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Nervous System > Headache > Flashcards

Headache Flashcards

1
Q

What the two classifications of headaches?

A

Primary and secondary

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2
Q

Describe primary headaches

A

No underlying medical cause:
• Tension type headache
• Migraine
• Cluster headache

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3
Q

What are secondary headaches?

A 
Identificable structural or biochemical cause:
• Tumour 
• Meningitis 
• Vascular disorders 
• Systemic infection 
• Head injury 
• Drug-induced
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4
Q

Describe Tension Type Headaches

A

Mild, bilateral headache which is often pressing or tightening in quality

No significant associated features and is not aggravated by routine physical activity

• Most frequent, but is NOT disabling

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5
Q

What is the treatment for primary headaches?

A

Abortive
• Aspirin or paracetamol
• NSAIDs
• Limit to 10 days per month

Preventative
• Rarely required
• Tricyclic antidepressants (amitriptyline, dothiepin, nortriptyline)

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6
Q

Describe a migraine

A

Migraine is a neurologic chronic disorder with episodic manifestation, characterised by recurrent and reversible attack of pain and associated symptoms.

It is generally recognised that migraine arises from a primary brain dysfunction that leads to activation and sensitisation of the trigeminal system.

• Most frequent DISABLING headache

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7
Q

What are the requirement of a headache?

A

Requires the headache attack to last between 4-72hrs, with at least two of the following features:
• Unilateral location
• Pulsating quality
• Moderate or severe pain intensity
• Aggravation by routine physical activity (i.e. walking, climbing stairs)

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8
Q

What symptoms are experienced during an attack with a migraine?

A
  • Headache
  • Nausea, photophobia, phonophobia
  • Functional disability
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9
Q

What symptoms are experienced in-between attacks with a migraine?

A
  • Enduring predisposition to future attacks

* Anticipatory anxiety

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10
Q

Name seven triggers of migraines

A
  • Stress
  • Hunger
  • Sleep disturbance
  • Dehydration
  • Diet
  • Environmental stimuli
  • Changes in oestrogen level in women
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11
Q

Describe the progression of migraines

A

It is a constellation of symptoms that evolve through the various phases of a migraine attack; symptoms typically associated with each phase of an attack often recur during other phases of the attack, resulting in a continuum of symptoms, rather than distinct phases

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12
Q

Name the different phases in a headache attack

A
  1. Premonitory
  2. Aura
  3. Early headache
  4. Advanced headache
  5. Postdrome
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13
Q

Describe the premonitory phase

A

Symptoms often seen as predictor of the headache attack

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14
Q

What are different symptoms experienced in premonitory phase of attack?

A
  • Mood changes
  • Fatigue
  • Cognitive changes
  • Muscle pain
  • Food craving
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15
Q

Describe the aura phase

A

Involves focal, reversible neurological symptoms that often precede the headache. Symptoms are thought to rise from an electrical disturbance called cortical spreading depression (CSD).

Slow evolution of symptoms; moves from one area to the next (i.e. vision sensory speech)

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16
Q

What are the symptoms experience in aura phase of headache attacks?

A
  • Fully-reversible
  • Neurological changes: visual somatosensory
  • Loss of vision
  • Paresthesia (tingling)
  • Motor aura experienced on one side of body

Can be excused with a TIA

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17
Q

Describe the headache (early and advanced) phase of headache attacks

A

Subdivided according to headache pain intensity into an early phase and an advanced phase.

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18
Q

What are the symptoms experience in early headache phase of headache attacks?

A
  • Dull headache
  • Nasal congestion
  • Muscle pain
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19
Q

What are the symptoms experience in advanced headache phase of headache attacks?

A
  • Unilateral
  • Throbbing
  • Nausea
  • Photophobia
  • Photophobia
  • Osmophobia (hypersensitivity to odours)
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20
Q

Describe the postdrome phase of headache attacks

A

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

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21
Q

What are the symptoms which are experience during the postdrome phase of headache attacks?

A
  • Fatigue
  • Cognitive changes
  • Muscle pain
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22
Q

What are the requirements of a 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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23
Q

What are the features which suggest a migraine has become a chronic migraine?

A
  • History of episodic migraine
  • Increasing frequency of headaches over weeks / months / years
  • Migrainous symptoms become less frequent and less severe
  • Many patients have episodes of severe migraine on a background of less severe, featureless, frequently headaches
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24
Q

How can medication affect migraines?

A

Transformation can occur with or without escalation in medication use. In patients with medication overuse, discontinuing the overused medication often dramatically improves headache frequency.

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25
Q

What are the requirements for medication overuse headache?

A

Headache presents on > 15 days / month which has developed or worsened whilst taking regular symptomatic medication

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26
Q

What drugs can cause medication overuse headache?

A

Can occur in any primary headache:
• Triptans, ergots, opioids and combination analgesics > 10 days/month
• Simple analgesics > 15days
• Caffeine overuse

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27
Q

What is the abortive treatment for migraines?

A
  • Aspirin or NSAIDs (900mg)
  • Triptans
  • Limit to 10 days per month (~2days per week) to avoid the development of medication overuse headache
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28
Q

What is the prophylactic treatment for migraines?

A
  • Propranolol, candesartan
  • Anti-epileptics; topuramate, valproate, gabapentin
  • Tricyclic antidepressants; amitriptyline, dothiepin, nortriptyline
  • Venlaxfaxine
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29
Q

What are the specific issues with migraines in women?

A
  • First migraine can occur during pregnancy (particularly with aura)
  • Combined OCP is contraindicated in active migraine with aura
  • Avoid anti-epileptics in women of child bearing age
30
Q

What is the treatment of migraine in pregnancy?

A
  • Acute attack -> paracetamol

* Preventative -> propanolol or amitriptyline

31
Q

What are Trigeminal Autonomic Cephalalgias?

A

a group of headache disorders characterised by attacks of moderate to severe unilateral pain in the head or face

32
Q

Give examples of four Trigeminal autonomic cephalalgias

A
  • Cluster headache
  • Paroxysmal hemicrania
  • SUNT (short-lasting unilateral neuralgiform with conjunctival injection and tearing)
  • SUNA (short-lasting unilateral neuralgiform with autonomic symptoms)
33
Q

What are the features of trigeminal autonomic cephalalgias?

A
  • Unilateral head pain
  • Very severe / excruciating
  • Cranial autonomic symptoms
  • Attack frequency and duration differs
34
Q

What are the cranial autonomic symptoms?

A
  • Conjunctival injections / lacrimation
  • Nasal congestion / rhinorrhoea
  • Eyelid oedema
  • Forehead + facial sweating
  • Miosis / ptosis (hornet’s syndrome)
35
Q

Describe the attack of cluster headache

A
  • Orbital and temporal pain
  • Unilateral attacks
  • Rapid onset
  • 15mins - 3hrs
  • Rapid cessation of pain
  • Excruciatingly severe (‘suicide headache’)
  • Patients restless and agitated during attack
  • Prominent ipsilateral autonomic symptoms
36
Q

What are the migrainous symptoms which are present in cluster headaches?

A

Premonitory symptoms:
• Tireness
• Yawning

Associated symptoms:
• Nausea 
• Vomiting 
• Photophobia 
• Photophobia

Typical aura

37
Q

Describe the pattern of cluster headaches

A

Episodic:
• Attacks in bouts typically lasting 1-3months with periods of remission lasting at least 1 month
• May be continuous background pain between attacks

38
Q

What is the abortive treatment for cluster headaches?

A
  • Subcutaneous sumatriptan (injection) or nasal spray
  • 100% oxygen

Headache bout:
• Occipital depomedrone injection (same side as headache)
• Oral prednisolone

39
Q

What are the preventative treatment of cluster headaches?

A
  • Verapamil
  • Lithium
  • Methylsergide
  • Topiramate
40
Q

What is the pattern in cluster headaches?

A
  • Attacks occur at the same time each day

* Bouts occur at the same time each year

41
Q

Describe the attack of paroxysmal hemicrania?

A
  • Orbital and temporal pain
  • Unilateral pain
  • Rapid onset
  • 2-3omins duration
  • Rapid cessation of pain
  • Excruciatingly severe
  • Ipsilateral autonomic symptoms
  • Migrainous symptoms
  • Absolute response to indomethacin
42
Q

What is the treatment of paroxysmal hemicrania?

A
  • No abortive treatment
  • Prophylaxis with indomethacin
  • Alternatives – COX-II inhibitors, topiramate
43
Q

Describe the attack of SUNCT

A 
• Unilateral orbital, supraorbital or temporal pain 
• Stabbing or pulsating pain 
• 10-240s duration 
• Cutaneous triggers
  o Wind, cold 
  o Touch 
  o Chewing 
• Pain accompanied by conjunctival injection and lacrimation
44
Q

What is the treatment for SUNCT?

A 
• No abortive treatment 
• Prophylaxis 
  o Lamotrigine 
  o Topiramate 
  o Gabapentin 
  o Carbamasepine
45
Q

What is trigeminal neuralgia?

A

Chronic pain condition that affects the trigeminal nerve, which carries sensation from your face to your brain

46
Q

Describe the pain felt with trigeminal neuralgia

A 
• Unilateral maxillary or mandibular division > ophthalmic division
• Stabbing pain 
• 5-10s duration 
• Cutaneous tirggers 
  o Wind, cold
  o Touch 
  o Chewing

Attack similar to SUNCT

47
Q

What is the main difference between SUNCT and trigeminal neuralgia?

A

TN affects lower face and SUNCT affects higher face

48
Q

What is the treatment of trigeminal neuralgia?

A 
• No abortive treatment
• Prophylaxis:
  o Carbamazepine
  o Oxcarbazepine
• Surgical intervention:
  o Glycerol ganglion injection
  o Steriotactic radiosurgery
  o Decompressive surgery
49
Q

In secondary headaches, what is the presentation of a sinister underlying cause?

A
  • Associated head trauma
  • First or worst
  • Sudden (thunderclap) onset
  • New daily persistent headache
  • Change in headache pattern or type
  • Returning patient
50
Q

What are red flags of secondary headaches?

A
  • New onset
  • New or change in headache; > 50yrs, immunosuppression or cancer
  • Change in frequency or symptoms
  • Neurological symptoms
  • Neck stiffness / fever
  • High pressure symptoms
  • Low pressure symptoms
  • GCA - giant cell arteritis
51
Q

What are the high pressure symptoms?

A
  • Worse lying down
  • Waking patient up
  • Precipitate by physical exertion
  • Precipitate by Valsalva manoeuvre
  • Risk factors for cerebral venous sinus thrombosis
52
Q

What are the low pressure symptoms?

A

Headache precipitated by sitting/standing up

53
Q

What is the clinical presentation of Giant Cell Arteritis?

A
  • Jaw claudication or visual disturbance

* Prominent or beaded temporal arteries

54
Q

What is a thunderclap headache?

A

A high intensity headache reaching maximum intensity in less than 1 minute. May be primary or secondary.

55
Q

Give nine examples of a differential diagnoses for a thunderclap headache

A
  • Primary (migraine etc)
  • Subarachnoid haemorrhage!
  • Intracerebral haemorrhage
  • TIA / stroke
  • Carotid / vertebral dissection
  • Cerebral venous sinus thrombosis
  • Meningitis / encephalitis
  • Pituitary apoplexy
  • Spontaneous intracranial hypotension

1/10 patients with TH will have a SAH

56
Q

What is the main cause of a subarachnoid haemorrhage?

A

Aneurysm - so early coiling of aneurysm is life saving

57
Q

What is a general presentation of thunderclap headache?

A

All patients presenting with a sudden severe headache that peaks within a few minutes and lasts for at least 1 hour

• Examination is often normal

58
Q

What investigations are used for thunderclap headaches?

A
  • CT brain
  • Lumbar puncture – must be done > 12hrs after headache onset
  • CT +/- LP – unreliable after 2 weeks and angiography is required
59
Q

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

A 
CNS infection (meningitis and encephalitis)
• Look for a rash
60
Q

What are the symptoms of meningitis?

A 
Nausea +/-:
• Vomiting
• Photophobia 
• Phonophobia 
• Stiff neck
61
Q

What is the presentation of encephalitis?

A
  • Altered mental state consciousness
  • Focal symptoms and signs
  • Seizures
62
Q

How does lesions raises intracranial pressure?

A

Lesion inside brain causes blood and CSF to compensate and squash them. This raises the pressure.

63
Q

What is the clinical presentation suggestive of a lesion?

A

• Progressive headache with associated symptoms and signs
• Warning features:
o Worse in morning or wakes patient from sleep
o Worse lying flat or brought on by Valsalva (cough, stooping, straining)
o Focal symptoms or signs
o Non-focal symptoms i.e. cognitive or personality change, drowsiness
o Seizures
o Visual obscuration and pulsatile tinnitus

64
Q

Name five causes of intracranial hypotension

A
  • Dural CSF leak
  • Spontaneous or iatrogenic (post lumbar puncture)
  • Clear postural component to headache (worse standing)
  • 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 postural component
65
Q

What investigations are used for intracranial hypotension?

A

MRI brain and spine

66
Q

What is the treatment for intracranial hypotension?

A
  • Bed rest, fluids, analgesia, caffeine
  • IV caffeine (raises CSF pressure)
  • Epidural blood patch – blood injected between meninges which either seals hole or makes the meninges thicker to slow CSF leak
67
Q

What is giant cell arteritis?

A

Arteritis of large arteries

68
Q

What is the clinical presentation of giant cell arteritis?

A
  • Headache usually diffuse, persistent and may be severe
  • The patient may be systemically unwell
  • Specific features; scalp tenderness, jaw claudication and visual disturbance
  • Prominent, beaded or enlarged temporal arteries may be present
69
Q

What is the presentation in the lab tests of GCA?

A
  • An elevated ESR supports the diagnosis

* Raised CRP and platelet count

70
Q

What is the treatment of GCA?

A
  • High dose prednisolone

* Temporal artery biopsy

71
Q

What is conjunctival injection?

A

Bloodshot eyes - appear red due to dilation of the conjunctival vessels overlying the sclera

Nervous System (47 decks)

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