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Systems Nervous System > Headache > Flashcards

Headache Flashcards

1
Q

What are examples of primary causes of headaches?

A

Tension type headache

Migraine

Cluster headache

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2
Q

What is a secondary causes of headache?

A

Definable or structural biochemical cause

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3
Q

What are examples of secondary headaches?

A

Tumour

Meningitis

Vascular disorders

Systemic infection

Head injury

Drug-induced

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4
Q

What is the most frequenct primary headache?

A

Tension type

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5
Q

What are the features of tension type headaches?

A

Not disabling

Rarely presents to doctors

Mild

Bilateral

Pressing or tightening in quality

No significant associated features

Not aggravated by routine physical activity

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6
Q

What is abortive treatment for tension type headache?

A

–Aspirin or paracetamol

–NSAIDs

–Limit to 10 days per month (~2 days per week) to avoid the development of medication overuse headache

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7
Q

What is the preventative treatment for tension type headache?

A

Rarely required

Tricyclic antidepressants

•amitriptyline, dothiepin, nortriptyline

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8
Q

What is the most frequent disabling primary headache?

A

Migraine

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9
Q

What is the epidemiology of migraine?

A

10% in men

22% in women

Most sufferers aged 20 to 50

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10
Q

What is the underlying pathology of migraine?

A

It is generally recognized that migraine arises from a primary brain dysfunction that leads to activation and sensitization of the trigeminal system

Complex pathophysiology

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11
Q

What are definable features of a migraine?

A

Headache lasts 4 to 72 hours

Unilateral location

Pulsating quality

Moderate or severe pain intensity

Aggravation by / causing avoidance of routine physical activity

During the headache phase, 1 of the following symptoms should be present:

Nausea

Vomiting

Photophobia

Phonophobia

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12
Q

What are migraine triggers?

A

Stress

Hunger

Sleep disturbance

Dehydration

Diet

Environmental stimuli

Changes in oestrogen level in women

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13
Q

What are the five stages of migraine?

A

The premonitory phase

The aura phase

Early headache

Advacned headache phase

Postdrome

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14
Q

Premonitory symptoms are ecperienced by seventy percent of patients suffering from migraine, what are premonitory symptoms?

A

Premonitory symptoms are often seen as predictors of the headache attack.

Mood alterations, muscle pain, food cravings, cognitive changes, fluid retention, and yawning are common premonitory symptoms.

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15
Q

What is the aura phase?

A

An aura involves focal, reversible neurologic symptoms that often precede the headache.

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16
Q

What is affected by aura?

A

Visual somatosensory system

Speech

Visual aura is the most common aura symptom - loss of vision

Sensory aura - paresthesia in the hand spreading to the arm, elbow, face, lips and tongue

Motor aura is typically experienced on one side and affects the hand and arm

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17
Q

What is an aura called that is not followed by headache pain?

A

Acephalgic migraine

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18
Q

What separates the two stages of headache (early and advanced)?

A

Early headache: mild pain, without the sensory symptoms associated with migraine, may have muscle pain and nasal congestion

Advanced headache: Moderate to severe pain with associated symptoms of nausea, photophobia, phonophobia or disability

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19
Q

What is postdrome?

A

Phase of migraine-associated symptoms beyond the resolution of the headache; often entails significant disability that can last for 1 or 2 days

Such as fatigue

Cognitive changes

Muscle pain

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20
Q

What persentage of migraineurs are affected by aura?

A

33%

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21
Q

What causes aura?

A

Cortical or brainstem dysfunction

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22
Q

What is the duration of aura?

A

15- 60 minutes

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23
Q

What is the key difference between aura and TIA?

A

TIA- Symptoms all start at same time and can be localised to a specific vascular area

Aura -

•Slow evolution of symptoms

–Moves from 1 area to next e.g.

vision → sensory → speech

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24
Q

What is the definition of chronic migraine?

A

•Headache on ≥ 15 days per month, of which ≥ 8 days have to be migraine, for more than 3 months

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25
Q

In medication overuse migraine, how can headache frequency be improved?

A

Discontinuing the overused medication

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26
Q

What is meant by medication overuse headache?

A

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

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27
Q

Who is particularly likely to develop a medication overuse headache?

A

Migraineurs

Migraineurs taking pain medication for another reason can develop chronic headache

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28
Q

What are common drugs that cause medication overuse headaches?

A

•Use of triptans, ergots, opiods and combination

analgesics >10 days / month

  • Use of simple analgesics > 15 days per month
  • Caffeine overuse: coffee, tea, cola, irn bru
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29
Q

What is abortive treatment for migraine?

A

Aspirin or NSAIDs

Triptans

Limit to 10 days per month (around 2 days per week) to aviod medication overuse headache

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30
Q

What is prophylactic treatment for migrain?

A

–Propranolol, Candesartan

–Anti-epileptics

•Topiramate, Sodium Valproate (teratogenicity), Gabapentin

–Tricyclic antidepressants

•amitriptyline, dothiepin, nortriptyline

–Venlafaxine

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31
Q

Why is the combined oral contraceptive pill contraindicated in active migraine with aura?

A

Aura with migraine comes with risk of stroke

Combination OCP also comes with a risk of stroke

The two combined is considered to be too high

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32
Q

Name some trigeminal autonomic cephalalgias

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)

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33
Q

What are cranial autonomic symptoms?

A
  • Conjunctival injection / lacrimation
  • Nasal congestion / rhinorrhoea
  • Eyelid oedema
  • Forehead & facial sweating
  • Miosis / ptosis (Horner’s syndrome)
34
Q

Where is the pain in a cluster headache?

A

Mainly orbital and temporal, strictly unilateral

Rapid Onset

Excruciatingly severe

35
Q

What is the duration of a cluster headache?

A

15 mins to 3 hours, rapid cessation of pain

36
Q

Where are autonomic symptoms in a headache?

A

Ipsilateral

37
Q

What are the migrainous symptoms often common in cluster headache?

A

–Premonitory symptoms: tiredness, yawning

–Associated symptoms: nausea, vomiting, photophobia, phonophobia

–Typical aura (often under recognised)

38
Q

What is the frequency of cluster headaches?

A

Cluster into bouts lasting 1-3 months with periods of remission lasting at least 1 month.

During a bout, attack frequency is around 1 every other day / 8 every day

May be background pain between attacks

39
Q

What is the effect of alcohol on cluster headache?

A

–Alcohol triggers attacks during a bout, but not in remission

40
Q

Describe the rhythmicity of cluster headaches

A

–attacks occur at the same time each day

–bouts occur at the same time each year

41
Q

What is a chronic cluster (10 - 20% have a chronic cluster)

A

–Bouts last >1 year without remission or

–Remissions last <1 month

42
Q

What are the following autonomic cephalalgias?

A
  • Cluster Headache
  • Paroxysmal Hemicrania
  • SUNCT
43
Q

Where is the pain in paroxysmal hemicranial?

A

Mainly orbital and temporal

Attacks are strictly unilateral

Migrainous symptoms may be present

44
Q

What is the duration of an attack in paroxysmal hemicrania?

A

2- 30 minutes

Rapid cessation of pain

45
Q

Where are autonomic symptoms present in paroxysmal hemicranial?

A

Ipsilateral

46
Q

What is the frequency of attacks of paroxysmal hemicrania?

A

2-40 attacks per day

47
Q

What is the treatment for PH?

A

Indomethacin

48
Q

Describe the pain in SUNCT

A
  • Unilateral orbital, supraorbital or temporal pain. Described as stabbing or pulsating
  • Pain is accompanied by conjunctival injection and lacrimation
49
Q

What is the duration of a SUNCT?

A

10 - 240 seconds

50
Q

What are the cutaneous triggers for SUNCT?

A

Wind, cold

Touch

Chewing

51
Q

What is the attack frequency of SUNCT?

A

3-200/day, no refractory period

52
Q

What is the pain like in trigeminal neuralgia?

A

Unilateral maxillary or mandibular division pain - ophthalmic division

Stabbing pain

Lasts 5-10 seconds

53
Q

What are the cutaneous triggers for trigeminal neuralgia?

A
  • Wind , cold
  • Touch
  • Chewing - laughing?
54
Q

What is the attack frequency of trigeminal neuralgia?

A

Similar to SUNCT, has a refractory period

55
Q

What are the autonomic features of trigeminal neuralgia?

A

Uncommon

56
Q

What is the treatment of trigeminal neuralgia?

A

Carbamazepine

57
Q

What is abortive treatment for cluster headache - during the actual headache?

A

Subcutaneous sumatriptan

Nasal zolmatriptan

100% oxygen 7-12 litres per minute

58
Q

What is abortive treatment for cluster headache bout?

A

Occipital depomedrone injection - same side as the headache

Tapering course of oral prednisone

59
Q

What is preventative treatment for cluster headache?

A

Verapamil (high dose may be acquired)

Lithium

Topiramate

Methysergide

60
Q

What is the treatment for paroxysmal hemicrania?

A

No abortive treatment

Prophylaxis with indometacin

Alternatives - COX-II inhibitors

Topiramate

61
Q

What is the treatment for SUNCT/SUNA?

A

No abortive treatment

Prophylaxis is carbamazepine and oxycarbazepine

62
Q

What is the surgical intervention for trigeminal neuralgia?

A

Glycerol ganglion injection

Stereotactic radiosurgery

Decompressive surgery

63
Q

Which presentations of headache are likely to have a sinister cause?

A

–Associated head trauma

–First or worst

–Sudden (thunderclap) onset

–New daily persistent headache

–Change in headache pattern or type

–Returning patient

64
Q

What are red flags for headache?

A
  • new onset headache
  • new or change in headache

–aged over 50

–Immunosupression or cancer

  • change in headache frequency, characteristics or associated symptoms
  • focal neurological symptoms
  • non-focal neurological symptoms
  • abnormal neurological examination
  • neck stiffness / fever
  • high pressure

–headache worse lying down

–headache wakening the patient up

–headache precipitated by physical exertion

–headache precipitated by valsalva manoeuvre

–risk factors for cerebral venous sinus thrombosis

•low pressure

–headache precipitated by sitting / standing up

•GCA (giant cell arteritis)

–jaw claudication or visual disturbance

–prominent or beaded temporal arteries

65
Q

What is the definition of a thunderclap headache?

A

High intensity headache reaching maximum intensity in less than a minute

Majority have peak instantaneously

66
Q

What is the differential diagnosis for thunderclap headache?

A

–Primary (migraine, primary thunderclap headache, primary exertional headache, primary headache associated with sexual activity)

–Subarachnoid haemorrhage

–Intracerebral haemorrhage

–TIA / stroke

–Carotid / vertebral dissection

–Cerebral venous sinus thrombosis

–Meningitis / encephalitis

–Pituitary apoplexy

–Spontaneous intracranial hypotension

67
Q

What is the most comon cause of thunderclap haemorrhage?

A

SAH - sub arachnoid haemorrhage

1 in 10 patients with thunderclap headache will have SAH

68
Q

What is the most common cause of SAH?

A

Aneurysmal

69
Q

What is potential treatment of brain aneurysms?

A

Coiling

Clipping

70
Q

What is investigation for Subarachnoid haemorrhage?

For all patients presenting with a sudden severe headache that peaks within a few minutes and lasts for atleast an hour

–CT +/- LP is unreliable beyond 2 weeks and angiography is required beyond this time

A

Brain CT

Lumbar puncture - Wait for 12 hours for lumbar puncture, need to wait for the blood to break down so we can see bilirubin in the blood

71
Q

What should be considered with any patient presenting with a headache and a fever?

A

CNS infection (Meningitis and encephalitis)

72
Q

What are the symptoms of meningitis?

A

Nausea with or without vomiting

Photophobia

Phonophobia

Stiff neck

rash

73
Q

What are the symptoms of encephalitis?

A

Altered mental state / consciousness

Focal symptoms and signs

Seizures

rash

74
Q

What are causes of raised intracranial pressure?

A

Papilloedema

Cerebral abscess

Venous infarct with local area of haemorrhage

Hydrocephalus

75
Q

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

A

Progressive headache with associated symptoms and signs

–Headache worse in morning or wakes patient from sleep

–Headache worse lying flat or brought on by valsalva (cough, stooping, straining)

–Focal symptoms or signs

–Non-focal symptoms e.g. cognitive or personality change, drowsiness

–Seizures

–Visual obscurations and pulsatile tinnitus

76
Q

What causes intracranial hypotension?

A

Dural CSF leak

Can be spontaneous or iatrogenic (post lumbar puncture)

77
Q

What are the features of intracranial hypotension?

A
  • Headache develops or worsens soon after assuming an upright posture and lessens or resolves shortly after lying down
  • Once the headache becomes chronic it often loses its postural component
78
Q

What is the investigation for intracranial hypotension?

A

MRI brain and spine

79
Q

What is the treatment for intrcranial hypotenison?

A

–Bed rest, fluids, analgesia, caffeine

(e.g. 1 can red bull qds)

–i.v. caffeine

–Epidural blood patch

Blood patch – epidural – anaesthetic – in epidural space – take the patients own blood in epidural space, blood will track up and down and cause an iritation, stiffeneing of the meninges

80
Q

Describe the symptoms present in someone with giant cell arteritis?

A

Diffuse headache, may be severe

Systemically unwell

Scalp tenderness

Jaw claudication

Visual disturbance

Prominent temporal arteries may be present

Elevated ESR supports the diagnosis (ESR: Abbreviation for erythrocyte sedimentation rate, a blood test that detects and monitors inflammation in the body. It measures the rate at which red blood cells (RBCs) in a test tube separate from blood serum over time, becoming sediment in the bottom of the test tube.)

Raised CRP and platelet count are other usedful markers

81
Q

What action is taken if giant cell arteritis is suspected?

A

HIgh dose prednisolone

Temporal artery biopsy

82
Q
A

Systems Nervous System (48 decks)

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