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Year 3 > Headache > Flashcards

Headache Flashcards

1
Q 
A 41-year-old man complains of terrible headache. It started without warning, while at work. It affects the right side of his head. He scores it ‘11/10’ on severity. He had a similar episode six months ago, experiencing very similar headaches over 2 weeks which resolved spontaneously. On observation, the right eye is red and he also has ptosis on the right side.  What is the diagnosis?
A. Subarachnoid haemorrhage
B. Tension headache
C. Intracerebral haemorrhage
D. Migraine
E. Cluster headache
A

Cluster headache

Subarachnoid haemorrhage → not recurrent, no ANS symptoms
B. Tension headache → no ANS symptoms
C. Intracerebral haemorrhage not recurrent, no ANS symptoms
D. Migraine → no ANS symptoms

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2
Q 
A 40-year-old man comes in with a headache. The headache started yesterday and he feels it more over one side of his head. He is also quite nauseous and the only thing that helps him is to seat in the dark. He says that he has had similar headaches in the past for which the GP advised ibuprofen and NSAIDs but these did not help him. What’s the next most appropriate step in his management?
Codeine
Diclofenac
Sumatriptan
Topiramate
Amitriptyline
A

Sumatriptan

migraine:
unliateral, nausea, photophobia

Codeine → opioids should be avoided in migraine as they can cause dependence
Diclofenac → NSAIDs haven’t worked so need to step up
Topiramate → first-line for prevention but doesn’t manage headache acutely
Amitriptyline → second-line for prevention

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3
Q

Define secondary headache

A 
Headaches arising secondary to a condition known to cause headache. 
More worrying (can lead to serious complications)
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4
Q

List some causes of secondary headache

A 
Trigeminal neuralgia
Meningitis
Encephalitis
Raised ICP
Bleeds
CNS tumours
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5
Q

How can tension headaches be classified?

A

Episodic - occurs on < 15 days per month

Chronic - occurs on > 15 days per month

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6
Q

Tension headache risk factors

A

stress

disturbed sleep

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7
Q

SOCRATES- symptoms of a simple headache

A 
S: Generalised, Bilateral.
O: Gradual or acute onset
C: Dull – “tight band”
R: Neck/shoulders
A- no associated symptoms
T: Lasts 3-4 hours
E: Analgesics help
S: Moderate
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8
Q

Management of tension headache

A

Conservative: Headache diaries (avoid triggers, relaxation)
Medical: Simple analgesia (paracetamol, ibuprofen)

IMPORTANT: Beware of medication-overuse headaches

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9
Q

What happens in medication overuse headache?

A

analgesics cease to provide pain relief and actually perpetuate and intensify the headaches.

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10
Q

What is migraine?

A

chronic condition that causes attacks of headaches

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11
Q

Pathophysiology of migraine

A

Not clear
Inflammation of the trigeminal nerve changes
the way that the brain process stimuli

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12
Q

Epidemiology of migraine

A

Females: 3X more than males
More common in young adult females
FHx- strong genetic component

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13
Q

Triggers for migraine

A 
Chocolate
Hangovers
Orgasms
Cheese/Caffeine
Oral contraceptives/hormonal fluctuations
Lie-ins
Alcohol
Travel
Exercise
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14
Q

SOCRATES- pain character of a migraine (not associated symptoms)

A 
S: Unilateral
O: Paroxysmal, comes on gradually
R: may radiate to neck
C: Pulsating/throbbing
T: 4 – 72h 
E: lying in a quiet, dark room (triggers see previous)
S: Moderate to severe
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15
Q

What are the associated symptoms of migraine?

A 
Aura: flashing lights, tingling
Photophobia, phonophobia
Nausea, vomiting
Visual changes
Tingling
Numbness
Migraine interferes with current activities
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16
Q

Which characteristic of a migraine is pathognomic?

A

Aura- flashing light, blurring, spots, tingling burning

present only in 15-20% of people

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17
Q

Which characteristic of a migraine is pathognomic?

A

Aura- flashing light (visual disturbances), blurring, spots, tingling burning
present only in 15-20% of people

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18
Q

Briefly explain the phases of migraine

A
  1. prodrome (days before)- change in mood, behaviour, sleep
  2. aura (minutes before)- visual changes, flashing lights.
  3. migraine attack
  4. postdrome- weakness and fatigue
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19
Q

How do you investigate migraine?

A

clinical diagnosis

may do investigations to rule out sinister cause

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20
Q

Migraine management

A

Start conservative and move down if previous not effective:

① Conservative: Headache diary, avoid triggers

②Acute Medical

  • Paracetamol, Ibuprofen, NSAIDs
  • Triptans

③ Preventative

  • Propranolol (BB) or topiramate (antiepileptic)
  • Amitriptyline (antidepressant)
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21
Q

Migraine management

A

Start conservative and move down if previous not effective:

① Conservative: Headache diary, avoid triggers

②Acute Medical

  • Paracetamol, Ibuprofen, NSAIDs
  • Triptans

③ Preventative

  • Propranolol (BB) or topiramate (antiepileptic)
  • Amitriptyline (antidepressant) = second line
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22
Q

Which medication is used specifically to treat acute migraines?

A

triptans

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23
Q

Define cluster headaches

A

A neurological disorder characterized by

recurrent, severe headaches on one side of the head, which occur in a cyclical pattern

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24
Q

epidemiology of cluster headache

A

20-40 years old

more common in males

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25
Q

SOCRATES- cluster headache (not associated symptoms)

A

S: UNILATERAL, behind the eye (temporal/retro-orbital)
O: Acute onset, CYCLICAL PATTERN, occur at same time, usually at night
C: intense, sharp, penetrating
T: 15 minutes – 3 hours
E: triggered by alcohol & strong smells
S: Severe – Can be disabling

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26
Q

What are the associated symptoms/signs of cluster headache?

A

Watery, red eye
Facial flushing
Nasal congestion
Partial horner’s syndrome (ptosis, miosis)

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27
Q

What are the associated symptoms of cluster headache (ptosis, miosis, red eye etc) as a result of?

A

Trigeminal and autonomic activation 2/2 hypothalamic activation

Partial horner’s is due to third order postganglionic neuron damage.

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28
Q

RF for cluster headaches

A

smoking, alcohol

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29
Q

Define trigeminal neuralgia

A

Facial pain syndrome in the distribution of 1 or more divisions of the trigeminal nerve.

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30
Q

Pathophysiology of trigeminal neuralgia

A

Compression of the trigeminal nerve by a loop of

artery or vein

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31
Q

Trigeminal neuralgia is associated with which disease?

A

MS (plaque deposition)

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32
Q

Triggers for trigeminal neuralgia

A

ANYTHING TO COMPRESS TRIGEMINAL NERVE:

  • brushing hair
  • like washing your face
  • eating
  • brushing teeth
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33
Q

RF for trigeminal neuralgia

A

HYPERTENSION
arteriosclerotic vascular changes
aging
FHx

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34
Q

SOCRATES- trigeminal neuralgia

A

S: Unilateral, along the trigeminal division
O: paroxysmal
C: stabbing, shooting
R: doesn’t radiate (division of trigeminal nerve)
A: Numbness
T: lasts for seconds
E: brushing teeth, speaking, shaving, talking
S: can be severe

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35
Q

Define meningitis

A

inflammation of the meninges

Microorganisms reach the CNS, irritate the meninges and lead to symptoms. Once they enter the subarachnoid space, they multiply, causing and inflammatory reaction and this leads to symptoms

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36
Q

What is the most common pathogenic group causing meningitis?

A

viral more common and less deadly

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37
Q

Most common bacterial cause of meningitis in neonates

A

E. Coli

Group B Strep

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38
Q

Most common bacterial cause of meningitis in children

A

H. influenzae,

Strep. pneumoniae

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39
Q

Most common bacterial cause of meningitis in young adults

A

Neisseria meningitidis

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40
Q

Most common bacterial cause of meningitis in elderly/adults.

A

Strep pneumoniae,

Listeria monocytogenes

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41
Q

Meningococcal disease presents how?

A

Typically presents with acute onset fever and malaise progressing rapidly to signs and symptoms of sepsis and/or meningitis
NON-BLANCHING, PETICHEAL RASH

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42
Q

What are the symptoms of meningitis?

A

EARLY SYMPTOMS
Acute, severe headache
Fevere

LATE SYMPTOMS
Meningism:
  - Neck stiffness 
  - Photophobia
Rash
Vomiting
Seizures
Altered mental status
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43
Q

RF for meningitis

A

Closed communities/Crowding

Age <5, >65

44
Q

Signs of meningitis on examination

A

Kernig’s Sign
Brudzinski’s Sign
Petechial or purpuric rash is typically associated with meningococcal meningitis
Signs of infection: Fever, Tachycardia, Hypotension

45
Q

What is Kernig’s sign

A

Pain/resistance on passive knee extension when the hip is flexed - this is due to severe stiffness in the hamstrings

46
Q

What is Brudzinki’s sign

A

Flexion of the hips and knees when the neck is flexed - this is due to severe neck stiffness

47
Q

Investigations for meningitis

A
  1. CT head (raised ICP- neurological deficit or ↓ consciousness)
  2. Lumbar puncture = DIAGNOSTIC
  3. Blood cultures
    If suspected meningitis, do not delay treatment to wait for results- start empirical Abx
48
Q

Compare the appearance of CSF in meningitis caused by:

  • bacterial
  • viral
  • TB
A 
BACTERIAL = turbid
VIRAL = clear
TB = fibrin web
49
Q

Compare the cells in CSF in meningitis caused by:

  • bacterial
  • viral
  • TB
A 
BACTERIAL = ↑ neutrophils (polymorphs)
VIRAL = ↑ lymphocytes (mononuclear)
TB = ↑ lymphocytes (mononuclear)
50
Q

Compare the glucose in CSF in meningitis caused by:

  • bacterial
  • viral
  • TB
A 
BACTERIAL = low (bacteria metabolise glucose)
VIRAL = normal
TB = low
51
Q

Compare the protein in CSF in meningitis caused by:

  • bacterial
  • viral
  • TB
A 
BACTERIAL = high
VIRAL = normal/high
TB = high

protein indicates inflammation of the CSF

52
Q

Management of meningitis

A

FIRST STEP:

  • broad spectrum empirical Abx
  • (A+E)- IV ceftriaxone
  • (GP) - IM benzylpenicillin, acyclovir (suspect viral)

other medical:

  • IV glucocorticoids (dexamethasone)- anti-inflammatory- reduce risk of complications
  • Targeted antibiotic Tx depending on sensitivities
53
Q

What are the complications of meningitis?

A 
Hearing loss- most common
Shock/sepsis
Spread to the brain parenchyma = meningoencephalitis (causes altered mental status)
Seizures
Waterhouse-Friderichen Syndrome
54
Q

What is Waterhouse-Friderichen Syndrome?

A

bilateral adrenal haemorrhage caused by severe meningococcal infection

55
Q

Define encephalitis

A

Inflammation of the brain parenchyma. (Can be

FATAL)

56
Q

most common aetiological cause of encephalitis

A

Usually viral:

  • HSV1-2
  • CMV
  • EBV
  • HIV
  • measles
57
Q

non-viral causes of encephalitis

A 
bacterial meningitis
TB
malaria
listeria
Lyme disease
legionella
58
Q

epidemiology of encephalitis

A

extremes of age
<1
>65

59
Q

How does encephalitis usually present?

A

Acute onset febrile illness with behavioural, cognitive, psychiatric manifestations:

  • Viral prodrome prodrome (rash, lymphadenopathy)
  • Fever
  • Headache

ALTERED MENTAL STATE:

  • Memory disturbances
  • Personality changes
  • Psychiatric manifestations
  • Impaired consciousness
60
Q

Investigations for encephalitis

A
  • LP- CSF analysis would show similar changes to meningitis, depending on causative agent)
  • Bloods
  • EEG
  • MRI (oedema/hyperintense lesions)
61
Q

compare presentations of encephalitis and meningitis

A

encephalitis presents with altered mental status/impaired consciousness, meningitis doesn’t

62
Q

2 broad causes of raised ICP

A

SOL (tumour, abscess, haemorrhage)

Hydrocephalus (increased CSF volume)

63
Q

Symptoms of raised ICP

A

headache:

  • worse in morning
  • worse with coughing and sneezing
  • bilateral, gradual onset
  • throbbing/bursting

Associated symptoms:

  • Vomiting
  • Altered GCS
  • Seizures
64
Q

Signs of raised ICP

A 
Focal neurological symptoms
Papilloedema
Cushing’s reflex → Cushing’s triad
1. ↑SBP
2. Cheyne-stokes respiration
3. Bradycardia
65
Q

What is Cheyne - stokes respiration? Associated conditions

A

Abnormal pattern of breathing characterised by progressively deeper and sometimes faster breathing followed by a gradual decrease that results in apnoea.

Associated with:

  • HF
  • stroke
  • hyponatraemia
  • TB
  • brain tumours
66
Q

How does raised ICP cause focal neurological symptoms?

A

↑ICP can put pressure in nearby structures

eg 3rd nerve palsy, 6th nerve palsy, horner’s syndrome

67
Q

Investigations for raised ICP

A

URGENT CT-head

↑ICP is a CONTRAINDICATION to LP!
can contribute to brainstem herniation

68
Q

Define EDH

A

A collection of blood in the potential space between the dura and the bone

69
Q

cause of EDH

A

head trauma
Often due to a fractured temporal or parietal bone causing a laceration of the MMA
This lies under the pterion

70
Q

epidemiology of EDH

A

young- 20-30 yrs

men

71
Q

How does EDH present?

A
  1. Usually following head trauma (may lose consciousness)
  2. There will then be a lucid interval
  3. Followed by increasingly severe headache

May develop to N&V, confusion, seizure, paresis, brainstem herniation

72
Q

Investigations for EDH

A

O/E- may show ipsilateral pupil dilation due to compression of oculomotor nerve CNIII

Urgent Non-contrast CT head-scan

MRI

73
Q

What are the CT features of EDH?

A
  1. Fluid collection shows lenticular (lemon) shape

2. Does not cross suture lines- dura attaches to the skull more tightly across the suture lines- can’t expand across

74
Q

Define SDH

A

A collection of blood between the dural and arachnoid covering of the brain

75
Q

Aetiology/RF for SDH

A

Rupture of the bridging veins

  • Head trauma & falls (often following minor trauma up to 9 weeks before which patients have forgotten)
  • Old age (brain atrophy)
  • Alcoholics (brain atrophy)
  • Anticoagulation
76
Q

vessels affected SDH versus EDH

A 
SDH = bridging veins
EDH = MMA
77
Q

Symptoms of SDH

A 
Gradual onset, continuous headache
Fluctuating consciousness
Confusion
Personality changes
Symptoms of ↑ ICP
78
Q

How is SDH classified?

A

Depending on the onset of symptoms they can be separated into:

  • Acute: <3 days
  • Subacute: 3-21 days
  • Chronic: >21 days
79
Q

State the characteristics of an acute SDH

A

within 72 hours

occur in younger patients and are associated with major trauma + reduced consciousness

80
Q

State the characteristics of a subacute SDH

A

worsening headache 7-14 days after injury
altered mental status
elderly

81
Q

State the characteristics of a chronic SDH

A

> 21 days (up to 9 weeks)
elderly eg following a fall

headache, confusion, cognitive impairment, psychiatric symptoms, gait deterioration, focal weakness, seizures.

82
Q

Investigations for SDH

A

urgent non-contrast CT

83
Q

CT features of SDH

A

BANANA shaped

subdural fluid collection is usually crescentic in shape and can cross suture lines.

84
Q

SDH small (<10mm) and no significant neurological dysfunction management

A

Conservative management:
admit, observe and monitor. Do a follow-up CT in 2-3 weeks.

  • Prophylactic antiepileptics
  • ICP monitoring if GCS < 9
  • Correct coagulopathies
  • Lower ICP
85
Q

management of a large SDH

A

If large or significant neurological dysfunction: Burr hole or craniotomy

86
Q

Definition/aetiology of SAH

A

Bleeding into the subarachnoid space, most commonly due to rupture of a saccular/berry aneurysm

87
Q

Symptoms of SAH

A

Thunderclap headache- very severe, very acute
continuous + diffuse

May be associated with meningism and signs of raised ICP

88
Q

RF for SAH

A

PKD (5x increased risk of aneurysms)
alcohol
smoking
hypertension

89
Q

Investigations for SAH

A

Urgent non-contrast CT scan of the head within 12 hours (sensitivity decreases with time 98-50% in a week)

  • ECG (patients may present with arrhythmias/abnormalties)
  • bloods (deranged clotting)
  • LP if CT normal
90
Q

What would you see in the LP of a patient with a SAH?

A

Xanthochromia & oxyhaemoglobin
From 12 hours after symptom onset- haem metabolised to bilirubin
(CSF may be bloody if active bleeding)

91
Q

What would you see in the CT of a patient with a SAH?

A

Hyperattenuation around the circle of willis

92
Q 
An older man with a longstanding history of AF on anticoagulation with warfarin is brought into A & E by his carer, who is concerned about the patient's confusion at home. The carer describes frequent falls over the last several months. On examination, he has a right-sided pronator drift and is weaker on his right side. His mental status testing reveals poor concentration. What is the most likely cause of his symptoms?
Stroke
Subdural haemorrhage
Alzheimer’s disease
Encephalitis
Parkinson’s disease
A

SDH

Stroke → UMN (can have pronator drift but more acute presentation)
Alzheimer’s disease → wouldn’t present with one-sided weakness and pronator drift
Encephalitis → has changes in behaviour and mental state but here the patient does not have any features suggestive of infection, and the anticoagulation is a stronger RF for bleeding
Parkinson’s disease → would present more with resting tremor, bradykinesia

93
Q

Where do most brain tumours arise?

A 
Majority metastasise:
lung
breast
colon
kidney
melanoma
94
Q

What is the most common primary CNS tumour?

A

Glioma

95
Q

How can primary brain tumours be classified?

A

Intra-axial tumours: within the brain parenchyma

Extra-axial tumours: outside the brain parenchyma (eg meninges, spinal cord)

96
Q

What type of brain tumour is more common in children?

A

Medulloblastomas

Brain tumours are the second most common cancer in children (15–25% all paediatric malignancies)

97
Q

What is the peak age for brain cancer?

A

60-70

98
Q

Symptoms of CNS tumours

A

Headache (↑ICP)

  • Bilateral
  • Gradual
  • throbbing/bursting
  • worse in the morning, on coughing, sneezing

other:

  • FLAWS
  • Focal neurological signs
  • Weakness
  • Difficulty walking
  • Seizures
  • Personality changes
99
Q

What might you find O/E of a patient with a CNS tumour?

A

Papilloedema

Focal neurological signs: visual field defects, dysphasia, agnosia, hemianopial, hemiparesis

100
Q

RF for brain tumours

A 
History of cancer
FHx of cancer
Ionising radiation
Immunosuppression (HIV)
Inherited syndromes (eg neurofibromatosis)
101
Q

What factors may cause a benign brain tumour to be dangerous?

A
  1. Direct effect: brain is infiltrated and local function impaired
  2. Secondary effects of raised ICP and shift of intracranial contents (papilloedema, vomiting, headache)
  3. Provoking generalised or partial seizures
  4. May transform into malignancy
102
Q

What might be some features of a tumour in the frontal lobe?

A

personality disturbance
apathy
impaired intellect

103
Q

How might a right parietal lobe tumour present?

A

L homonymous hemianopia
L sided hemiparesis
L sensory loss

104
Q

What type of brain tumour may present with progressive deafness?

A

Vestibular schwannoma (benign tumour of vestibulo-cochlear nerves)

105
Q

Investigations for brain tumours

A

CT = FIRST LINE
MRI (better resolution)
CXR, CT thorax, abdo & pelvis to check for metastases
Biopsy = DIAGNOSTIC

106
Q

State the headache red flags

A
  • FLAWS- systemic signs
  • Neurological deficit- papilloedema, hemiparesis, hemi-sensory loss, diplopia, dysarthria
  • very acute onset (thunderclap)
  • New headache aged >50 years
  • change in quality/frequency/location of existing headaches
107
Q

A 33-year-old woman attends her six-month follow-up appointment for headache. They are migrainous in nature but whereas she used to have them every few months, over the last three months she has experienced a chronic daily headache. She takes co-codamol qds and ibuprofen
tds. What is the best medical management?
A. Stop all medication
B. Start paracetamol
C. Start sumatriptan
D. Start propranolol
E. Continue current medication

A

Stop all medication

The treatment is to withdraw analgesics which initially will worsen the headache (the patient should be prepared for this) but in the long run will alleviate it.

It is not advisable for headache patients to take simple analgesia more than 2 days a week.

Year 3 (38 decks)

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