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Week A12 - Neurology > Headache > Flashcards

Headache Flashcards

1
Q

Name the different types of headache syndromes:

  1. primary headache syndromes? [4]
  2. secondary headache syndromes? [4]
A
  1. Primary Headache Syndromes
    • migraine
    • trigeminal autonomic cephalgia
    • tension headaches
    • cluster headaches
  2. Secondary Headache Syndromes
    • thunderclap headache
    • high pressure headache
    • low pressure headache
    • neuralgias
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2
Q

What history of presenting compliant questions should be asked to a patient coming in with a headache? [11]

A
  1. Age of onset
  2. Pattern:
    • chronic headache,
    • episodic (define pattern)
    • constant/recurrent
  3. Onset — time to peak:
    • thunderclap or gradual onset
  4. Progression/Periodicity:
    • frequency/duration
    • is the patient headache-free between attacks?
  5. Location:
    • facial/retro-orbital/frontal/occipital/parietal
    • unilateral/bilateral
    • radiation of pain
  6. Character: Aura
    • typically reversible visual, sensory or language symptoms
  7. Intensity:
    • use visual analogue scale 0-10
  8. Precipitating factors:
    • what were they doing when they got the headache?
  9. Exacerbating or relieving factors:
    • (features of high or low pressure)
  10. Associated symptoms:
    • nausea/vomiting
    • photophobia (fear of light)
    • phonophobia (fear of sound)
  11. Concerns about headaches: what do they think it is?
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3
Q

What other questions should be asked to a patient coming in with a headache?

  1. PMHx? [9]
  2. DH? [2]
  3. FM? [2]
  4. SH? [6]
  5. Others? [3]
A
  1. PMH
    • Immunosuppression
    • Cancer
    • Foreign travel
    • Cardiac, cerebrovascular renal, hepatic, psychiatric, gastric disease
  2. DH
    • Medications that cause HA
    • Drug-drug interactions for potential therapy
  3. FM
    • Migraine
    • Tumour
  4. SH
    • Sleep
    • Meals
    • Exercise
    • Caffeine
    • Illicit drugs, alcohol (falls??)
    • Gas appliances
  5. Others
    • impact
    • concerns
    • expectations
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4
Q

What examinations should you carry out on a patient with a headache? [9]

A
  1. Blood pressure, urine dipstick, pregnancy test, temperature, weight
  2. GCS, mental status examination
  3. Palpation — skull, neck, greater occipital nerves, TMJ, temporal arteries, nuchal rigidity?
  4. Eyes
    • Acuity, visual fields, (blind spot), fundi, assessment for papilloedema and spontaneous venous pulsation, movements
  5. Presence or absence of Horner’s 3rd, 6th nerve palsies
  6. Facial sensation
  7. Autonomic features if during an attack
  8. Cranial nerves, routine neurological examination
  9. Skin exam (rashes), cervical lymphadenopathy, tympanic examination
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5
Q

What investigations should you do on a patient with a headache? [8]

A

(depends on circumstance)

  1. Blood pressure
  2. ECG
  3. Urinalysis
  4. Bloods (e.g. ESR, CRP, FBC, UEs, thyroid function)
  5. CT Brain/MRI Brain
  6. Lumbar puncture (opening pressure, blood products, other constituents)
  7. CT angiogram/MR angiogram
  8. CT venogram/MRI venogram
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6
Q

Which headache patients should you do imaging on? [9]

A
  1. Systemic symptoms
  2. Secondary risk factors
  3. Seizures
  4. Neurological symptoms/Focal neurological deficit
  5. Depending on onset and progression (incl. change in attack frequency, nature)
  6. Older
  7. Presence of papilloedema
  8. Precipitated by cough, exertion, sleep, valsalva
  9. Change in nature of headache (or new headache)
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7
Q

What is the diagnostic criteria for a tension type headache? [8]

A
  1. At least 10 episodes of headache occurring on <1 day/month on average (<12 days/year) and fulfilling criteria B-D (2-4)
  2. Lasting from 30 minutes to 7 days
  3. At least two of the following four characteristics:
    • bilateral location
    • pressing or tightening (non-pulsating) quality
    • mild or moderate intensity
    • not aggravated by routine physical activity such as walking or climbing stairs
  4. Both of the following:
    • no nausea or vomiting
    • no more than one of photophobia or phonophobia
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8
Q

Describe the basic pathophysiology of a migraine [3]

A
  1. Interaction between primary afferent nociceptive neurons/trigeminovascular system/brainstem/thalamus/hypothalamus/cortex - i.e. brain disorder
  2. Calcitonin gene related peptide (CGRP)
  3. NOT a primary vascular problem
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9
Q

What is the ICHD-3 diagnostic criteria for a migraine? [8]

A
  1. At least five attacks fulfilling criteria B-D
  2. Headache attacks lasting 4-72 hours (when untreated or unsuccessfully treated)
  3. Headache has at least two of the following four characteristics:
    • unilateral location
    • pulsating quality
    • moderate or severe pain intensity
    • aggravation by or causing avoidance of routine physical activity (e.g. walking or climbing stairs)
  4. During headache at least one of the following:
    • nausea and/or vomiting
    • photophobia and phonophobia
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10
Q

What are the 4 phases of a migraine? [4]

A
  1. Prodrome
  2. Aura
  3. Headache
  4. Postdrome
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11
Q

Prodrome phase of a migraine:

  1. when does it occur? [1]
  2. what are the symptoms? [8]
A
  1. Occurs hours-days before the headache
  2. Symptoms:
    • Yawning
    • Polyuria
    • Depression
    • Irritability
    • Food cravings
    • Poor concentration
    • Sensitivity to light and sound
    • Poor sleep
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12
Q

Aura phase of a migraine:

  1. when does it occur? [1]
  2. visual disturbance symptoms? [3]
  3. somatosensory symptoms? [2]
  4. motor symptoms? [4]
  5. speech/language symptoms? [2]
A
  1. Occurs 5-60mins before the headache
  2. Visual disturbance symptoms:
    • chaotic distorting
    • “melting”
    • jumbling of lines, dots, or zigzags, scotomata
    • hemianopia
  3. Somatosensory symptoms:
    • paraesthesia, spreading from fingers to face
  4. Motor symptoms:
    • dysarthria
    • ataxia
    • ophthalmoplegia
    • hemiparesis
  5. Speech/Language:
    • dysphasia
    • paraphasia
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13
Q

Headache phase of a migraine:

  1. how long does it last? [1]
  2. symptoms? [5]
A
  1. Lasts 4-72 hours
  2. Symptoms:
    • throbbing headache
    • nausea
    • vomiting
    • photophobia
    • worse with activity
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14
Q

Postdrome phase of a migraine:

  1. how long does it last? [1]
  2. symptoms? [4]
A
  1. Lasts 24-48hrs after headache
  2. Symptoms:
    • depression
    • euphoria
    • poor concentration
    • fatigue
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15
Q

What is the acute treatment of a migraine? [3]

A
  1. Restrict acute medication to 2 days a week:
    • Simple analgesics: aspirin or ibuprofen
    • Triptans
      • Sumatriptan
  2. Only work once headache starts
  3. General efficacy is to work for 2 out of 3 attacks
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16
Q

If a person with a migraine has early or persistent vomiting, how should you treat them? [3]

A
  1. Add antiemetic metoclopramide or prochlorperazine
  2. Consider nasal zolmitriptan or subcutaneous sumatriptan
17
Q

Describe the strategy for prophylactic therapy for migraines [7]

A
  1. Give lifestyle advice/identify triggers (if any)
  2. Identify and treat medication overuse
  3. Prophylaxis if >4-5 disabling headaches per month
    • Propranolol
    • Topiramate
    • Amitriptyline
    • Candesartan
    • Flunarizine
  4. Use headache diaries
  5. For each medication, determine efficacy at 3 months (30-50% reduction in headache days?)
  6. If ineffective, wean medication and try another one
  7. If effective, continue 6-12 months.
18
Q

Describe the diagnostic criteria for a cluster headache [12]

A
  1. At least five attacks fulfilling criteria B-D
  2. Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15-180 minutes (when untreated)
  3. Either or both of the following:
    • at least one of the following symptoms or signs, ipsilateral to the headache:
      • conjunctival injection and/or lacrimation
      • nasal congestion and/or rhinorrhoea
      • eyelid oedema
      • forehead and facial sweating
      • forehead and facial flushing
      • sensation of fullness in the ear
      • miosis and/or ptosis
    • a sense of restlessness or agitation
  4. Occurring with a frequency between one every other day and 8 per day
19
Q

What are the clinical presenting features of raised pressure headaches? [6]

A
  1. Worse on lying flat, improved on sitting/standing up
  2. Worse in the morning
  3. Persistent nausea/vomiting
  4. Worse on valsalva (e.g. coughing, laughing, straining)
  5. Worse with physical exertion
  6. Transient visual obscurations with change in posture
20
Q

What would you find on examination in a patient with a raised pressure headache? [6]

A
  1. Optic disc swelling— papilloedema
  2. Impaired visual acuity / colour vision
  3. Restricted visual fields / enlarged blind spot
  4. 3rd nerve palsy
  5. 6th nerve palsy (false localising sign)
  6. Focal neurological signs
21
Q

What are the causes of a thunderclap headache? [8]

A
  1. Subarachnoid haemorrhage (most common)
  2. Intracerebral haemorrhage;
  3. Arterial dissection (vertebral or carotid);
  4. Cerebral venous sinus thrombosis;
  5. Ischaemic Stroke
  6. Bacterial meningitis;
  7. Spontaneous intracranial hypotension,
  8. Pituitary apoplexy;
22
Q

What are the features of a low CSF pressure headache? [3]

A
  1. Headache worse on sitting/standing up and relieved by lying down
  2. Results from CSF leakage
  3. Loss of CSF volume causes traction on meninges, cerebral/cerebellar veins and CN V, IX and X;
23
Q

What are the causes of low CSF pressure headaches? [2]

A
  1. Post-lumbar puncture
  2. Spontaneous intracranial hypotension
    • Results from spontaneous dural tear;
    • Can occur following valsalva;

Week A12 - Neurology (15 decks)

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