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Nervous System > Headache > Flashcards

Headache Flashcards

1
Q

Tension type headache presentation

A
  • BILATERAL PRESSING/TIGHTENING QUALITY
    • NO SIG. ASS/ FEATURES
    • NOT AGGRAVATED BY ROUTINE PHYSICAL ACTIVITY

NOT DISABLING

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2
Q

Tension type headache management

A

SIMPLE ANALGESIA

Abortive rx:

  • ASPIRIN/PARACETAMOL
  • NSAIDs
  • TO AVOID MEDICATION OVERUSE HEADACHE = LIMIT TO 10 DAYS PER MONTH (~ 2 days per week)

Preventative rx:

  • RARELY REQ.
  • TRICYCLIC ANTIDEPRESSANTS
    • AMITRIPYLINE, DOTHIEPIN, NORTRIPYLINE
    • Limited to no more than ~ 2 days per week
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3
Q

Migraine presentation

A

Premonitory:

  • WARNING SIGNS
  • MOOD CHANGES
  • FATIGUE
  • COGNITIVE CHANGES
  • MUSCLE PAIN
  • FOOD CRAVINGS

Aura:

  • FULLY REVERSIBLE
  • NEUROLOGICAL CHANGES
  • VISUAL SOMATOSENSORY

Early Headache:

  • DULL HEADACHE
  • NASAL CONGESTION
  • MUSCLE PAIN

Advanced Headache:

  • UNILATERAL, THROBBING, WORSENS IN SEVERITY
  • NAUSEA, PHOTOPHOBIA, PHONOPHOBIA, OSMOPHOBIA

Postdrome:

  • FATIGUE
  • COGNITIVE CHANGES
  • MUSCLE PAIN
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4
Q

What is aura + how is it different from TIA

A

TRANSIENT NEUROLOGICAL SYMPTOMS - resulting form cortical/brainstem dysfunction

can involve visual, sensory, motor, speech systems

slow evolution of symptoms + moves from 1 are to next

lasts 15 - 60 mins

TIA = loss of function, sudden onset, symptoms all start at same time + can be localised to specific vascular area

AURA = starts, spreads, worsens, more gradual

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5
Q

Migraine characteristics

A
  • DISABLING PRIMARY HEADACHE
    • CHRONIC DISORDER + EPISODIC ATTACKS + COMPLEX CHANGES IN BRAIN
    • HAS TRIGGERS + SENSORY SENSITIVITY

triggers incl. = normal life events, sleep disturbance, hunger, stress, diet, dehydration, environmental stimuli e.g. light, sound, changes in oestrogen lvl

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6
Q

Migraine management

A

Abortive rx:

  • ASPIRIN/NSAIDs
  • TRIPTANS
  • LIMIT TO ~ 10 DAYS/MONTH (to avoid medication overuse headache)

Prophylactic rx:

  • PROPANOLOL, CANDESARTAN
  • ANTI-EPILEPTICS
    • TOPIRAMATE, VALPROATE, GABAPENTIN
  • TRICYCLIC ANTIDEPRESSANTS
    • AMITRIPTYLINE, DOTHIEPIN, NORTRIPTYLINE
  • VENLAFLAXINE
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7
Q

Chronic Migraine

A

HEADACHE ≥ 15 DAYS/MONTH - of which ≥ 8 DAYS = MIGRAINE; ALL FOR > 3 MONTHS

transformed migraine: w/ or wo escalation in medication use

* Hx EPISODIC MIGRAINE
* INCREASING FREQ. of HEADACHES: over weeks/months/years
* MIGRAINOUS SYMPTOMS BECOME LESS FREQ. & LESS SEVERE
* MANY PT. HAVE SEVERE MIGRAINE EPISODES + LESS SEVERE FEATURELESS FREQ./DAILY HEADACHE
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8
Q

Medication overuse

A

HEADACHE ≥ 15 DAYS/MONTH - DEVELOPED/WORSENED WHILE TAKING REGULAR SYMPTOMATIC MEDICATION

CAN OCCUR IN ANY PRIMARY HEADACHE

DISCONTINUING MEDICATION OVERUSE OFTEN (not always) DRAMATICALLY IMPROVES HEADACHE FREQ.

* TRIPTANS, ERGOTS, OPIODS + COMBINATION ANALGESICS > 10 DAYS PER MONTH (~ > 2 days/week)
* SIMPLE ANALGESICS > 15 DAYS/MONTH
* CAFFEINE OVERUSE

	○ LIMIT DRUG USE TO ~ ≤ 2 DAYS PER WEEK
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9
Q

Trigeminal autonomic cephalgia general presentation

A
  • UNILATERAL HEAD PAIN = predominantly V1
    • V.SEVERE/EXCRUCIATING
    • CRANIAL AUTONOMIC SYMPTOMS
		○ CONJUNCTIVAL INJECTION/LACRIMATION
		○ NASAL CONGESTION/RHINORRHOEA
		○ EYELID OEDEMA
		○ FOREHEAD & FACIAL SWEATING
		○ MIOSIS/PTOSIS (HORNER'S SYNDROME)
* ATTACK FREQ. & DURATION DIFFERS
* TREATMENT RESPONSES DIFFER
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10
Q

Cluster headache presentation

A

Attack:

  • UNILATERAL PAIN = ORBITAL & TEMPORAL mainly
    • EXCRUCIATINGLY SEVERE (suicide headache)
  • RESTLESS & AGITATED DURING ATTACK
  • PROMINENT IPSILATERAL AUTONOMIC SYMPTOMS
  • MIGRANE SYMPTOMS OFTEN PRESENT
    • PREMONITORY SYMPTOMS = TIREDNESS, YAWNING
    • ASS. SYMPTOMS = NAUSEA, VOMITING, PHOTOPHOBIA, PHONOPHOBIA
    • TYPICAL AURA
  • RAPID ONSET = comes on w/i minutes
  • DURATION = 15 mins - 3 hrs, majority are 45 - 90 mins
  • RAPID CESSATION of PAIN
  • SEVERAL ATTACKS PER DAY

Bout:

  • EPISODIC IN 80 - 90%
    • ATTACKS CLUSTER INTO BOUTS = typically lasting 1 - 3 MONTHS w/ PERIODS of REMISSION ≥ 1 MONTHS
    • ATTACK FREQ. = 1 EVERY OTHER DAY - 8/DAY (increases as bout progresses)
    • May be CONTINUOUS BACKGROUND bwtn ATTACKS
    • ALCOHOL = TRIGGERS ATTACKS DURING BOUT, but NOT IN REMISSION
  • STRIKING CIRCADIAN RHYTHMICITY
    • ATTACKS OCCUR AT SAME TIME EVERY DAY + BOUTS OCCUR AT SAME TIME EACH YEAR
  • CHRONIC CLUSTER IN 10 - 20%
    • BOUTS LAST > 1 YEAR w/o REMISSION
    • Or REMISSION < 1 MONTH
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11
Q

Cluster headache management

A

Abortive (headache)

  • S/C SUMATRIPTAN 6mg/NASAL ZOLMATRIPTAN 5mg
  • 100% O2 7 - 12 L/min via TIGHT FITTING NON-REBREATHING MASK

Abortive (headache bout)

  • OCCIPITAL DEPOMEDRONE INJECTIONS = SAME SIDES as HEADACHE
  • TAPERING COURSE of ORAL PREDNISOLONE

Preventative

  • VERAPAMIL (high doses may be req.)
  • LITHIUM
  • METHYLSERGIDE (risk of retroperitoneal fibrosis)
  • TOPIRAMATE
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12
Q

Paroxsysmal hemicrania presentation

A

• UNILATERAL PAIN = ORBITAL & TEMPORAL mainly

	○ EXCRUCIATINGLY SEVERE
	○ BACKGROUND CONTINUOUS PAIN can be PRESENT

* 50% RESTLESS &amp; AGITATED DURING ATTACK
* PROMINENT IPSILATERAL AUTONOMIC SYMPTOMS
* MIGRANOUS SYMPTOMS poss. PRESENT

* RAPID ONSET
* DURATION = 2 - 30 mins
* RAPID CESSATION of PAIN
* FREQ. = 2 - 40 ATTACKS/DAY + NO CIRCADIAN RHYTHM

TRIGGER = BENDING/ROTATING HEAD ~ 10%
80% CHRONIC : 20% EPISODIC

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13
Q

Paroxsysmal hemicrania management

A
  • NO ABORTIVE TREATMENT
    • PROPHYLAXIS = INDOMETACIN
    • ALTERNATIVES = COX-II INHIBITORS, TOPIRAMATE
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14
Q

SUNCT/SUNA presentation

A
  • UNILATERAL ORBITAL/SUPRAORBITAL/TEMPORAL PAIN
    • STABBING/PULSATING PAIN
    • SOME AUTONOMIC SYMPTOMS = CONJUNCTIVAL INJECTION & LACRIMATION
    • DURATION = 10 - 240 s
    • ATTACK FREQ. = 3 - 200/DAY + NO REFRACTORY PERIOD

CUTANEOUS TRIGGERS = WIND, COLD, TOUCH, CHEWING

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15
Q

SUNCT/SUNA management

A

NO ABORTIVE TREATMENT

PROPHYLAXIS:

* LAMOTRIGNINE
* TOPIRAMATE
* GABAPENTIN
* CARBAMAZEPINE/OXYCARBAZEPINE
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16
Q

Trigeminal neuralgia presentation

A
  • UNILATERAL MAXILLARY/MANDIBULAR PAIN > OPTHALMIC PAIN
    • STABBING
    • AUTONOMIC FEATURES UNCOMMON
    • DURATION = 5 - 10 s
    • ATTACK FREQ. = SIMILAR to SUNCT + REFRACTORY PERIOD

CUTANEOUS TRIGGERS = WIND, COLD, TOUCH, CHEWING

17
Q

Trigeminal neuralgia management

A

NO ABORTIVE TREATMENT

PROPHYLAXIS = CARBAMAZEPINE, OXYCARBAZEPINE

SURGICAL INTERVENTION:

* GLYCEROL GANGLION INJECTION
* STERIOTACTIC RADIOSURGERY
* DECOMPRESSIVE SURGERY
18
Q

Secondary headaches aetiology

A
  • TUMOUR
    • MENINGITIS
    • VASCULAR DISORDERS
    • SYSTEMIC INFECTION
    • HEAD INJURY
    • DRUG-INDUCED
19
Q

Sinister headaches

A

SERIOUS INTRACRANIAL PATHOLOGY = V. UNLIKELY IN LONGSTANDING EPISODIC HEADACHE

PRESENTATIONS MORE LIKELY TO BE SINISTER:

* ASS. HEAD TRAUMA
* 1ST/WORST
* SUDDEN (THUNDERCLAP) ONSET
* NEW DAILY PERSISTENT HEADACHE
* CHANGE IN HEADACHE PATTERN/TYPE
* RETURNING PT.
20
Q

Red flags in headaches

A
  • NEW ONSET HEADACHE
    • NEW/CHANGE IN HEADACHE (> 50 YRS, IMMUNOSUPPRESSION/CANCER)
    • CHANGE IN HEADACHE FREQ./CHARACTERISTICS/ASS. SYMPTOMS
    • FOCAL/NON-FOCAL NEUROLOGICAL SYMPTOMS
    • ABNORMAL NEUROLOGICAL EXAMINATION
    • NECK STIFFNESS/FEVER
    • HIGH PRESSURE
    ○ HEADACHE WORSE when LYING DOWN
    ○ HEADACHE WAKENING PT. 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
    ○ JAW CLAUDICATION/VISUAL DISTURBANCE
    ○ PROMINENT/BEADED TEMPORAL ARTERIES
21
Q

What is a thunderclap headache

A

• HIGH INTENSITY HEADACHE = REACHES MAX. INTENSITY IN < 1 MIN
○ MAJORITY PEAK INSTANTANEOUSLY

• PRIMARY/SECONDARY (no reliable differentiating factors)
22
Q

DDx of thunderclap headaches

A 
• PRIMARY
		○ MIGRAINE
		○ PRIMARY THUNDERCLAP HEADACHE
		○ PRIMARY EXERTIONAL HEADACHE
		○ PRIMARY HEADACHE ass. w/ SEXUAL ACTIVITY
* SUBARACHNOID HAEMORRHAGE
* INTRACEREBRAL HAEMORRHAGE
* TIA/STROKE
* CAROTID/VERTEBRAL DISSECTION
* CEREBRAL VENOUS SINUS THROMBOSIS
* MENINGITIS/ENCEPHALITIS
* PITUITARY APOPLEXY
* SPONTANEOUS INTRACRANIAL HYPOTENSION
23
Q

Subarachnoid haemorrhage presentation + pathophysiology

A
  • SUDDEN SEVERE HEADACHE + PEAKS w/i FEW MINUTES + LASTS FOR ≥ 1 HR
    • VOMITING, COLLAPSE, SEIZURES, COMA
    • O/E = MAY BE NORMAL○ NECK STIFFNESS
      ○ KERNIG’S SIGN - takes 6hrs to develop
      ○ FOCAL NEUROLOGY at presentation may suggest ANEURYSMAL SITE (pupil changes = 3rd nerve palsy)/INTRACEREBRAL HAEMATOMA
      ○ LATER DEFICITS suggest COMPLICATIONS

85% aneurysmal

24
Q

Subarachnoid haemorrhage investigations

A
  1. SAME DAY HOSPITAL ASSESSMENT
    1. CONSIDER SAH/OTHER AETIOLOGY
    2. CT BRAIN (if < 12hrs)
    3. LP > 12 hrs (enough time for blood breakdown products to enter CSF)
    4. CT ± LP UNRELIABLE > 2 weeks = ANGIOGRAPHY REQ. after this (would still do ANGIOGRAPHY after confirming SAH - for identification of bleed site for clipping/coiling)
25
Q

Subarachnoid haemorrhage management

A

ENDOVASCULAR COILING/SURGICAL CLIPPING

26
Q

Subarachnoid haemorrhage complications

A
  • REBLEEDING
    • CEREBRAL ISCHAEMIA due to vasospasm may cause PERMANENT CNS DEFICIT
    • HYDROCEPHALUS
    • HYPONATRAEMIA
27
Q

Features suggestive of SOL/raised ICP + warning features

A

• PROGRESSIVE HEADACHE w/ ASS. SYMPTOMS & SIGNS

	○ HEADACHE COMMON 1ST PRESENTING FEATURE, OTHER SYMPTOMS &amp; SIGNS usually PRESENT

* HEADACHE WORSE in MORNING/WAKES pt. from SLEEP
* HEADACHE WORSE LYING FLAT/brought on by VALSALVA (COUGH, STOOPING, STRAINING)
* FOCAL SYMPTOMS/SIGNS
* NON-FOCAL SYMPTOMS e.g. COGNITIVE/PERSONALITY CHANGE, DROWSINESS
* SEIZURES
* VISUAL OBSCURATIONS &amp; PULSATILE TINNITUS
28
Q

Intracranial hypotension - presentation, investigations, management

A

• HEADACHE - CLEAR POSTURAL ELEMENT

	○ DEVELOPS/WORSENS SOON AFTER assuming UPRIGHT POSTURE &amp; LESSENS/RESOLVES SHORTLY AFTER LYING DOWN

	○ Once HEADACHE becomes CHRONIC = often LOSES POSTURAL COMPONENT

• MRI BRAIN &amp; SPINE

* BED REST
* FLUIDS
* ANALGESIA
* CAFFEINE = ORAL/IV
* EPIDURAL BLOOD PATCH
29
Q

Giant cell arteritis - presentation, investigations, management

A
  • HEADACHE = DIFFUSE, PERSISTENT, SEVERE
    • SYSTEMICALLY UNWELL
    • SCALP TENDERNESS
    • JAW CLAUDICATION
    • VISUAL DISTURBANCE
    • PROMINENT/BEADED/ENLARGED TEMPORAL ARTERIES
    • ESR = ELEVATED usually > 50, OFTEN MUCH HIGHER, RARELY NORMAL
    • RAISED CRP & PLATELET COUNT
    • HIGH DOSE PREDNISOLONE (if diagnosis likely)
    • TEMPORAL BIOPSY

Nervous System (12 decks)

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