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Neuro Pathology > Headache > Flashcards

Headache Flashcards

1
Q

Types of headache

A

Primary

Secondary

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2
Q

What % of headaches are primary?

A

90%

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3
Q

What is a primary headache?

A

A headache that has no underlying medical cause

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4
Q

What is a secondary headache?

A

A headache which has an identifiable structural or biochemical cause

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5
Q

Types of primary headaches

A

Tension type headache
Migraine
Cluster Headache

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6
Q

Causes of secondary headaches

A 
Tumour
Meningitis
Vascular disorders
Systemic infection 
Head injury 
Drug induced
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7
Q

What is the most frequently disabling primary headache?

A

Migraine

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8
Q

Which gender gets more migraines?

A

Females

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9
Q

What age is the most common for migraines?

A

20 - 50

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10
Q

Features of migraine

A

A chronic disorder

Episodic attacks

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11
Q

Features of migraine attacks

A

Episodic
Recurrent
Reversible

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12
Q

Presentation of migraine

A 
Headache
Nausea 
Vomiting
Photophobia 
Phonophobia 
Functional disability 
Nasal congestion 
Muscle pain 
Osmophobia
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13
Q

Effects of in between attacks of migraine

A

Enduring predisposition to future attacks

Anticipatory attacks

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14
Q

How long can headache attacks of migraine last for?

A

4 to 72 hours

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15
Q

To diagnose migraines by the international headache society, what must be present?

A 
Unilateral location 
Pulsating quality 
Moderate or severe pain intensity 
And/or aggravation by or causing avoidance of routine physical activity (e.g. walking, climbing stairs) 
During the headache phase, 1 of the following symptoms should be present,
- nausea and/or vomiting
- photophobia
- phonophobia
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16
Q

Possible physiological changes in the CNS that have been found in migraine suffers are…..

A

Between attacks - deficit of habituation or potentiation, reported for several sensory modalities (visual, auditory, somatosensory, cognitive and painful stimuli)
Interictal allodynia - alteration in thresholds between episodes

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17
Q

Triggers for migraine

A 
Stress
Hunger 
Sleep disturbance
Dehydration 
Diet
Environmental stimuli 
Changes in oestrogen level in women
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18
Q

When do women commonly get migraines due to changes in oestrogen level?

A

Before / during period

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19
Q

Features of the headache in migraine

A

Unilateral

Throbbing

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20
Q

Pre migraine symptoms

A 
Aura
Mood changes
Fatigue
Cognitive changes
Muscle pain 
Food craving
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21
Q

Postdrome symptoms of migraine

A

Fatigue
Cognitive changes
Muscle pain

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22
Q

What % of migrainerus have aura?

A

33%

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23
Q

What is an aura?

A

Transient neurological symptoms resulting from cortical or brainstem dysfunction
May involve visual, sensory, motor or speech systems

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24
Q

Where does an aura start and go?

A

Starts in periphery
Spreads all over brain
Evolution of symptoms - moves from one area to next e.g. vision to sensory to speech

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25
Q

Duration of aura

A

15 - 60 mins

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26
Q

Treatment of migraine

A 
Abortive treatment
- aspirin 
- NSAIDs
- Triptans (if they dont work)
Prophylactic treatment
- propanolol 
- candesartan 
- antiepileptics (topiramate, valproate, gabapentin)
- Venlafaxine
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27
Q

What is an issue of migraine treatment in women?

A

Teratogenic

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28
Q

Abortive treatment for migraine is limited to what and why?

A

10 days per month (approx. 2 days per week) to avoid the development of medication overuse headache

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29
Q

In migraine without aura, in what situation in women do they get better?

A

Pregnancy

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30
Q

Does migraine with aura usually get better in any situation in women?

A

No

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31
Q

What migraine can particularly occur for the first time during pregnancy?

A

Migraine with aura

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32
Q

What is contraindicated in active migraine with aura?

A

OCP

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33
Q

Treatment of migraine in pregnancy

A

Acute attack; paracetamol

Preventative; Propanolol or amytiptyline

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34
Q

Definition of chronic migraine

A

Headache on over and including 15 days per month, of which over and including 8 days have to be migraine, for more than 3 months

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35
Q

What is a transformed migraine?

A

History of episodic migraine
Increasing frequency of headaches over weeks/months/years
Migranous symptoms become less frequent and less severe

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36
Q

Presentation of transformed migraine

A

Episodes of severe migraine on the background of less severe featureless frequent daily headache

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37
Q

Types of transformed migraine

A

With medication use

Without medication use

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38
Q

Definition of medication overuse headache

A

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

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39
Q

Who are particular prone to medication overuse headache?

A

Migraineurs

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40
Q

Causes of medication overuse headache

A

Migraneurs taking triptans, opoids and combination analgesics for other things > 10 days/months
Simple analgesics > 15 days per month
Caffeine overuse; tea, coke, irn bru, coffee

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41
Q

Types of trigeminal autonomic cephalalgias

A

Cluster headache
Paroxysmal hemicrania
SUNT
SUNA

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42
Q

What does SUNCT stand for?

A

Short lasting unilateral neuralgiform headache with conjunctival injection and tearing

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43
Q

What does SUNA stand for?

A

Short lasting unilateral neuralgiform headache with autonomic symptoms

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44
Q

Symptoms of trigeminal autonomic cephalalgias

A 
Unilateral head pain 
- predominately V1
Very severe/excruciating 
Cranial autonomic symptoms
- conjunctival injection/lacrimation 
- nasal congestion/rhinnorhoea
- eyelid oedema
- forehead and facial swelling
- miosis/ptosis (horners syndrome)
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45
Q

Features of a cluster headache attack

A 
Pain 
- orbital 
- temporal 
Sharp and throbbing
Strictly unilateral 
Restless and agitated 
- rocking / walking about
Prominent ipsilateral autonomic symptoms
Redness of eye, lacrimation, lid swelling 
Nasal stuffiness 
Migraneous symptoms often present
- premonitory symptoms; tiredness, vomiting
- Associated symptoms; nausea, vomiting, photophobia, phonophobia 
Typical aura
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46
Q

Onset of the attack of cluster headache

A

Rapid onset (max within 9 mins in 86%)

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47
Q

Duration of cluster headache attack

A

15 mins to 3 hours
Majority 45 - 90 mins
Rapid cessation of pain
- very quick, very severe and then goes very quickly

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48
Q

What % of people with cluster headaches have episodic symptoms?

A

80 - 90%

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49
Q

How many attacks of cluster headaches do people get during a cluster?

A

1 every other day to 8 per day

may be continuous background pain between attacks

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50
Q

When does alcohol trigger cluster headaches?

A

During a bout, not attacks

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51
Q

What is so peculiar about cluster headaches?

A

Striking circadian rhythm

  • attacks occur at same time each day
  • bouts occur at same time each year
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52
Q

What % of people with cluster headaches have a chronic cluster?

A

10 - 20%

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53
Q

Features of chronic cluster headaches

A

Bouts last > 1 yr without remission OR

Remissions last < 1 month

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54
Q

Features of paroxysmal hemicrania headaches

A

Pain
- orbital
- temporal
Strictly unilateral
Excrutiatingly severe
50% restless and agitated during an attack
Prominent ipsilateral autonomic syndromes
Migraneous symptoms may be present
Background continous pain may be present between the attacks

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55
Q

Onset of paroxysmal hemicrania headaches

A

Rapid onset

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56
Q

Duration of paroxysmal hemicrania headaches

A

2 - 30 mins

57
Q

How quickly does the pain cessede after the attack of a paroxysmal hemicrania headache?

A

Rapidly

58
Q

10% of paroxysmal hemicarnia attacks are precipitated by what?

A

Bending

Rotation of the head

59
Q

What % of patients have chronic and episodic PH?

A

Chronic - 80%

Episodic - 20%

60
Q

Frequency of paroxysmal hemicrania headaches/attacks

A

2 - 40 attacks per day

61
Q

Circadian rhythm of paroxysmal hemicrania

A

It does not have a circadian rhythm

62
Q

What does paroxysmal hemicrania have an absaloute response to?

A

Indomethacin

63
Q

Features of SUNCT

A

Unilateral
Orbital, supraorbital or temporal pain
Stabbing / pulsating pain
Conjunctival injection and lacrimation

64
Q

Duration of SUNCT

A

10 - 240 seconds

65
Q

What are the triggers of SUNCT?

A

Cutaneous triggers

  • wind
  • cold
  • touch
  • chewing
66
Q

Attack frequency of SUNCT

A

2 - 200 per day

No refractory period

67
Q

Presentation of trigeminal neuralgia

A

Unilateral
Maxillary or mandibular division pain > opthlamic division
Therefore lower face
Stabbing pain

68
Q

Duration of trigeminal neuralgia

A

5 - 10 seconds

69
Q

Triggers of trigeminal neuralgia

A

Cutaneous triggers

  • wind
  • cold
  • touch
  • chewing
70
Q

Frequency of attacks of trigeminal neuralgia

A

2 - 200 per day

Has a refractory period

71
Q

Are autonomic features in trigeminal neuralgia common?

A

No

72
Q

What is trigeminal neuralgia usually caused by?

A

A blood vessel touching the nerve

73
Q

Treatment of cluster headache

A

Abortive - headache
- subcutaneous sumatriptan or nasal zolmatriptan
- 100% oxygen 7-12 l/min via a tight fitting non rebreathing mask
Abortive - the bout
- occipital depomedrone injection on the same side as the headache
- tapering course of prednisolone
Preventative
- VERAPAMIL
- lithium
- methysergide
- topiramate

74
Q

How does 100% oxygen treat an attack of a cluster headache?

A

High flow oxygen dampens down the autonomic pathway

75
Q

How much treatment can be used in cluster headache vs migraine?

A

Migraine - up to 2 per WEEK

Cluster headache - up to 2 per DAY

76
Q

Treatment of paroxysmal hemicrania

A 
NO abortive treatment
Prophylaxis - indometacin 
Also could try 
- COX-II inhibitors
- Topiramate
77
Q

Treatment of SUNCT/SUNA

A 
NO abortive treatment
Prophylaxis
- lamotrigine
- topiramate
- gabapentin 
- carbamazepine
78
Q

Treatment of trigeminal neuralgia

A 
NO abortive treatment 
Prophylaxis
- CARBAMAZEPINE
- oxcarbazepine
Glycerol ganglion injection 
Stereotactic radiosurgery 
Decompressive surgery
79
Q

Red flags for secondary headache

A 
New onset headache 
New or change in a headache if
- > 50 y/o 
- immunosuppression or cancer 
Change in headache frequency, characteristics or assosiated symptoms
Focal neurological symptoms 
Non focal symptoms of
- drowsiness
- depressed
- cortical symptoms 
Abnormal neurological examination 
Neck stiffness / fever
High pressure 
Low pressure
GCA
- jaw claudication or visual disturbance
80
Q

What indicates a high pressure headache?

A

Headache worse when

  • lying down
  • wakening up the patient
  • precipitated by physical exertion
  • precipitated by the valsalva manouvre
81
Q

What indicates a low pressure headache?

A

Precipitated by sitting/standing up

82
Q

What is a high pressure headache a risk factor for?

A

Cerebral venous sinus thrombosis

83
Q

Headache presentations which are more likely to have a sinister cause

A 
Assosiated head trauma
First or worst
Sudden (thunderclap) onset - feels like they have been hit with something
New daily persistent headache
Change in headache pattern or type
Returning patient
84
Q

A longstanding episodic headache is unlikely to be caused by what?

A

A serious intracranial pathology

85
Q

What is the most frequent primary headache?

A

Tension type headache

86
Q

What % of men and women have tension type headaches?

A

42% men

49% women

87
Q

Presentation of a tension type headache

A

Mild, bilateral headache which is often pressing or tightening in quality
No significant associated features
Not aggravated by routine physical activity

88
Q

Classification of tension type headaches

A

Infrequent TTH
Frequent TTH
Chronic TTH

89
Q

How often do you have to have a headache for in a month to have infrequent TTH?

A

< 1 day / month

90
Q

How often do you have to have a headache for in a month to have frequent TTH?

A

1 - 14 days / month

91
Q

How often do you have to have a headache for in a month in order to have a chronic TTH?

A

> 15 days / month

92
Q

Treatment for a tension type headache

A 
Abortive
- aspirin or paracetamol 
- NSAIDs
Preventative (rarely required)
- tricyclic antidepressants
1. amytriptyline
2. dothiepin 
3. nortriptyline
93
Q

What is abortive treatment in TTH limited to and why?

A

10 days per month (approx. 2 days per week)

To avoid the development of medication overuse headache

94
Q

Definition of a thunderclap headache

A

A high intensity headache reaching maximum intensity in less than 1 minute

95
Q

Differential diagnosis for thunderclap headache

A 
Primary 
- migraine
- primary thunderclap headache
- primary exertional headache
- primary headache associated with sexual activity 
SAH
Intracerebral haemorrhage
TIA/Stroke
Carotid/vertebral dissection 
Cerebral venous sinus thrombosis
Meningitis/encephalitis
Pituitary apoplexy 
Spontaneous intracranial hypotension
96
Q

What is the most common cause for thunderclap headache?

A

SAH

97
Q

What does SAH stand for?

A

Subarachnoid haemorrhage

98
Q

What is SAH usually due to?

A

An aneurysm that bursts

99
Q

What parts of the head does the subarachnoid space cover? Therefore what does this mean for the presentation of a SAH?

A

Goes around the whole brain

Therefore the headache is over the whole head

100
Q

How many patients who have a thunderclap headache will have a SAH?

A

1 in 10

101
Q

Mortality of SAH

A

50%

102
Q

Examination findings of SAH

A

Often NORMAL

103
Q

Investigations for SAH

A

CT brain
LP (> 12 hours after headache onset)
CT +/- LP unreliable after 2 weeks and angiography is required after this time

104
Q

If think the cause of the thunderclap headache is meningitis, what must be done?

A

DO not wait for results to do treatment - start immediately

105
Q

When should CNS infection be considered in a patient with a headache? When the patient has all of….

A

Headache and fever
Meningism
Encephalitis

106
Q

What does encephalitis consist of?

A

Altered mental state / consciousness
Focal symptoms / signs
Seizures

107
Q

What does ICP stand for?

A

Intracranial pressure

108
Q

What does papilloedema present with?

A

Headache

109
Q

What is papilloedema?

A

BILATERAL swollen optic discs

110
Q

What does papilloedema indicate?

A

Raised ICP

111
Q

What is glioblastoma multiforme? What does it present with?

A

A tumour

Presents with a seizure

112
Q

Features that are suggestive of a space occupying lesion and/or raised ICP

A

Progressive headache with assosiated symptoms/signs
Warning features
- headache worse in morning
- headache wakens patient from sleep
- headache worse by lying flat or brought on by valsalva
- focal symptoms/signs
- non focal symptoms (cognitive or personality change, drowsiness)
- Seizures
- visual obscurations and pulsatile tinnitus

113
Q

Examples of the valsalva manouvre

A

Cough
Stooping
Straining

114
Q

Examples of visual obscurations seen due to high CSF pressure

A

Clouding/dulling on vision when stand up / move

115
Q

Pathology of intracranial hypotension

A

Dural CSF leak

116
Q

Causes of intracranial hypotension

A

Spontaneous

Iatrogenic (post LP)

117
Q

Features of intracranial hypotension headache

A

Better when lie flat

Worsens soon after assuming upright posture and lessens or resolves shortly after lying down

118
Q

When an intracranial hypotension headache becomes chronic, what feature does it often lose?

A

Its postural component

119
Q

Investigations of intracranial hypotension

A

MRI brain and spine

120
Q

What would be seen on MRI in intracranial hypotension?

A

CSF leaking out a hole in the meningeal sac
Brain sags down
Pulls down meninges/nerves

121
Q

Treatment of intracranial hypotension

A 
Bed rest
Fluids
Analgesia 
Caffeine (e.g. 1 can red bull qds)
IV caffeine
Epidual blood patch
122
Q

What does epidural mean?

A

In epidual space

123
Q

How does an epidural blood patch work?

A

Put patients blood in the epidural space and the blood will tract up and down, causing irritation which will seal the hole

124
Q

What is GCA on spectrum with?

A

Polymyalgia rheumatica

125
Q

What does GCA stand for?

A

Giant cell arteritis

126
Q

Pathology of GCA

A

Arteritis of the large arteries
Big blood vessels to eye/brain
Narrowing of blood vessels due to inflammation - risk of infarction to the optic nerve and brain

127
Q

Who should GCA always be considered in?

A

Any patient > 50 y/o presenting with new headache

128
Q

Presentation of GCA

A 
Headache
- diffuse
- persistent
- may be severe
Systemically unwell 
Scalp tenderness
Jaw claudication 
Visual disturbance
Prominent, beaded or enlarged temporal arteries
Elevated ESR (usually > 50)
Raised CRP 
Raised platelet count
129
Q

Definition of claudication

A

Exercise induced pain

130
Q

Definition of jaw claudication

A

Pain when eat which stops when stop eating

131
Q

Investigations of GCA

A

History and exam
ESR and CRP
Temporal artery biopsy

132
Q

Treatment for GCA

A

Prednisolone

133
Q

What is the 1st choice for prophylaxis of tension type headache?

A

Acupuncture

134
Q

What anti emetic has strong extra pyramidal side effects common in children and young adults?

A

Metoclopramide

135
Q

What group of symptoms are common in children with migraine?

A

Gastrointestinal

136
Q

Prophylaxis of primary sexual headache

A

Indomethacin

Propanolol

137
Q

What is a contraindication to triptan use?

A

CVS disease

138
Q

Examples of higher cognitive impairments

A 
Disinhibition (aggression)
Change in impulse control e.g. gambling
Inflexible thinking
Poor problem solving
Worsening decision making

Neuro Pathology (21 decks)

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