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Neurology > Headache > Flashcards

Headache Flashcards

1
Q

What is the key feature of a headache caused by low ICP

A

Comes on when they stand up and gets better when they lie down

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2
Q

What is the key feature of a headache caused by high ICP

A

Headache when lying down, gets better when upright

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3
Q

How does a cluster headache present

A

Extremely severe
One-sided
Lasts around 45-90mins at a time but will get 1-8 per day
These episodes can last weeks to months
People often want to keep moving around
May also have nausea, vomiting, lacrimation, rhinorrhea

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4
Q

What are common associated symptoms of headache that should be asked about

A 
Autonomic features such as nausea and vomiting 
Photophobia 
Phonophobia 
Positive visual symptoms
Miosis - constricted pupil 
Ptosis 
Nasal stuffiness - sinus
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5
Q

Which demographic tends to get migraines

A

Young women
Typically teens to 20s
Another peak in the 40s

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6
Q

What are the headache red flags

A 
New onset headache in the over 55s 
Known or previous malignancy - risk of mets
Immunosuppression - risk of infection 
Early morning headache - wakes you up 
Exacerbation by the Valsalva manoeuvre
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7
Q

What are the diagnostic criteria for migraine without aura

A

AT least 5 attacks lasting between 4-72 hours
2 from: moderate/severe pain, unilateral, throbbing or worse on movement
1 from: autonomic features, photophobia or phonophobia

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8
Q

Migraines can be hormonally driven - true or false

A

True

Can be related to the menstrual cycle in women

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9
Q

Describe the pathophysiology of migraines

A

Both vascular and neural influences
Stress can trigger changes in the brain which cause release of serotonin
The blood vessels constrict and dilate
Chemicals can irritate the blood vessels and nerves causing pain

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10
Q

Which is more common - migraine with or without aura

A

Without

Only 20% of people with migraines get auras

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11
Q

What is an aura

A

A fully reversible visual, sensory, motor or language symptom
e.g. visual disturbance, speech problems, word finding difficulty

Visual is most common
Lasts around 20-60 mins

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12
Q

Does an aura always have to occur alongside the headache

A

No
Headache can follow the aura - but will be less than one hour between them
Can also occur simultaneously

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13
Q

What can trigger a migraine

A 
Sleep 
Diet - dark choc, cheese and alcohol are the main ones 
Hormones - menstrual cycle 
Physical exertion
Stress
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14
Q

What non-pharmacological treatments are available for migraine

A

Education - what triggers are and how to avoid them
Headache diary to find trigger and monitor symptoms
Relaxation/stress management
Acupuncture
Regular exercise and healthy diet
Hydration
Reduce caffeine intake

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15
Q

What acute treatment is available for migraines

A

NSAIDs - take ASAP
Paracetamol
Aspirin
Triptans - rizatriptan, sumatriptan

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16
Q

How can triptans be taken

A

Come as tablets, nasal spray, SC injections and wafers that dissolve in the mouth
Wafers take a while to be absorbed
Ideally given at the start of headache

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17
Q

At which point is migraine prophylaxis considered

A

If a person has had more than 3 attack per month

If the migraines are particularly severe

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18
Q

How is migraine prophylaxis administered (generally)

A

Aim to slowly titrate the drug up to the efficient and tolerated dose
Aim for the lowest dose possible
Must trial each drug for at least 3 months

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19
Q

Which drugs can be used for migraine prophylaxis

A

Amitriptyline- 10-25mg
Propranolol - 80-240mg
Topiramate (carbonic anhydrase inhibitor ) - 25-100mg
Candesartan

Gabapentin, sodium valproate, botox

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20
Q

What are the side effects of amitriptyline

A

Dry mouth
Postural hypotension
Sedation

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21
Q

When should beta blockers be avoided

A

In asthmatics, PVD and heart failure

Can affect heart rate and BP

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22
Q

What are the adverse effects of topiramate

A

Weight loss
Paraesthesia
Impaired concentration
Enzyme induction

Reserved drug as it causes so many issues - start low go slow

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23
Q

How is botox used in the treatment of migraines

A

32 botox injections in the scalp every month – used for resistant migraines

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24
Q

What is the risk of prescribing sodium valproate

A

Risky to prescribe to women of child bearing age as it is very teratogenic

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25
Q

What is an acephalgic migraine

A

Get aura and feel sick but no headache

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26
Q

What is a basilar migraine

A

Severe form

Get vertigo and loss of balance

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27
Q

What is a hemiplegic migraine

A

Develop severe issues similar to stroke when they get their migraines, drowsy and unresponsive, speech and limb issues

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28
Q

How might children present with migraine

A

Recurrent abdominal pain

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29
Q

How does a tension headache present

A 
Mild to moderate pain 
Pressing or tingling quality 
Bilateral 
No nausea or vomiting 
No photo or phonophobia
30
Q

How can you treat tension headaches

A

Relaxation physiotherapy
Antidepressants - amitriptyline
Reassure

31
Q

What are trigeminal autonomic cephalgia’s

A

Group of primary headache disorders

Characterised by unilateral trigeminal pain that occurs alongside ipsilateral cranial autonomic features

32
Q

What are the ipsilateral cranial autonomic features seen in TACs

A 
Ptosis
Miosis
Nasal Stuffiness
Nausea/ vomiting
Tearing
Eye lid oedema
33
Q

What are the 4 types of trigeminal autonomic cephalgia’s

A

Cluster headaches
Paroxysmal hemicrania
Hemicrania continua
SUNCT

34
Q

Who gets cluster headaches

A

Most commonly young men

30s-40s

35
Q

When do cluster headaches occur

A

Seem to have circadian and seasonal variation

Bouts will last weeks to months

36
Q

How do you treat cluster headaches

A

High flow oxygen 100% for 20 mins
Sub cut sumatriptan 6mg
Steroids- reducing course over 2 weeks
Verapamil for prophylaxis

37
Q

Who gets paroxysmal hemicrania

A

Older people - 50-60

Women more commonly than men

38
Q

What are the features of paroxysmal hemicrania

A

Severe unilateral headache
Unilateral autonomic features
Lasts 10-30 mins
Can get 1-40 attacks per day

39
Q

How do you treat paroxysmal hemicrania

A

Indomethacin

Has an absolute response

40
Q

What is hemicrania continuum

A

Severe unilateral headache which is present all the time during an exacerbation
Also get the autonomic symptoms

41
Q

What is SUNCT

A 
Primary headache syndrome 
Short lived (15-120 secs)
Unilateral
Neuralgiaform headache 
Conjunctival injections 
Tearing
42
Q

How do you treat SUNCT

A

Lamotrigine

Gabapentin

43
Q

What investigations are needed if there is new onset of cranial autonomic symptoms

A

MRI brain

MR angiogram

44
Q

Who gets idiopathic intracranial hypertension

A

More common in women

Overweight - getting more common as obesity rises

45
Q

How does idiopathic intracranial hypertension present

A

Headache that is worse in the morning - diurnal variation
Morning N&V
Gets better when they stand up
Visual loss

46
Q

What investigations need to be done if you suspect idiopathic intracranial hypertension

A

MRI brain - rule out more sinister causes
Should be normal
If normal do a LP - will show elevated pressure
Visual fields examination

47
Q

When should you not do a LP

A

In someone with signs of raised ICP

Unless they have a brain scan and it is normal

48
Q

How do you treat idiopathic intracranial hypertension

A

Weight loss - can be the cure
Acetazolamide - carbonic anhydrase inhibitor
VA or LP shunt - if at risk of blindness
Monitor the visual fields and CSF pressure

49
Q

Who gets trigeminal neuralgia

A

Elderly - over 60

More common in women

50
Q

What triggers trigeminal neuralgia

A

Aggravated by touch – shooting pain when touch their face
e.g. on shaving, applying makeup, brushing teeth
Also made worse by chewing, wind etc

51
Q

How does trigeminal neuralgia present

A 
Severe, stabbing pain - excruciating, some commit suicide it is so bad 
Unilateral 
Aggravated by touch 
Lasts 1-90secs 
Can get 10-100 attacks per day 
Bouts may last from weeks to months
52
Q

How do you treat trigeminal neuralgia

A

Carbamazepine
Gabapentin
Phenytoin
Baclofen

Surgical:
Microvascular decompression
Decompression better in young patients

Percutaneous injection - need repeated
- glycerol
- ballon compression of the nerve
- thermocoagulation (high risk of numbness)
Good for elderly or those not fit for surgery

53
Q

Which other structures (non-neurological) can cause facial pain

A 
Eyes 
Ears 
Sinuses 
Teeth 
TMJ
54
Q

How does migraine present

A

Unilateral, throbbing
headache
Autonomic symptoms include photophobia
Aura

55
Q

Which conditions may present with acute headache

A 
Sub-arachnoid haemorrhage
Meningitis 
Other serious intra-cranial pathology i.e. post-trauma 
Cluster headache 
Eye issues - glaucoma, optic neuritis
56
Q

Which conditions may present with chronic headache

A

Tension headache - most common
Migraine
Brain tumour

57
Q

How can you treat recurrent vomiting in migraine

A

Prochloperazine

58
Q

What are the most common types of headache seen in practice

A

Tension headache

Migraine

59
Q

Which other symptoms may be associated with headache caused by sinusitis

A

Preceding cold or nasal discharge

60
Q

Which other symptoms may be associated with headache caused by glaucoma

A

Misting of vision

Haloes around objects

61
Q

Which other symptoms may be associated with headache caused by optic neuritis

A

Loss of vision

62
Q

Which other symptoms may be associated with headache caused by haemorrhage

A

Instant onset
Vomiting
Neck stiffness

63
Q

Which other symptoms may be associated with headache caused by hydrocephalus

A

Impaired conscious level

Impaired up gaze

64
Q

Which other symptoms may be associated with headache caused by infections

A

Impaired conscious level
Acute onset
Neck stiffness
Fever

65
Q

Which other symptoms may be associated with headache caused by tumours

A

Vomiting

Disc oedema

66
Q

Which other symptoms may be associated with headache caused by sub-dural haematoma

A

Impaired conscious level

Focal neurological signs

67
Q

Which other symptoms may be associated with headache caused by benign intracranial hypertension

A

Disc oedema

Visual symptoms

68
Q

Which other symptoms may be associated with headache caused by temporal arteritis

A

Scalp tenderness
Jaw claudication
Thickened temporal artery

69
Q

Which other symptoms may be associated with headache caused by chronic tension

A

Anxiety and depression

70
Q

Which other symptoms may be associated with headache caused by cervical spondylosis

A

Neck and arm pain

Neurology (18 decks)

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