neuralgiform headache with conjunctival injection and tearing

SUNA - short-lasting unilateral neuralgiform headache with autonomic symptoms

23
Q

Describe cluster headaches

A

Strictly unilateral attacks of rapid onset that last between 15mins and 3 hours
The pain is extremely severe, often described by mothers as worse than childbirth - patients are restless and agitated
Cessation of the pain occurs rapidly
In 90% of patients alcohol is a precipitating factor in the hour before the onset of the bout

24
Q

How does paroxysmal hemicrania differ from cluster headache?

A

Technically, the only difference is that PH responds completely to indometacin. However, PH is characterised by shorter duration and higher frequency- generally 2-40 attacks per day, and lack of connection with alcohol consumption

25
Q

Describe SUNCT - short-lasting unilateral neuralgiform headache with conjunctival injection and tearing

A

Unilateral orbital, supraorbital or temporal pain that is stabbing or pulsating
Lasts for 10-240 seconds
Often has cutaneous triggers such as wind, cold, touch and chewing
Between 3 and 200 attacks per day

26
Q

Describe trigeminal neuralgia

A

Unilateral maxillary or mandibular division pain - stabbing
Lasts for 5-10 seconds
Attack period 3-200

27
Q

What treatment is available for paroxysmal hemicrania

A

Abortive - none

Prophylaxis - indometacin

28
Q

What abortive treatment is available for SUNCT/SUNA?

A

Abortive - none

Prophylactic - lamotrigine, topiramate, gabapentin, carbamazepine/oxcarbazepine

29
Q

What treatment is available for trigeminal neuralgia?

A

Abortive - none
Prophylactic - carbamazepine, oxcarbazepine
Surgical - glycerol ganglion injection, stereotactic radio surgery, decompressive surgery

30
Q

What preventative treatment is available for cluster headache?

A

High dose verapamil
Lithium
Methysergide
Topiramate

31
Q

Give some associating factors which can suggest a more sinister cause of headaches

A 
Associated head trauma
First or worst headache
Sudden thunderclap onset
New persistent daily headache
change in headache pattern or type
32
Q

Give some red flags indicative of serious secondary headaches

A

New onset headache

New or change in headache - aged over 50, immunosuppression or cancer

Change in frequency, characteristics or associated symptoms

Focal neurological symptoms
Non-focal neurological symptoms
Abnormal neurological examination

Neck stiffness/fever

High pressure

  • worse when lying down
  • wakening the patient up
  • precipitated by physical exam
  • precipatated by valsalva
  • risk factors for cerebral venous sinus thrombosis

Low pressure
-headache caused by sitting/standing up

GCA

  • jaw claudication or visual disturbance
  • prominent or beaded temporal arteries
33
Q

What is the definition of a thunderclap headache?

A

A high intensity headache reaching maximum intensity in less than one minute - the majority peak instantaneously

34
Q

Give some likely differential diagnoses for thunderclap headaches

A

Primary - migraine/primary thunderclap
Subarachnoid haemorrhage
Intracerebral haemorrhage
TIA/stroke

35
Q

What proportion of patients with a thunderclap headache will have a subarachnoid haemorrhage?

A

10%

85% of the SAHs are aneurysmal

36
Q

What are key factors in management of patients who may have a SAH?

A

Never consider them too well, examination is often normal

At the time of the thunderclap headache, they must have a same day hospital assessment to determine cause

CT and LP must be done

37
Q

What is an early treatment for SAH which can save lives if caught?

A

Coiling

38
Q

What is it important to consider in any patient presenting with headache and fever?

A

CNS infection

39
Q

What are the characteristics of meningitis?

A

Nausea with or without vomiting, photo/phonophobia, stiff neck
Look for rash

40
Q

What are the characteristics of encephalitis?

A

Altered mental state or consciousness, focal symptoms or signs, seizures
Look for rash

41
Q

Give some cases of raised intracranial pressure

A 
Glioblastoma multiforme
Cerebral abscess
Venous infarct with focal area of haemorrhage
Meningioma
Hydrocephalus
Pappilloedema
42
Q

What are features suggestive of a space occupying lesion and or raised intracranial pressure?

A

A progressive headache with associated symptoms and signs

Warning signs include headaches waking the patient up, positional changes to headache and focal neurological signs

43
Q

What causes intracranial hypotension?

A

A dural CSF leak that may be spontaneous or iatrogenic

44
Q

How will intracranial hypotension due to a dural CSF least manifest in headache?

A

There will be a clear postural component to the headache, developing or worsening soon after assuming an upright position and lessens or resolves upon lying down
Once the headache becomes chronic it may lose its postural component

45
Q

What is the Ix for suspected intracranial hypotension?

A

MRI brain and spine

46
Q

What it the management for intracranial hypotension?

A

Bed rest, fluids, analgesia, caffeine
I.v. caffeine
Epidural blood patch

47
Q

What is giant cell arteritis?

A

Arteritis of the large arteries in the brain

Should be suspected in any patient over the age of 50 presenting with new headache

48
Q

What are the characteristics of headache and the patient in general that is suffering from giant cell arteritis?

A

Usually diffuse, persistent and may be severe
The patient may be systemically unwell
Specific features include scalp tenderness, jaw claudication and visual disturbance
Prominent, beaded or enlarged temporal arteries may also be present

49
Q

What investigative indicators are suggestive of giant cell arteritis?

A

An elevated ESR - usually more than 50 often much higher
Raised CRP
Raised platelet count

50
Q

What is the immediate management for suspected giant cell arteritis?

A

High dose prednisolone should be started

Temporal artery biopsy arranged

Neurology (42 decks)

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