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Neurology > Headache and Brain Tumors > Flashcards

Headache and Brain Tumors Flashcards

1
Q

What percent of HAs are due to significant underlying pathology?

A

~1%

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2
Q

Where HA’s can originate

A
  • Extracranially
    • skin, muscle, blood vessels, periosteum
  • Intracranially
    • venous sinuses/arteries
    • Dura
    • Falx cerebri
  • Brain parenchyma itself incapable of producing pain
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3
Q

Migraine Headache Epidemiology

A
  • 70% have family history
  • usually begins in adolescence or young adulthood
  • may begin in childhood
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4
Q

Common Migraine

Characteristics, Duration

A

AKA Migraine without aura

  • MC kind
  • Duration: 4-72hrs

Symptoms

  • Unilateral
  • Pulsating or Bounding
  • Intensity: moderate to severe
  • Aggravated by physical activity
  • N/V
  • Photophobia/phonophobia

Should have at least 5 attacks before dx

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5
Q

Classic Migraine

A
  • SImilar characteristics to common migraine but has aura that comes on gradually, lasting <60min

Types of aura

  • visual most common (scotoma - blind spots; flashing lights also common)
  • sensory (unliteral paresthesias, numbness)
  • motor aura (unilateral weakness, speech difficulty)
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6
Q

Migraine Precipitants

A
  • Menstruation
  • too much/little sleep
  • fasting
  • physical activity
  • stress
  • tyramine containing foods (red wines, hard cheeses, herring)
  • chocolate (phenylethlamine)
  • nitrites (processed meats)
  • caffeine withdrawal or excess
  • medications (OCPs, anti HTN)
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7
Q

Classes of Drugs to Tx Migraines

ppx and abortive

A

PPX

  • beta-blockers
  • CCB
  • SSRI
  • TCA
  • AED

Abortive

  • OTC Analgesics
  • Ergots (vasoconstrictors)
  • Anti-emetics
  • Serotonin agonists
  • Narcotics
  • Steroids
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8
Q

Cluster Headaches

A
  • A cluster or series of HA’s over a period of 2-3 months, usually occuring every 1-2 years
  • Much less common than migraines, affecting more males (late 20’s)
  • May be triggered by **alcohol, nitroglycerin, histamine **
  • Path: dilation of retroorbital blood vessels and inflammation of trigeminal nerve branches

Symptoms

  • ALWAYS unilateral
  • excrutiating
  • penetrating or stabbing pain
  • pain in trigeminal nerve distribution, usually behind eye
  • often with autonomic features - lacrimation, conjunctival injection, nasal congestion/rhinorrhea, ptosis/miosis

**Treatment: **

  • Oxygen - very effective!
  • pharm similar to migraines ( - BB)
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9
Q

Tension Headaches

A
  • Most common type of HA
  • Duration: 30min - 7days

Symptoms

  • pressing/tightness/band-like (non-pulsating)
  • mild-moderate intensity
  • unaffected by physical activity
  • +/- photo/phonophobia
  • no N/V

Treatment

  • mild analgesics
  • stress reduction
  • relaxation techniques
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10
Q

Extracranial Sources of HA

A
  • Sinusitis
  • Acute glaucoma
  • Temporal arteritis
  • TMJ
  • Trigeminal neuralgia
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11
Q

Sinusitis

A
  • stabbing or aching that is worse with bending forward, coughing
  • better when supine
  • percussion over sinuses produces pain
  • often associated with nasal congestion, rhinorrhea, URI sxs
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12
Q

Acute Glaucoma

A
  • Orbital pain often associated with N/V
  • cornea is edematous, injected conjunctiva
  • decreased vision
  • measure intra-ocular pressure via tonometry device
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13
Q

Temporal arteritis

A
  • vasculitis of the temporal artery affected pts >50, more common in females
  • Presentation
    • jabbing, excrutiating pain over temple
    • usually unilateral, but can be bilateral
    • visual loss may be present
    • may have symptomatic sx (fevers, malaise)
    • temporal artery tender to palpation
  • Lab: elevated ESR; bx
  • prompt tx with steroids to decrease chance of vision loss
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14
Q

TMJ Syndrome

A
  • usually due to spasms around TMJ
  • causes: overbite previous dental work, grinding teeth
  • unilateral or bilateral TMJ pain, tender to palpation
  • may feel clicking in joint
  • tx - NSAIDs + dental referral
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15
Q

Trigeminal Neuralgia

A
  • AKA tic doloureux
  • brief, severe attacks in trigeminal nerve (or branch of) distribution
  • due to partial demyelinization of trigeminal nerve, possibly due to compression
  • pain is lancinating, electric shock pain
  • may be triggered by eating, talking, or washing face (pt will be hesitant to do these actions)
  • Rx: narcotic analgesics, carbamezapine, phenytoin
  • surgery by ENT if doesn’t respond to medical treatment
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16
Q

Life Threatening Headaches

A
  • subarachnoid hemorrhage
  • meningitis
  • brain tumors
  • subdural/epidural hematoma
  • hypertensive HA
17
Q

Subarachnoid Hemorrhage

A
  • bleed from ruptured aneurysm, or less commonly AVM
    • aneurysm MC’ly comes off of the Circle of Willis
  • sudden onset of severe HA - “worst HA of my life,” thunderclap HA
    • may have a sentinal HA where aneurysm begins to bleed, but then clots off; will rupture later
    • often brought on when ICP increases - valsalva (BM, heavy lifting, sex)
  • LOC, focal neuro signs, sz possible
  • +/- nuchal rigidity
  • CT scan ~90% sensitive. If negative do LP

Treatment:

  • CCB –> decrease secondary vasospasm
  • phenytoin –> sz ppx b/c ICP rising
  • urgent neurosurgical consultation - clipping or interventional radiology coiling
18
Q

Meningitis

A
  • symptoms
    • HA
    • fever
    • toxicity
    • nuchal rigidity
  • diagnosis
    • LP
  • treatment
    • bacterial: IV antibodies, possibly steroids
    • viral: supportive
19
Q

Subdural Hematoma

A
  • HA, often with confusion, obtundation
  • often seen in elderly after previously forgotten minor head injury
  • dx: CT
20
Q

Epidural Hematoma

A
  • hx. of trauma
  • brief LOC, then awake with HA, then deteriorating mental status
  • may rapidly progress by herniation
  • dx by CT
  • urgent neurosurg consult to drill burr holes
21
Q

Hypertensive HA

A
  • DBP >130
  • lower BP with antiHTN to relieve HA
  • may be overdiagnosed - have to question if high BP caused HA or HA caused high BP
22
Q

Symptoms of Brain Tumors

A
  • Headache that is progressively worsening over days to weeks, often worse in the morning with vomiting
  • weakness, paralysis, sensory deficits, cranial nerve palsies
  • visual disturbance
  • ataxia
  • altered mental status
  • seizures (new onset)
  • dx: MRI is best, can also use CT with contrast
23
Q

Types of Brain Tumors

A

Astrocytoma (gliomas)

Meningioma

Acoustic neuroma

Metastases - secondary brain tumors

24
Q

Astrocytoma

A
  • MC primary brain tumor
  • arise from astrocytes (type of glial cell)
  • MC site - cerebral hemispheres
  • Grading (from least to most malignant)
    • low grade astrocytoma
    • anaplastic astrocytoma
    • glioblastoma multiforme
  • Risk factors: radiation, genetics, +/- cell phones
  • Treatment: surgery, radiation (gamma knife), chemo; steroids if cerebral edema present, anticonvulsants for szs
25
Q

Meningioma

A
  • Second most common type of brain tumor
  • arise from meninges–> on the surface of the brain (out the outside)
  • may be single or multiple
  • usually benign, slow growing –> good survival rates
  • risk factors: radiation, genetics, +/- cell phones
  • treatment: observation with regular f/u imaging if small and asymptomatic; otherwise surgery is generally very successful b/c tumor is **superficial and easily accessible **
26
Q

Acoustic Neuroma

A
  • benign, slow-growing tumor
  • arises from Schwann cell sheath around vestibulocochlear nerve
  • occupies cerebello-pontine angle
  • risk factors: radiation, neurofibromatosis type 2
  • symptoms:
    • unilateral hearing loss (sudden, persistent, or fluctuating)
    • tinnitus
    • vertigo
    • disequilibrium
    • HA
    • facial numbness or weakness (b/c of proximity to facial nerve)
  • tx: surgical excision
27
Q

Cerebral Metastases

A
  • more common than primary brain tumors - >20% of all cancer patients
  • MC sources: lung and breast
  • general presents with multiple lesions
  • want to do a systemic work up to find primary source - CT of chest, abdomen, pelvis +/- CXR
  • brain bx if etiology is uncertain and no hx of CA
  • management: mainly palliative, can consider whole brain radiation therapy (WBRT) and surgery (if solitary lesion >3cm in noneloquent part of brain; limited systemic disease)
28
Q

Summary - RED FLAGA in HA Eval

A
  • first severe HA or worst HA of pt’s life especially with acute onset
  • HA that gets progressively worse over days to weeks
  • severe HA with fever
  • nuchal rigidity - subarachnoid hemorrhage or meningitis
  • decreased LOC or focal neuro signs

Neurology (10 decks)

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