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
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
3
Q
Define secondary headache
A
Headaches arising secondary to a condition known to cause headache. More worrying (can lead to serious complications)
4
Q
List some causes of secondary headache
A
Trigeminal neuralgia Meningitis Encephalitis Raised ICP Bleeds CNS tumours
5
Q
How can tension headaches be classified?
A
Episodic - occurs on < 15 days per month
Chronic - occurs on > 15 days per month
6
Q
Tension headache risk factors
A
stress
disturbed sleep
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
8
Q
Management of tension headache
A
Conservative: Headache diaries (avoid triggers, relaxation)
Medical: Simple analgesia (paracetamol, ibuprofen)
IMPORTANT: Beware of medication-overuse headaches
9
Q
What happens in medication overuse headache?
A
analgesics cease to provide pain relief and actually perpetuate and intensify the headaches.
10
Q
What is migraine?
A
chronic condition that causes attacks of headaches
11
Q
Pathophysiology of migraine
A
Not clear
Inflammation of the trigeminal nerve changes
the way that the brain process stimuli
12
Q
Epidemiology of migraine
A
Females: 3X more than males
More common in young adult females
FHx- strong genetic component
13
Q
Triggers for migraine
A
Chocolate Hangovers Orgasms Cheese/Caffeine Oral contraceptives/hormonal fluctuations Lie-ins Alcohol Travel Exercise
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
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
16
Q
Which characteristic of a migraine is pathognomic?
A
Aura- flashing light, blurring, spots, tingling burning
present only in 15-20% of people
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
18
Q
Briefly explain the phases of migraine
A
- prodrome (days before)- change in mood, behaviour, sleep
- aura (minutes before)- visual changes, flashing lights.
- migraine attack
- postdrome- weakness and fatigue
19
Q
How do you investigate migraine?
A
clinical diagnosis
may do investigations to rule out sinister cause
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)
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
22
Q
Which medication is used specifically to treat acute migraines?
A
triptans
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
24
Q
epidemiology of cluster headache
A
20-40 years old
more common in males
25
SOCRATES- cluster headache (not associated symptoms)
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
26
What are the associated symptoms/signs of cluster headache?
Watery, red eye
Facial flushing
Nasal congestion
Partial horner’s syndrome (ptosis, miosis)
27
What are the associated symptoms of cluster headache (ptosis, miosis, red eye etc) as a result of?
Trigeminal and autonomic activation 2/2 hypothalamic activation
Partial horner’s is due to third order postganglionic neuron damage.
28
RF for cluster headaches
smoking, alcohol
29
Define trigeminal neuralgia
Facial pain syndrome in the distribution of 1 or more divisions of the trigeminal nerve.
30
Pathophysiology of trigeminal neuralgia
Compression of the trigeminal nerve by a loop of
| artery or vein
31
Trigeminal neuralgia is associated with which disease?
MS (plaque deposition)
32
Triggers for trigeminal neuralgia
ANYTHING TO COMPRESS TRIGEMINAL NERVE:
- brushing hair
- like washing your face
- eating
- brushing teeth
33
RF for trigeminal neuralgia
HYPERTENSION
arteriosclerotic vascular changes
aging
FHx
34
SOCRATES- trigeminal neuralgia
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
35
Define meningitis
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
36
What is the most common pathogenic group causing meningitis?
viral more common and less deadly
37
Most common bacterial cause of meningitis in neonates
E. Coli
| Group B Strep
38
Most common bacterial cause of meningitis in children
H. influenzae,
| Strep. pneumoniae
39
Most common bacterial cause of meningitis in young adults
Neisseria meningitidis
40
Most common bacterial cause of meningitis in elderly/adults.
Strep pneumoniae,
| Listeria monocytogenes
41
Meningococcal disease presents how?
Typically presents with acute onset fever and malaise progressing rapidly to signs and symptoms of sepsis and/or meningitis
NON-BLANCHING, PETICHEAL RASH
42
What are the symptoms of meningitis?
EARLY SYMPTOMS
Acute, severe headache
Fevere
```
LATE SYMPTOMS
Meningism:
- Neck stiffness
- Photophobia
Rash
Vomiting
Seizures
Altered mental status
```
43
RF for meningitis
Closed communities/Crowding
| Age <5, >65
44
Signs of meningitis on examination
Kernig's Sign
Brudzinski's Sign
Petechial or purpuric rash is typically associated with meningococcal meningitis
Signs of infection: Fever, Tachycardia, Hypotension
45
What is Kernig's sign
Pain/resistance on passive knee extension when the hip is flexed - this is due to severe stiffness in the hamstrings
46
What is Brudzinki's sign
Flexion of the hips and knees when the neck is flexed - this is due to severe neck stiffness
47
Investigations for meningitis
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
Compare the appearance of CSF in meningitis caused by:
- bacterial
- viral
- TB
```
BACTERIAL = turbid
VIRAL = clear
TB = fibrin web
```
49
Compare the cells in CSF in meningitis caused by:
- bacterial
- viral
- TB
```
BACTERIAL = ↑ neutrophils (polymorphs)
VIRAL = ↑ lymphocytes (mononuclear)
TB = ↑ lymphocytes (mononuclear)
```
50
Compare the glucose in CSF in meningitis caused by:
- bacterial
- viral
- TB
```
BACTERIAL = low (bacteria metabolise glucose)
VIRAL = normal
TB = low
```
51
Compare the protein in CSF in meningitis caused by:
- bacterial
- viral
- TB
```
BACTERIAL = high
VIRAL = normal/high
TB = high
```
protein indicates inflammation of the CSF
52
Management of meningitis
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
What are the complications of meningitis?
```
Hearing loss- most common
Shock/sepsis
Spread to the brain parenchyma = meningoencephalitis (causes altered mental status)
Seizures
Waterhouse-Friderichen Syndrome
```
54
What is Waterhouse-Friderichen Syndrome?
bilateral adrenal haemorrhage caused by severe meningococcal infection
55
Define encephalitis
Inflammation of the brain parenchyma. (Can be
| FATAL)
56
most common aetiological cause of encephalitis
Usually viral:
- HSV1-2
- CMV
- EBV
- HIV
- measles
57
non-viral causes of encephalitis
```
bacterial meningitis
TB
malaria
listeria
Lyme disease
legionella
```
58
epidemiology of encephalitis
extremes of age
<1
>65
59
How does encephalitis usually present?
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
Investigations for encephalitis
- LP- CSF analysis would show similar changes to meningitis, depending on causative agent)
- Bloods
- EEG
- MRI (oedema/hyperintense lesions)
61
compare presentations of encephalitis and meningitis
encephalitis presents with altered mental status/impaired consciousness, meningitis doesn't
62
2 broad causes of raised ICP
SOL (tumour, abscess, haemorrhage)
| Hydrocephalus (increased CSF volume)
63
Symptoms of raised ICP
headache:
- worse in morning
- worse with coughing and sneezing
- bilateral, gradual onset
- throbbing/bursting
Associated symptoms:
- Vomiting
- Altered GCS
- Seizures
64
Signs of raised ICP
```
Focal neurological symptoms
Papilloedema
Cushing’s reflex → Cushing’s triad
1. ↑SBP
2. Cheyne-stokes respiration
3. Bradycardia
```
65
What is Cheyne - stokes respiration? Associated conditions
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
How does raised ICP cause focal neurological symptoms?
↑ICP can put pressure in nearby structures
eg 3rd nerve palsy, 6th nerve palsy, horner’s syndrome
67
Investigations for raised ICP
URGENT CT-head
| ↑ICP is a CONTRAINDICATION to LP!
can contribute to brainstem herniation
68
Define EDH
A collection of blood in the potential space between the dura and the bone
69
cause of EDH
head trauma
Often due to a fractured temporal or parietal bone causing a laceration of the MMA
This lies under the pterion
70
epidemiology of EDH
young- 20-30 yrs
| men
71
How does EDH present?
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
Investigations for EDH
O/E- may show ipsilateral pupil dilation due to compression of oculomotor nerve CNIII
Urgent Non-contrast CT head-scan
MRI
73
What are the CT features of EDH?
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
Define SDH
A collection of blood between the dural and arachnoid covering of the brain
75
Aetiology/RF for SDH
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
vessels affected SDH versus EDH
```
SDH = bridging veins
EDH = MMA
```
77
Symptoms of SDH
```
Gradual onset, continuous headache
Fluctuating consciousness
Confusion
Personality changes
Symptoms of ↑ ICP
```
78
How is SDH classified?
Depending on the onset of symptoms they can be separated into:
- Acute: <3 days
- Subacute: 3-21 days
- Chronic: >21 days
79
State the characteristics of an acute SDH
within 72 hours
| occur in younger patients and are associated with major trauma + reduced consciousness
80
State the characteristics of a subacute SDH
worsening headache 7-14 days after injury
altered mental status
elderly
81
State the characteristics of a chronic SDH
>21 days (up to 9 weeks)
elderly eg following a fall
headache, confusion, cognitive impairment, psychiatric symptoms, gait deterioration, focal weakness, seizures.
82
Investigations for SDH
urgent non-contrast CT
83
CT features of SDH
BANANA shaped
| subdural fluid collection is usually crescentic in shape and can cross suture lines.
84
SDH small (<10mm) and no significant neurological dysfunction management
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
management of a large SDH
If large or significant neurological dysfunction: Burr hole or craniotomy
86
Definition/aetiology of SAH
Bleeding into the subarachnoid space, most commonly due to rupture of a saccular/berry aneurysm
87
Symptoms of SAH
Thunderclap headache- very severe, very acute
continuous + diffuse
May be associated with meningism and signs of raised ICP
88
RF for SAH
PKD (5x increased risk of aneurysms)
alcohol
smoking
hypertension
89
Investigations for SAH
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
What would you see in the LP of a patient with a SAH?
Xanthochromia & oxyhaemoglobin
From 12 hours after symptom onset- haem metabolised to bilirubin
(CSF may be bloody if active bleeding)
91
What would you see in the CT of a patient with a SAH?
Hyperattenuation around the circle of willis
92
```
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
```
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
Where do most brain tumours arise?
```
Majority metastasise:
lung
breast
colon
kidney
melanoma
```
94
What is the most common primary CNS tumour?
Glioma
95
How can primary brain tumours be classified?
Intra-axial tumours: within the brain parenchyma
| Extra-axial tumours: outside the brain parenchyma (eg meninges, spinal cord)
96
What type of brain tumour is more common in children?
Medulloblastomas
| Brain tumours are the second most common cancer in children (15–25% all paediatric malignancies)
97
What is the peak age for brain cancer?
60-70
98
Symptoms of CNS tumours
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
What might you find O/E of a patient with a CNS tumour?
Papilloedema
| Focal neurological signs: visual field defects, dysphasia, agnosia, hemianopial, hemiparesis
100
RF for brain tumours
```
History of cancer
FHx of cancer
Ionising radiation
Immunosuppression (HIV)
Inherited syndromes (eg neurofibromatosis)
```
101
What factors may cause a benign brain tumour to be dangerous?
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
What might be some features of a tumour in the frontal lobe?
personality disturbance
apathy
impaired intellect
103
How might a right parietal lobe tumour present?
L homonymous hemianopia
L sided hemiparesis
L sensory loss
104
What type of brain tumour may present with progressive deafness?
Vestibular schwannoma (benign tumour of vestibulo-cochlear nerves)
105
Investigations for brain tumours
CT = FIRST LINE
MRI (better resolution)
CXR, CT thorax, abdo & pelvis to check for metastases
Biopsy = DIAGNOSTIC
106
State the headache red flags
- 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
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
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.
