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Year 2 Neuro > Headache > Flashcards

Headache Flashcards

1
Q

What is headache?

A

Symptom

Half to three quarters of adults aged 18–65 years in the world have hadheadachein the last year and, among those individuals, 30% or more have reportedmigraine

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2
Q

What categories can cause headaches?

A

Structural

Pharmacological e.g. blood dilators dilate vessels in brain

Psychological e.g. stress

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3
Q

What do we divide headaches into?

A

Acute single headache

Dull headache, increasing in severity

Dull headache, unchanged over moths

Recurrent headaches

Triggered headaches

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4
Q

What can cause acute single headaches?

A 
Febrile illness, sinusitis
First attack of migraine
Following a head injury
Subarachnoid haemorrhage
Meningitis, tumour, drugs, toxins, stroke
Thunderclap (sudden onset), low pressure
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5
Q

What can cause a dull headache that increases in severity?

A 
Usually benign
Overuse of medication (e.g. codeine)
Contraceptive pill, hormone replacement therapy
Neck disease
Temporal arteritis
Benign intracranial hypertension
Cerebral tumour
Cerebral venous sinus thrombosis
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6
Q

What can cause a dull headache that is unchanged over months?

A

Chronic tension headache

Depressive, atypical facial pain

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7
Q

What can cause a triggered headache?

A

Coughing, straining, exertion
Coitus
Food and drink

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8
Q

What can cause recurrent headaches?

A

Migraine
Cluster headache
Episodic tension headache
Trigeminal or post-herpetic neuralgia

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9
Q

What are red flags for headahces? (onset)

A

Thunderclap
Acute
Subacute
Strictly unilateral

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10
Q

What are red flags for headaches? (Meningism)

A
  • photophobia
  • phonophobia
  • stiff neck
  • vomiting
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11
Q

What are red flags for headaches? (systemic symptoms)

A

Fever, rash, weight loss

Orthostatic - better lying down

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12
Q

What are red flags for headaches? (neurological symptoms or focal signs)

A

Visual loss, confusion, seizures, hemiparesis, double vision, 3rd nerve palsy, Horner syndrome, papilloedema

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13
Q

What is Horner syndrome?

A

Sympathetic supply to the eye is affected

Eye is droopy

Pupil is slightly smaller

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14
Q

What are the features of subarachnoid haemorrhage?

A

Sudden generalised headache
‘blow to the head’.

Meningism - stiff neck and photophobia

Most are caused by a ruptured aneurysm, a few from arteriovenous malformations.

50% instantly fatal

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15
Q

How do you diagnose subarachnoid haemorrhage?

A

Nimodipine and BP control.

High risk of a further bleed
.
Early neurosurgical assessment will confirm the bleed
and establish the cause.

CT brain, Lumbar puncture (will be pink) (RBC and xanthochromia) and MRA, angiogram.

Blood is white on CT

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16
Q

How do you treat subarachnoid haemorrhage?

A

Nimodipine

Aneurysms used to be clipped or wrapped.

Nowadays filled with platinum coils.

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17
Q

What is coning?

A

Causes raised intracranial pressure

Weak points in the brain

tumour or mass grows when volume becomes significant

Brain no longer compliant after a point and seeps into weak points

Causes herniation

Brainstem death

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18
Q

What is papilloedema?

A

Papilloedema

Optic disc swelling due to raised ICP

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19
Q

Why is neck pain common in headaches?

A

Headache can also arise due to pathology in the large arteries of the neck.

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20
Q

What often causes stroke in young people?

A

Carotid & vertebral artery dissection

20% of ischaemic strokes <45 years (young stroke)

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21
Q

What imaging do you use to diagnose dissections?

A

MRI/MRA, Doppler, Angiography

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22
Q

How do you try prevent stroke?

A

Aspirin or anticoagulation X 6/12

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23
Q

What is SDH?

A

Chronic Subdural haemorrhage

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24
Q

Why are SDH common in older people?

A

They fall

Often on blood thinners

> 65 years

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25
Q

How do SDH’s show on CT?

A

Dark patches

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26
Q

What is temporal arteritis?

A

Constant unilateral headache, scalp tenderness and jaw claudication

25% of those with Polymyalgia Rheumatica-proximal muscle tenderness. Shoulder and pelvic pain worse in the morning.

Involvement of the posterior ciliary arteries causes blindness (amaurosis fugax)

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27
Q

Who gets temporal arteritis?

A

Over the age of 55.
Three times commoner in females.
Polymyalgia rheumatica

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28
Q

How do you diagnose temporal arteritis?

A

Elevated ESR and CRP

Temporal artery are usually inflamed and tortuous.

Visible on ultrasound

Temporal artery biopsy shows inflammation and Giant Cells - definitive test
^ should not delay treated

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29
Q

How do you treat temporal arteritis?

A

High dose steroids and aspirin.

Oral prednisolone immediately

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30
Q

What are the main features of cerebral venous thrombosis?

A

Thrombosis in dural venous sinus or cerebral vein
Unusual amount of headache due to raised ICP
Non-territorial ischaemia “venous infarcts”
Haemorrhage

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31
Q

What causes cerebral venous thrombosis (like risk factors)?

A

Thrombophilia, pregnancy, dehydration, Behcets

32
Q

What can cause meningitis?

A

Infections:
Viral- Coxsackie, ECHO, Mumps, EBV

Bacterial - Meningococci, Pneumococci, Haemophilus
Tuberculous

Fungal - Cryptococci

Granulomatous- Sarcoid, Lyme, Brucella, Behçet’s, Syphilis
Carcinomatous

33
Q

What are the presenting symptoms of meningitis?

A 
Malaise
Headache 
Fever
Neck stiffness
Photophobia
Confusion
Alteration of consciousness
34
Q

What is herpes simplex encephalitis (and what it affects)?

A

Affects temporal lobes

haemorrhagic traces

35
Q

What is the management plan for meningitis?

A

Treat then diagnose as it can kill in minutes

36
Q

How do you treat meningitis?

A

Blood and urine culture
Look for signs of raised ICP

If no: 
Lumbar puncture within an hour
Increased White Cell Count, decreased glucose, Antigens
IV Abs
Dexa 10mg IV

If yes:
ABs
Airways support
Fluid resus

37
Q

What are the main symptoms of sinusitis?

A 
Malaise, headache, fever.
Blocked nasal passages. 
Loss of  vocal resonance.
Anosmia.
Nasal or postnasal catarrh.
Local pain and tenderness.

Frontal pain characteristically starts 1-2 hours after rising and clears up during the afternoon.

38
Q

How can a brain tumour cause headache?

A

Oedema around tumor generates huge amount of pressure

39
Q

What are the symptoms of idiopathic intracranial hypertension?

A

Headache, visual obscurations, diplopia, tinnitus

Papilloedema, +/- visual field loss

40
Q

Who gets idiopathic intracranial hypertension?

A

Often young obese women

41
Q

What causes idiopathic intracranial hypertension?

A

Weight gain

Drugs: hormones, steroids, antibiotics, vitamin E

42
Q

How do you treat idiopathic intracranial hypertension?

A 
weight loss (bariatric surgery)
diuretics
optic nerve sheath decompression
lumboperitoneal shunt
stenting of stenosed venous sinuses
43
Q

Can low pressure cause headaches?

A

Yes

44
Q

What causes low pressure headaches?

A

CSF leak due to tear in dura

Traumatic post lumbar puncture or spontaneous

45
Q

How do you treat low pressure headaches?

A

Treatment rehydration, caffeine, blood patch

46
Q

What is characteristic of low pressure headaches?

A

Orthostatic

47
Q

How do you diagnose low pressure headaches?

A

MRI shows meningeal enhancement

48
Q

What is chiari malformation?

A

Normal brain that just sits very low within the skull

49
Q

How doe chiari malformation cause headache?

A

Cerebellar tonsils descending through the foramen magnum

Descend further when patient cough and tug on the meninges causing cough headache

50
Q

How do you treat chiari malformation?

A

Operation to remodel base of brain

51
Q

What are the features of obstructive sleep apnoea?

A

Hypoxia, CO2 retention, non-refreshing sleep

Depression, impotence, poor performance at work

Require sleep study

Nocturnal NIV, Surgery

52
Q

What is trigeminal neuralgia?

A

Electric shock like pain in the distribution of a sensory nerve.

Often triggered by innocuous stimuli.

Any division of the trigeminal can be affected.

Neurovascular conflict at the point of entry of the nerve into the pons.

Can be symptom of M.S.

53
Q

How do you treat trigeminal neuralgia?

A

Carbamazepine, lamotrigine, gabapentin.

Posterior fossa decompression.

54
Q

What is atypical facial pain?

A

Most commonly in middle aged women. Depressed or anxious.

Daily, constant, poorly localised deep aching or burning.

Facial or jaw bones, but may extend to the neck, ear or throat.

Not lancinating.

Not conforming to the strict anatomical distribution of any nerve.

No sensory loss.

Pathology in teeth, temporomandibular joints, eye, nasopharynx and sinuses must be excluded.

55
Q

How do you treat atypical facial pain?

A

Unresponsive to conventional analgesics, opiates and nerve blocks.
Mainstay of management tricyclics

56
Q

What are the different mechanisms of post-traumatic headache?

A

Neck injury
Scalp injury
Vasodilation ? autonomic damage
Depression - often delayed

57
Q

What does post-traumatic headache depend on?

A

Correlates with previous history of headache

Nature of head injury:
High in victims of car accidents
Low in perpetrators of car accidents
Low in sports injuries

58
Q

How do you manage post-traumatic headache?

A

Explanation
Prevent analgesic abuse

Non-steroidal anti-inflammatories - ibuprofen, naproxen
Tricyclic antidepressants - Amitriptyline

Be patient 3-4 years

59
Q

What are the symptoms of cervical spondylosis?

A 
Usually bilateral
Occipital pain can radiate forwards to the frontal region
Steady pain
No nausea or vomiting
Worsened by moving the neck
60
Q

How do you manage cervical spondylosis?

A

Rest, deep heat, massage.
Anti-inflammatory analgesics.
Over-manipulation may be harmful.

61
Q

Why is cervical spondylosis common in older patients?

A

Arthritis

Narrowing of join space due to worn disc

62
Q

What signs are found in meningitis?

A

Kernig’s sign

Brudzinski’s sign

63
Q

What are the different properties of lumbar puncture

A

Bacterial - turbid, low glucose, high protein

Viral - clear

TB - fibrin web

64
Q

What ABs do you give in hospital for Meningitis?

A

Ceftriaxone
Cefotaxime
+ amoxcicillin if immunocompromised

65
Q

What is the most common cause of encephalitis in the UK?

A

Herpes Simplex Virus

66
Q

How does encephalitis present?

A

Prodome
Odd behaviour
Seizure’s

67
Q

What investigations should be done for encephalitis?

A

Blood cultures
LP
EEG
Contrast enhanced CT/MRI (will see bilateral temporal oedema)

68
Q

What are RFs for Trigeminal neuralgia?

A

60-80 years
MS
Female
HTN

69
Q

What are RFs for Trigeminal neuralgia?

A

60-80 years
MS
Female
HTN

70
Q

What are the investigations for subarachnoid haemorrhge?

A

Urgent CT < 12 hours
LP > 12 hours if CT is normal
Xanthochromic fluid

71
Q

What is the difference between Subarach and SDH?

A

More gradual onset

Venous bleed

72
Q

What are the features of extradural haemorrhage?

A

Extradural or Epidural

Acute build up of blodd between dura and periosteum

Due to trauma

73
Q

What are the presenting features of EDH?

A

Acute onset after lucid interval

Deteriorating of GCS and history of direct trauma

74
Q

What would a crescent shape bleed be on a CT?

A

Sub-dural haemorrhage

75
Q

What is the immediate management of haemorrhages?

A 
A-E
Immediate neurosurgical referral
Cardiopulmonary support
Maintain BP
Raise head of bed to 30 degrees
Osmotic diuretic

Year 2 Neuro (15 decks)

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