Headache and Intracranial Bleeds Flashcards
List red flag symptoms/signs related to headache
New onset in over 55 yr old
Known/previous cancer
Immunosuppressed
Early morning onset
Exacerbated by valsalva
What is a migraine?
Severe throbbing pain on one side of the head
Migraine affects males more than females. True/False?
False
Females more than males
What is the difference between migraine with and without aura? Which is more common?
Migraine with aura: warning signs before migraine begins, e.g. flashing lights
Migraine without aura is more common
What is the criteria for diagnosing migraine without aura?
At least 5 attacks in 72 hours
Moderate/severe unilateral throbbing pain, worse on movement
Autonomic features or photophobia/phonophobia
How long do auras typically last in migraine?
20-60 mins
List some visual auras
Central scomata
Central fortification
Hemianopia
List triggers of migraine
Sleep
Diet
Stress
Physical exertion
Hormones
List non-pharmacological treatment for migraine
Trigger diary
Education
Stress management
List pharmacological management of migraine
NSAID + anti-emetic if vomiting
Triptans (rizatriptan)
When should prophylaxis be considered for migraine?
More than 3 attacks in a month or very severe
List prophylactic therapy for migraine
Propranolol
Topiramate
Amitryptilline
What type of drug is topiramate and what are its adverse effects?
Carbonic anhydrase inhibitors
Weight loss, paraesthesia, impaired concentration, teratogenic
What are trigeminal autonomic cephalgias?
Headache disorders characterised by unilateral pain in a trigeminal distribution with ipsilateral cranial autonomic features
List some ipsilateral cranial autonomic features
Ptosis
Miosis
Nasal stuffiness
Nausea, vomiting
Tearing
Eyelid oedema
List the 4 main types of trigeminal cephalgias
Cluster headache
Paroxysmal hemicranias continua
Hemicrania continua
SUNCT
Who gets cluster headaches more - men or women?
Men
Typically 30-40 yr olds
When do cluster headaches typically come on?
Around sleep time
Describe a cluster headache
Severe unilateral headache lasting 20mins-3hrs
1 to 8 episodes a day
Outline management of cluster headache
MRI scan
High flow oxygen
Sumatripan
Steroid
Verapamil for prophylaxis
Who gets paroxysmal hemicranias continua more - men or women?
Women
Typically 50-60 yr olds
How would you distinguish paroxysmal hemicranias continua from cluster headache?
Shorter duration, more frequent
Which drug provides absolute response to paroxysmal hemicranias continua?
Indomethicin
What is a SUNCT trigeminal cephalgia?
Short
Unilateral
Neuralgia
Conjunctival injections
Tearing
What is the treatment for SUNCT?
Gabapentin
Who gets trigeminal neuralgia more - men or women?
Women
Typically elderly
What typically triggers trigeminal neuralgia?
Touch in V2/V3 region
How long does an episode of trigeminal neuralgia usually last?
1-90 seconds
10-100 episodes a day
List treatment for trigeminal neuralgia
Carbamazepine (anticonvulsant)
Gabapentin
Phenytoin
Surgical decompression
Where does bleeding occur in a subarachnoid haemorrhage?
Into subarachnoid space that encloses CSF
What is the most common underlying pathology in a subarachnoid haemorrhage?
Berry aneurysm
Otherwise arteriovenous malformation or no identifiable cause
List typical clinical features of a subarachnoid haemorrhage
Sudden onset “thunderclap” headache
Collapse
Meningism - vomiting, photophobia, neck pain
Subarachnoid haemorrhage can occur whilst having sex. True/False?
True
Which cranial nerve can be particularly affected in subarachnoid haemorrhage?
CN III
What may be seen on fundoscopy in someone who has had a subarachnoid haemorrhage?
Retinal or vitreous haemorrhage
CT scan of a brain may be normal in subarachnoid haemorrhage. True/False?
True
Depends on delay
Once blood spills out bleeding may stop
If a CT scan of a person with suspected subarachnoid haemorrhage is normal, what is the next best investigation?
Lumbar puncture
Describe CSF appearance on lumbar puncture in subarachnoid haemorrhage
Xanthochromatic or bloodstained
What investigation is gold-standard for identifying bleeding location of a subarachnoid haemorrhage?
Cerebral angiography with/without CT
List some complications of subarachnoid haemorrhage
Re-bleeding
Hydrocephalus
Hyponatraemia
Seizure
Delayed ischaemia
How is re-bleeding in the brain addressed?
Endovascular repair (mainstay)
Surgical clipping
When might delayed ischaemic neurological deficit occur post- subarachnoid haemorrhage? What is the drug of choice to treat?
3-12 days
Nimodipine
What is the H triple therapy used for delayed ischaemic neurological deficit?
Hypervolaemia
Haemodilution
Hypertension
How does hydrocephalus arise?
Increase in intracranial CSF pressure
How is hydrocephalus treated?
CSF drainage - lumbar puncture, ventricular drain, shunt
Why should you not fluid restrict someone with hyponatraemia as a complication of subarachnoid haemorrhage?
Will cause hypovolaemia, predisposing to vasospasm and cerebral ischaemia
What is the most common aetiology/risk factor for intracerebral haemorrhage?
Hypertension leading to microaneurysm
Typically where does a hypertensive intracerebral haemorrhage affect anatomically?
Basal ganglia (haematoma)
List the main investigations for intracerebral haemorrhage
CT scan (urgent if decreased consciousness)
Angiography
