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NEUROLOGY > HEADACHE AND FACIAL PAIN > Flashcards

HEADACHE AND FACIAL PAIN Flashcards

1
Q

Causes of headaches?

A

Tension headaches
Migraines
Cluster headaches
Secondary headaches
Sinusitis
Giant cell arteritis
Glaucoma
Intracranial haemorrhage
Venous sinus thrombosis
Subarachnoid haemorrhage
Medication overuse
Hormonal headache
Cervical spondylosis
Carbon monoxide poisoning
Trigeminal neuralgia
Raised intracranial pressure
Brain tumours
Meningitis
Encephalitis
Brain abscess
Pre-eclampsia

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2
Q

Headache red flags?

A

Compromised immunity e.g. HIV
Age <20 and Hx of malignancy
History of malignancy known to metastasise to the brain
Vomiting without other obvious cause
Worsening headache with fever
Sudden-onset headache reaching maximum intensity within 5 mins - “thunderclap”
New onset neurological deficit
New-onset cognitive dysfunction
Change in personality
Impaired level of consciousness
Recent head trauma
Headache triggered by cough, vasalva, sneeze or exercise,
orthostatic headache
Symptom suggestive of temporal arthritis or acute narrow-angle glaucoma
Substantial change in characteristics of headache

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3
Q

What are primary vs secondary headaches?

A

Primary headaches — these are not associated with another underlying condition, and include tension-type headache.
Secondary headaches — these are precipitated by another condition or disorder e.g. cancer

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4
Q

What are the 3 categories for tension headaches?

A

Infrequent episodic — less than 1 day of headache per month.
Frequent episodic — at least 10 episodes of headache occurring on fewer than 15 days per month on average, for more than 3 months.
Chronic — this evolves from frequent episodic tension-type headache, with 15 days or more of headache per month, for more than 3 months, in the absence of medication overuse.

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5
Q

Most common type of primary headache disorder?

A

Tension headache

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6
Q

Clinical features of tension type headache?

A

Recurrent episodes of headache lasting from 30 minutes to 7 days which are not associated with nausea or vomiting.
The headache may also be associated with no more than one of photophobia or phonophobia, and…

The headache has at least two of:
- Bilateral location.
- Pressing, tightening, non-pulsating quality (‘like a tight band’)
- Mild/moderate intensity.
- Not aggravated by routine physical activity

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7
Q

What can trigger tension-type headaches?

A

Stress
Sleep problems
Caffeine

Others:
Mood disorders
Poor posture
Neck pain
Alcohol
Skipping meals
Dehydration
Eye strain

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8
Q

Management of tension headaches?

A

Simple analgesia
Manage triggers
If frequent episodic or chronic then avoid excessive use of analgesia
Acupuncture, CBT or PT may be useful
Prophylaxis with amitryptiline can be used

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9
Q

What are trigeminal autonomic Cephalalgias?

A

A group of primary headache disorders characterised by strictly unilateral trigeminal distribution pain occurring in association with ipsilayeral cranial autonomic symptoms

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10
Q

Examples of trigeminal autonomic cephalalgias?

A

Cluster headaches - MC
Paroxysmal hemicrania
Short-lasting neuralgiform attacks with conjunctival injection and tearing or short-lasting neuralgiform attacks with cranial autonomic features
Hemicrania continua

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11
Q

What are episodic vs chronic cluster headaches?

A

Episodic — attacks occur in periods lasting from 7 days to one year and are separated by pain-free periods lasting at least 3 months.
Chronic — attacks occur for one year or longer without remission, or with remission periods lasting < 3 months.

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12
Q

What environmental factors can trigger acute attacks of cluster headaches?

A

Alcohol
Smoking
Histamine
Nitrate-containing foods e.g. cured meats
Smell of volatile substances e.g. paint, nail varnish, petrol

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13
Q

Epidemiology of cluster headaches?

A

Rare
More common in men and smokers

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14
Q

Clinical features of cluster headaches?

A

Intense, sharp, stabbing pain around 1 eye that occurs once or twice a day lasting 15 mins-3 hours
Pt is usually restless and agitated during the attack due to severity
Accompanies with redness, lacrimation, lid swelling, nasal stuffiness and in some, mitosis and ptosis

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15
Q

How long do these clusters of cluster headaches typically last?

A

4-12 weeks

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16
Q

Investigtaions for ?cluster headaches

A

Neuroimaging - usually MRI with gadolinium contrast
(This is because even when clinical symptoms are typical for cluster headaches, occasionally underlying brain lesions are found)

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17
Q

Acute management of cluster headaches?

A

Sumatriptan
Short burst oxygen therapy high flow

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18
Q

Drug prophylaxis for cluster headaches?

A

Verapamil

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19
Q

What is paroxysmal hemicrania?
What drug does it best respond to?

A

A rare form of trigeminal autonomic cephalgia
Causes severe throbbing and claw-like pain usually on one side of the face near the eye and occasionally around the back of the neck. May also be red and tearing eyes
Responds best to indomethacin

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20
Q

How does ICHD define a medication overuse headache?

A

As a headache occurring on 15 or more days per month in a person with a pre-existing primary headache disorder, which develops as a consequence of regular overuse of 1 or more drugs taken for headache, for more than 3 months

Simple analgesics or aspirin taken on 15 days or more per months
Ergotamines, Triptans, opioids taken on 10 days of more per month

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21
Q

Which medications are most likely to cause a medication overuse headache?

A

Opioids
Triptans

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22
Q

Epidemiology of medication overuse headache?

A

Affects up to 50% of people with chronic headaches
More common in females
Highest in those aged 40-49

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23
Q

Management of medication-overuse headache?

A

Explain diagnosis
Withdraw medications for at least 1 month - stop Triptans, ergotamines and simple analgesics abruptly - exaplin that this may initially worsen headaches
Arrange regular review
Consider use of prophylactic meds for underlying primary headache is appropriate

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24
Q

Episodic vs chronic migraine?

A

Episodic migraine occurs on less than 15 days per month.
Chronic migraine is headache occurring on at least 15 days per month (with features of migraine headache on at least 8 days per month) for more than 3 months.

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25
Q

Common triggers for migraines?

A

Disturbed sleep
Irregular meals
Excessive caffeine intake
Lack of exercise
Stress
Alcohol
COCP
Bright lights
Cheese, chocolate, red wine, citrus fruits
Menstruation

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26
Q

Epidemiology migraine?

A

Common - 1in 7
3:1 women:men
Most common age 25-55

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27
Q

What are the types of migraines?

A

Migraine without aura
Migraine with aura
Silent migraine (migraine with aura but without a headache)
Hemiplegic migraine

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28
Q

The 5 stages of migraines?

A

Prodromal stage - several days before headache
Aura - lasts up to an hour
Headache - 4-72 hours
Resolution
Postdromal phase

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29
Q

Prodromal stage symptoms of migraine?

A

Fatigue
Poor concentration
Neck stiffness
Yawning

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30
Q

Postdromal stage symptoms of migraine?

A

Fatigue
Elated or depressed mood

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31
Q

Features of migraine headache?

A

Unilateral (bilateral in children)
Pulsating
Moderate-severe intensity
Aggravated by routine ADLs and pt characteristically go to a dark quiet room
Nausea/vomiting
Photophobia and photophobia

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32
Q

How long does a migraine headache typically last?

A

4-72 hours

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33
Q

Aura symptoms in migraines?

A

Visual - zigzag lines, scotoma
Sensory - unilateral pins and needles or numbness
Speech or language - dysphasia

Atypical:
Motor weakness
Double vision
Visual symptoms only affecting 1 eye
Poor balance
Decreased level of consciousness

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34
Q

How long do aura symptoms typically last in a migraine?

A

5-60 minutes

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35
Q

Migraine diagnostic criteria?

A

At least 5 attacks
Headaches last 4-72 hours
Headaches have at least 2 of the following characteristics: unilateral, pulsating quality, moderate-severe intensity, aggravated by or causing avoidance of routine physical activity
During the headache at least 1 of the following: n&v or photophobia/phonophpobia
Not atttributed to another disordr

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36
Q

What is a hemiplegic migraine?

A

A variant of migraine in which motor weakness is a manifestation of aura in at least some attacks
Around 50% have a strong FHx
This is very rare!!

Often mimic a stroke or TIA

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37
Q

Management of migraine?

A

Avoidance of triggers
Simple analgesia (NOT opioids)
Triptans (oral in adults, nasal in 12-17 YOs)
Consider an anti emetic

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38
Q

Who should be offered preventive treatment for migraines?

A

If migraine attacks significantly impact QOL and daily function
The person is at risk of medication overuse headaches
Acute treatments are contraindicated or not effective

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39
Q

What preventative treatmwnt can be offered for migraines?

A

Propranolol or Topiramate or amitryptiline
Consider non-pharmacological therapies too e.g. behavioural interventions, riboflavin or acupuncture

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40
Q

Management of predictable menstrual migraines?

A

Frovatriptan or zolmitroptan

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41
Q

How do Triptans work?

A

They are 5HT receptor agonists = cranial vasoconstriction, inhibit transmission of pain signals and inhibit the release of inflammatory neuropeptides

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42
Q

Contraindications for Triptans?

A

Coronary vasospasm, IHD, hypertension, PVD, previous CV accident or MI or TIA, prinzmetal’s angina

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43
Q

Headache diary

A

A diary that contains the duration, severity, other sympotms, acute medication and comments
Helps a doctor make a diagnosis

44
Q

Symptoms of encephalitis?

A

Fever
Headache
Psychiatric Sx
Seizures
Vomiting
Focal features e.g. aphasia
Changes in personality
Confusion
LOC

45
Q

Cause of encephalitis?

A

HSV-1 is responsible for 95% of cases in adults

46
Q

Which areas of the brain does encephalitis most commonly affect?

A

Temporal and inferior frontal lobes

47
Q

Investigations for encephalitis?

A

Lumbar puncture
Neuroimaging - MRI
EEG

48
Q

Management of encephalitis?

A

IV aciclovir

49
Q

What is meningitis?

A

Inflammation of the 2 inner meninges the pia and arachnoid mater

50
Q

What is meningococcal disease?

A

An infection with neisseria meningitidis
It can result in meningococcal meningitis or meningococcal septicaemia

51
Q

Most common causative organisms of bacterial meningitis in adults?

A

Streptococcus pneumoniae - most common
Neisseria meningitidis
Haemophilus influenzae type b

52
Q

Complications of bacterial meningitis?

A

Death
Cerebral infarction leading to focal neurological deficits - hearing loss, seizures, cognitive impairment, motor deficits, visual impairment
Amputations
Skin scars
Reduced QOL
Hydrocephalus
Anxiety and emotional & behavioural difficulties
Waterhouse-Friderichsen syndrome (adrenal insufficiency secondary to adrenal haemorrhage)

53
Q

Presentation of meningitis and meningococcal septicaemia?

A

Fever
N&V
Headache
Non-blanching rash - in meningococcal septicaemia
Stiff neck
Photophobia
Drowsiness

54
Q

What is Kernig’s sign?

A

When the pt is unable to fully extend at the knee when the hip is flexed - sign of meningitis

55
Q

What is brudzinski’s sign?

A

When the pt’s knees and hips flex when the neck is flexed - sign of meningitis

56
Q

CSF findings in bacterial meningitis?

A

Cloudy appearance
Low glucose
High protein
White cells 10-5,000 polymorphs

57
Q

Management of suspected bacterial meningitis with a non-blanching rash or meningococcal septicaemia if in the pre-hospital setting?

A

Single dose of parenteral benzoyl penicillin

58
Q

Should you attempt a lumbar puncture in suspected bacterial meningitis or meningococcal septicaemia?

A

It considers aseptic technique and is technically diffiuclty so may take time and delay Tx
On the other hand, having a CSF sample can be useful to confirm diagnosis and guide antibiotic Tx
Lumbar puncture can’t be done if severe signs of sepsis, rapidly evolving rash, severe resp/cardiac compromise, significant bleeding risk or signs of raised ICP

59
Q

Management of pt with suspected meningitis in hospital?

A

Take bloods and blood culture. Do lumbar puncture if it can be done within the first hour
IV antibiotics - <50 give cefotaxime and if >50 give cefotaxime and amoxicillin
Consider adjunctive treatment with IV dexamethasone

60
Q

Management of contacts with meningitis?

A

Prophylaxis to household and close contacts within 7 days before the onset of illness - prophylactic oral ciprofloxacin or rifampicin

61
Q

Is meningitis and meningococcal disease notifiable?

A

Yes

62
Q

Presentation of temporal arthritis?

A

A person aged 50 or older with a unilateral temporal headache that came on in a few weeks
Tender, thick or nodular temporal artery. Skin overlying it may be read and pulsation may be reduced or absent
There may be visual loss, double vision, visual field defects or changes to colour vision
May be scalp tenderness
May be intermittent jaw claudication
May be systemic features e.g. fatigue, fever, anorexia
May be features of PMR, neurological features

63
Q

What % of pt with GCA will have PMR?

A

50%

64
Q

Investigations for GCA?

A

FBC, ESR and CRP
Diagnosis is confirmed with: Duplex USS pr temporal artery biopsy

65
Q

Management of GCA?

A

Urgent high dose glucocorticoids (before temporal aretry bpspy)
Urgent ophthalmology review
Bone protection will be required due to long term steroids
(Sometimes low dose aspirin is given)

66
Q

Which steroids are given for GCA?

A

No visual loss - high dose pred
Visual loss - IV methylprednisolone prior to starting high-dose pred

67
Q

Normal intracranial pressure?

A

7-12mmHg

68
Q

How do you calculate cerebral perfusion pressure?

A

MAP - ICP

69
Q

Causes of raised ICP?

A

idiopathic intracranial hypertension
traumatic head injuries
infection e.g. meningitis
tumours
hydrocephalus

70
Q

Presentation of raised ICP?

A

headache - constant throbbing which is worse in morning, when coughing.straining/bending forward
vomiting
reduced levels of consciousness
papilloedema - blurred vision, visual field loss, double vision, greyed out vision triggered by coughing/sneezing/bending down
Cushing’s triad - widening pulse pressure, bradycardia, irregular breathing

71
Q

Investigtaions for raised ICP?

A

Neuroimaging - CT/MRI to find underlying cause
Invasive ICP monitoring can be done where a catheter is placed into the lateral ventricles of the brain to monitor the pressure

72
Q

Maagement of raised ICP?

A

Tx underlying cause
Head elevation to 30 degrees
IV mannitol
Controlled hyperventilation (causes vasoconstriction of cerebral arteries)
Removal of CSF e.g. VP shunt or repeated LP

73
Q

What is a low-pressure headache?

A

A headache caused by low CSF e.g. spontaneous, following an LP, tear in meninges etc
Most commonly following an LP

74
Q

How common are post-lumbar puncture headaches?
Who are they most common in?

A

They occur in 1/3rd of pts
Most common in young females with low BMI

75
Q

Presentation of post-lumbar puncture headache?

A

Develops 24-48 hours following LP usually and lasts several days
Worse when upright and improves with recumbent position

76
Q

Presentation of sinusitis?

A

Frontal pressure facial pain worse on bending forwards + facial tenderness
Thick and purulent nasal discharge
Nasal obstruction

77
Q

What is a hormonal headache aka? How do they present?

A

Menstrual migraine
Unilateral, pulsation headache associated with nausea that occur 2 days before the the first 3 days of the MP
(May also occur in perimenopausal period and early pregnancy as due to low oestrogen)

78
Q

What is cervical spondylosis and how does it usually present?

A

Extremely common condition resulting from osteoarthritis in the cervical spine in people over 40
Commonly presents as neck pain worse with movement or may refer as a headache

79
Q

Which branches of the trigeminal nerve are most commonly affected in trigeminal neuralgia?

A

Typically, the maxillary or mandibular branches are affected, either alone or in combination. Involvement of the ophthalmic branch alone is uncommon.

80
Q

What is trigeminal neuralgia?

A

Severe, episodic, unilateral facial pain in the distribution of 1 or more branches of the trigeminal nerve

81
Q

What can trigger trigeminal neuralgia pains?

A

Touching the face e.g. shaving
Talking
Cold wind
Vibration
Cleaning teeth

82
Q

What is atypical trigeminal neuralgia?

A

When there is a persistent discomfort between paroxysms, or sensory loss

83
Q

What are the 3 aetiologies of trigeminal neuralgia?

A

Vascular compression of the trigeminal nerve root (known as classical TN)
It can occur as a consequence of major neurological disease e.g. tumour or cerebellopontine angle or MS (known as secondary TN)
Idiopathic

84
Q

RF for trigeminal neuralgia?

A

Advancing age -50-60
Female
MS
FHx - rarer RF

85
Q

Prognosis of trigeminal neuralgia?

A

Episode sof TN can occur daily for weeks/months and there can be months/years of remission
50% get remission of at least 6 months
65% of pt with newly diagnosed TN will have a second episode within 5 years
Periods of remission tend to get shorter with time and attacks of pain get longer

86
Q

Complications of trigeminal neuralgia?

A

Impairment of activities of daily living.
Depression/isolation.
Weight loss caused by inability to eat.

87
Q

Presentation of trigeminal neuralgia?

A

Severe, electric shock-like, sharp, shooting pain
Unilateral
Lasts a few seconds-minutes and stops suddenly
Many attacks a day
Episodic - pain free periods tend to gradually shorter between episodes
Provoked by factors such as light touch to face, taking, exposure to cold air

88
Q

What are some serious conditions that can lead to compression of the trigeminal nerve and cause symptoms similar to trigeminal neuralgia?

A

Tumours
MS
Epidermoid, dermoid or arachnoid cysts
Aneurysms or AVMs

89
Q

Red flag symptoms or signs to ask about in ?trigeminal neuralgia that may suggest a serious underlying cause…

A

Sensory changes
Deafness/ear problems
Pain in only ophthalmic division
Bilateral pain
Optic neuritis
FHx of MS
Age of onset before 40

90
Q

Management of trigeminal neuralgia?

A

Carbamazepine 100mg TD (titration up)
Once pain is in remission gradually reduce dosage

Failure to respond to Tx or atypical features -> refer to neurology

91
Q

Causes of facial pain?

A

Trigeminal neuralgia
TMJ disorders - TMJD, bruxism, arthritis of TMJ
Sinusitis
Dental problems - caries of abscesses
Tension headaches or cluster headaches
Migraines
Ophthalmic or ear disorders
GCA
Shingles
Trauma e.g. facial fractures
Referred pain

92
Q

What is chronic orofacial pain defined as?

A

Pain lasting >12 weeks

93
Q

What is mid facial segment pain?

A

Similar to a tension headache with a bilateral T-shaped distribution over the nose and frontal areas
Constant pain
Aetiology is unknown and its considered a diagnosis of exclusion

94
Q

What is bruxism?

A

Teeth grinding

95
Q

What forms the temporomandibular joint?

A

Articulation of the head of the mandible and 2 surfaces of the temporal bone (mandibular fossa and Radicular tubercle)
Note that the articular bones are lined by fibrocartilage and separated by an articular disc which splits the joint into 2 synovial joint cavities

96
Q

What are temporomandibular joint disorders?

A

A group of MSK conditions affecting the mastication muscle, temporomandibualr joint and associated structures
E.g. masticatory muscle disorders, degeneration of TMJ or disc displacement

97
Q

Cause of temporomandibular joint disorders?

A

Anatomical - disc displacement
Macrotraumas
Microtraumas e.g. bruxism
Stress, anxiety, depression
Co-morbidities e.g. fibromyalgia

98
Q

Presentation of temporomandibular joint disorder?

A

Pain in or around the TMJ or muscles of mastication - usually pre-auricular region and may radiate to temple/teeth/cheek/angle of jaw
Pain may be provoked by palpation of masseter, temporalis muscle or TMJ, or jaw movement
Joint noise - clicking, popping, crepitus
Headache in temporal region
May be locking of the jaw

99
Q

Management of temporomandibular joint disorder?

A

Reassure pt and educate about condition
Encourage self-management e..g soft diet, rest jaw if acute pain, avoid parafunctional activis e.g. yawning, apply ice or heat, massage muscles
Consider analgesia short term
Consider referral to surgery if persistent or worsening

100
Q

Who typically gets idiopathic intracranial hypertension?

A

Young, obese females
Pregnant women

101
Q

Which drugs can increase the risk of idiopathic intracranial hypertension?

A

COCP
Steroids
Tetracyclines
Retinoids
Lithium

102
Q

Presentation of idiopathic intracranial hypertension?

A

headache
blurred vision
papilloedema (usually present)
enlarged blind spot
sixth nerve palsy may be present and double vision
Pulsatile tinnitus

103
Q

Management of idiopathic intracranial hypertension?

A

Weight loss - meds may be used to help with this e.g. topiramate (also added benefit of being a CA inhibitor)
Carbonic anhydrase inhibitors e.g. acetazolamide
Repeated LP as a temporary measure
Surgery e.g. optic nerve sheath decompression and fenestration to prevent damage / lumboperitoneal or VP shunt

104
Q

How is idiopathic intracranial hyopertension diagnosed?

A

Typical symptoms + normal neurological exam except for papilloedema and visual field defect
CT or MRI is normal
LP with higher than normal pressure for defintive diagnosis

105
Q

How does acetazolamide work to treat idiopathic intracranial hypertension?

A

It’s a carbonic anhydrase inhibitor which decreases CSF production and therefore decreases ICP

106
Q

Complications of idiopathic intracranial hypertension?

A

Optic neuropathy
Loss of vision
Strokes
Seizures
Coma
Respiratory arrest

NEUROLOGY (16 decks)

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