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Headache Flashcards

1
Q

Headaches can be split into Primary and Secondary Types, what would be signs of a secondary headache? [6]

A
  • Trauma
  • First or worst ever headache
  • Thunderclap onset
  • A new daily & persistant headache
  • A change in the headaches pattern or type
  • Other symptoms such as jaw claudication, fevers, neuro signs/symptoms or worsened by position
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2
Q

What could cause a thunderclap headache [4]

A
  • intracranial aneurysm (saccular ‘berry’ aneurysms)- accounts for around 85% of cases, conditions associated with berry aneurysms include hypertension, adult polycystic kidney disease, Ehlers-Danlos syndrome and coarctation of the aorta
  • arteriovenous malformation
  • pituitary apoplexy
  • mycotic (infective) aneurysms
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3
Q

What causes most subarachnoid haemorrhages? [1]

A

Aneurysms

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4
Q

Do we order CT head or lumbar puncture to diagnose SAH?

A
  • NCCT Head: acute blood, hyperdense/bright on CT in basal cisterns, sulci, ventricles
  • If CTH within 6h and normal, dont do LP
  • If CTH >6h and normal, do LP because LP should be at least 12h following onset of sx to allow development of xanthochromia.
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5
Q

Define a thunderclap headache? [2]
Describe a few other associated features with SAH.

A

Thunderclap headache: High intensity [1] peaking instantly or within 1-5 minutes of onset [1]
* nausea and vomiting
* meningism (photophobia, neck stiffness)
* coma
* seizures
* ECG changes including ST elevation may be seen- this may be secondary to either autonomic neural stimulation from the hypothalamus or elevated levels of circulating catecholamines

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6
Q

What types of CNS infection cause thunderclap headache [3]

A

If the patients headache comes with fever, rash or: [1]
Meningitis [1]
Encephalitis [1]

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7
Q

What is the triad of meningism [4]

Describe presentation of encephalitis [3]

What could raise [4] or lower Intracranial pressure [2]?

A

Headache, neck stiffness, and photophobia, often with nausea and vomiting.

Encephalitis- Altered mental state, seizures, focal neuro symptoms/signs

Raised ICP:

  • Hydrocephalus
  • Cerebral Abscess
  • Glioblastoma/Meningioma
  • Venous sinus infarct

Lowered ICP:
- Dural CSF leak either spontaneously or after LP

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8
Q

What are the specific signs of raised ICP? [6]

A

Progressively worse headache
Worse in morning/wakes them up
Worse on flat, valsalva (poop/cough/strain) or on exertion
Neurological symptoms
Seizures
Visual obscurations and pulsatile (whooshing) tinnitus

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9
Q

What indicates an intracranial hypotension [3] and how do we approach it? [2]

A

Headache appearing/worsening on standing and lessening/resolving on lying down [2]

Sagittal MRI of brain and spine will show an empty subarachnoid space [1]

Conservative: Bed rest, fluids, analgesia, caffeine [1]

Epidural Blood patch (to stimulate healing of a CSF leak) [1]

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10
Q

What is an epidural blood patch? [3]

A

A treatment for leaking CSF that causes lowered ICP [1]

Put some of the patients blood in their epidural space [1] which will cause irritation leading to healing of the leak [1]

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11
Q

What is Giant Cell Arteritis [3] and what about a headache would indicate it [2]?

A

Giant cell granulomatous inflammation of the arteries [1] causing narrowing which can cause an infarction [1] to the brain and/or optic nerve [1]

The headache is diffuse persistant and may be severe associated with scalp tenderness, jaw claudication

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12
Q

What are the symptoms of giant cell arteritis? [4]

What is an associated condition [1]

A
  • Diffuse, persistant and severe headache
  • Jaw claudication (pathognomonic)
  • Visual Disturbance eg blindness, diplopia
  • Scalp Tenderness

Associated with PMR

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13
Q

GCA
Ix [5]
Dx [1]
Mx [1]

A

ESR/CRP/Platelets all elevated
Anemia, high ALP
Confirm with a temporal artery biopsy
Treat with prednisolone 60mg

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14
Q

What are the main types of Primary Headache? [4] + [3]

Indicate the most common cause of primary headache*

A
  • Tension-Type*
  • Migraine
  • Medication Overuse Headache
  • Trigeminal Neuralgia

And the Trigeminal Autonomic Cephalagias:

  • Cluster headache
  • Paroxysmal Hemicrania
  • SUNA/SUNCT
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15
Q

TTH
Presentation [4]
Cause/mechanisms [1]

A
  • Mild, bilateral
  • Described as ‘tight band’
  • Worse towards end of day
  • Not aggravated by ADL

Mechanism
- Muscular due to persistent contraction

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16
Q

What are the subtypes of Tension Type headache? [2]

A

Episodic - <15 days a month

Chronic - >15 days a month

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17
Q

TTH
Approach [3]
Rx [3]
Second line [2]

A

Reassurance
Reduce psychological stress
Reduce analgesic over-use

Aspirin, paracetamol or NSAIDs

2nd line: TCA

18
Q

Define Migraine? [4]
Describe subtypes [2]
Nature of headache [3]

A

Chronic episodic attacks [1] featuring phono/photophobia, functional disability and nausea. [3]

Types:

  1. Migraine with Aura (33%)
  2. Common migraine

Nature of headache: unilateral throbbing headache, 2-48h, less than 2x weekly

19
Q

What triggers a migraine? [8]

A
  • Barometric pressure/humidity.
  • Sleep (lack or excess).
  • Dietary intake, e.g. cheese, caffeine, alcohol.
  • Stress (either excess or in periods of relief)
  • Physical exertion.
  • Loud noise.
  • Bright light.
  • Hormonal changes such as puberty, menses and menopause.
20
Q

What is an “aura”? [4]

Describe visual [3], basilar [4], hemiplegic [1] and retinal auras [1]

A

A set of transient neurological symptoms [1] lasting 15-60 minutes.[1]
Can be of visual, sensory or motor type [1]
Often precedes headache [1]

Visual forms:
- Foritifications (zigzags)
- Flashing lights
- Scintillating scotoma
(migraine with occipital origin)

Basilar

  • Bilateral visual symptoms
  • Unsteadiness, vertigo,
  • Dysarthria
  • Limb paresthesia, LOC

Hemiplegic
- Unilateral paralysis persisting few days after headache settled

Retinal
- Unilateral visual loss reversible

21
Q

What defines a Chronic Migraine? [3]

A

Headaches >15 days a month for >3 months [2]

Of which atleast 8 a month must be migraines [1]

22
Q

Migraine management

2 approaches [7]

A

First line: simple analgesia, anti-emetics

Abortive:

  • Triptan 5HT AGONIST & NSAIDs
  • Adjunctive metoclopromide

Prophylactic: considered when headaches occur more than 5x a month.

  • Propanolol
  • Anti-epileptics topiramate 5HT ANTAGONIST
  • Tricyclic Antidepressants Amitripytyline
  • Acupuncture
  • Botulinum toxin A
23
Q

What should we be aware of in pregnant women with migraines? [2]

A

Dont give antiepileptics to those of child-bearing age as they’re teratogenic

Treat pregnant women with paracetamol or propanolol/Amitriptyline prophylactically

24
Q

Define a medication overuse headache? [2]

A

Headache >15 days a month [1] developed or worsened on regular symptomatic medications [1]

25
What causes a medication overuse headache? [5] List the duration of time used to induce such a headache
- Triptans - Ergots - Opiods More than 10 days a month Or simple analgesics used more than 15 days a month Also caffeine overuse
26
Where do Trigeminal Autonomic Cephalagias present with pain?
In the orbital, supraorbital and temporal regions
27
What do SUNA/SUNCT stand for? [2] | What are the autonomic symptoms that accompany Trgimenial autonomic cephalalgias [3]
Short Lasting Unilateral Neuralgiform headache With either Autonomic symptoms Redness, lacrimation, lid swelling Horner's syndrome Nasal congestion
28
Cluster headache | - Clinical features [5]
- Unilateral sharp/throbbing pain - Rapid onset and 15 min-2h minutes duration - Incredibly severe - Often comes with migranous symptoms such as nausea, aura and photo/phonophobia - Patient restless and agitated Also remember Autonomic symptoms with all TACs
29
Why are cluster headaches so named? Triggers [1] Pattern [1]
They are episodic, occuring in clusters [1] typically lasting 1-3 months with anything from 1-8 a day during an attack [1] The bouts may be triggered by alcohol [1] and may feature continuous background level pain They may show circadian rhythmicity with bouts coming the same time every year and attacks the same time each day [1]
30
How do you treat a cluster headache? Acute [2] Abortive Prevention [2]
Acute: 100% O2, injectable sumatriptan, Abortive: steroids, greater occipital nerve blockade (depomedrone) Prevention: Verapamil, lithium, methylsegide for prevention
31
Describe a paroxysmal hemicrania? [5]
``` Unilateral sharp/throbbing pain Rapid onset, duration 2-30 minutes Very severe Possible continuous background pain 2-40 attacks per day without circadian rythm ```
32
How do we treat Paroxysmal Hemicrania? | SE [2]
``` Prophylactic Indomethacin (An NSAID) systemic upset, nephrotoxic ```
33
Describe SUNCT? [5]
``` Unilateral Stabbing/pulsing pain Short 10-240 second duration Triggered by wind/cold/touch/chewing 3-200 attacks a day Comes with conjunctival injection (red eye) and tears ```
34
How do we treat SUNCT? [1]
Lamotrigine prophylactically (an anti-epileptic, same for SUNA)
35
Describe Trigeminal Neuralgia [4]
``` Unilateral stabbing pain [1] unlike TACs its to the maxillary/mandibular regions [1] 5-10 second duration Also triggered by wind/cold/touch/chew 3-200 a day Unlikely to have autonomic symptoms ```
36
How do we treat Trigeminal Neuralgia? [3]
Gabapentin for pain relief Carbamazepine prophylactic Surgical vascular loop decompression
37
Name a tricyclic antidepressant and what headaches its used for? [3]
Amitriptyline - Prophylaxis of Tension Type Headaches - Prophylaxis of Migraines
38
How do you differentiate the types of TACs? Frequency Duration Pain characteristic
Frequency: CH = 1-8 PH = 1-40 SUNCT = 3-200 Duration: CH = 15-180 mins PH=2-30mins SUNCT = 5-240 seconds I.e. frequency and duration are inversely proportional Pain is sharp and throbbing in CHs & PHs but stabbing/pulsing or burning in SUNCT All have a very severe pain CH most likely to show circadian rythmicity
39
``` Summary of Treatments for Headache Types: Thunderclap TTH Migraine MOH Trigeminal neuralgia Cluster headache Paroxysmal hemicrania SUNA/SUNCT ```
Thunderclap - Probably SAH - Coiling/clipping Tension Type Headache - Aspirin/NSAID/Paracetamol + Amitryptiline Migraine - Aspirin/NSAID/Triptan + Propanalol/Anti-epileptic/Amitryptiline Medication Overuse Headache - Use less meds Trigeminal Neuralgia - Carbamazepine Cluster Headache - 100% O2/SC Sumatriptan + Verapamil Paroxysmal Hemicrania - Prophylactic Indometacin NSAID SUNA/SUNCT - Anti-epileptic Lamotrigine
40
# SAH Further investigation and management
After spontaneous SAH is confirmed, the aim of investigation is to identify a causative pathology that needs urgent treatment: * CT intracranial angiogram (to identify a vascular lesion e.g. aneurysm or AVM) * +/- digital subtraction angiogram (catheter angiogram) Management of a confirmed aneurysmal subarachnoid haemorrhage supportive * bed rest * analgesia * venous thromboembolism prophylaxis * discontinuation of antithrombotics (reversal of anticoagulation if present) * vasospasm is prevented using a course of oral nimodipine * intracranial aneurysms are at risk of rebleeding and therefore require prompt intervention, preferably within 24 hours * most intracranial aneurysms are now treated with a coil by interventional neuroradiologists, but a minority require a craniotomy and clipping by a neurosurgeon
41
Complications of aneurysmal SAH [5]
* re-bleeding - happens in around 10% of cases and most common in the first 12 hours, if rebleeding is suspected (e.g. sudden worsening of neurological symptoms) then a repeat CT should be arranged, associated with a high mortality (up to 70%) * hydrocephalus- temporarily treated with an external ventricular drain (CSF diverted into a bag at the bedside) or, if required, a long-term ventriculoperitoneal shunt * vasospasm (also termed delayed cerebral ischaemia), typically 7-14 days after onset, ensure euvolaemia (normal blood volume)- consider treatment with a vasopressor if symptoms persist * hyponatraemia (most typically due to syndrome inappropriate anti-diuretic hormone (SIADH)) * seizures

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