Headache and Intracranial Bleeds Flashcards by Kerry Hendrie

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 (coughing, sneezing, straining)

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What is a migraine?

Severe throbbing pain on one side of the head

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Migraine affects males more than females. True/False?

False

Females more than males, especially if young

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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 (80%) is more common

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What is the criteria for diagnosing migraine without aura?

At least 5 attacks in 4-72 hours
2 of: Moderate/severe unilateral throbbing pain, worse on movement
1 of: Autonomic features or photophobia/phonophobia

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What is the pathophysiology of migraine?

Vascular and neural influence
Stress triggers serotonin release
Trigeminovascular system activation
Blood vessel constriction-dilation
Substance P irritates nerves and vessels, causing pain

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How long do auras typically last in migraine?

20-60 mins

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List some visual auras

Central scotoma (grey, black or blind spot in middle of vision)
Central fortification (disruption in middle of vision that expands outwards, typically a flickering light)
Hemianopia

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List triggers of migraine

Sleep
Diet
Stress
Physical exertion
Hormones

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List non-pharmacological treatment for migraine

Trigger diary
Education (avoidance of triggers, diet, hydration (min, 2l/day and avoid caffeine))
Stress management
Relaxation techniques e.g. acupuncture

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List pharmacological management of migraine

NSAID (aspirin, naproxen, ibuprofen) + anti-emetic if vomiting
Triptans (5HT agonist/ rizatriptan)
TAKE AS EARLY AS POSSIBLE INTO HEADACHE

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When should prophylaxis be considered for migraine?

More than 3 attacks in a month or very severe

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List prophylactic therapy for migraine

Propranolol
Topiramate
Amitryptilline
Gabapentin
Sodium valproate
Botulinum toxin

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What type of drug is topiramate and what are its adverse effects?

Carbonic anhydrase inhibitors

Weight loss, paraesthesia, impaired concentration

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What are trigeminal autonomic cephalgias?

Headache disorders characterised by unilateral pain in a trigeminal distribution with ipsilateral cranial AUTONOMIC features

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List some ipsilateral cranial autonomic features

Ptosis
Miosis
Nasal stuffiness
Nausea, vomiting
Tearing
Eyelid oedema

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List the 4 main types of trigeminal cephalgias

Cluster headache
Paroxysmal hemicranias continua
Hemicrania continua
SUNCT

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Who gets cluster headaches more - men or women?

Men

Typically 30-40 yr olds

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When do cluster headaches typically come on?

Around sleep time (stricing circadian rhythm)

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Describe a cluster headache

Severe unilateral headache lasting 20mins-3hrs + AUTONOMIC FEATURES
1 to 8 episodes a day

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Outline management of cluster headache

High flow oxygen
Sumatripan
Steroids
Verapamil for prophylaxis

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Who gets paroxysmal hemicranias continua more - men or women?

Women

Typically 50-60 yr olds

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How would you distinguish paroxysmal hemicranias continua from cluster headache?

Shorter duration (10-30 minutes typically), more frequent (1-40 a day)

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Which drug provides absolute response to paroxysmal hemicranias continua?

Indomethicin

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What is a SUNCT trigeminal cephalgia?

``` Short Unilateral Neuralgiform headache Conjunctival injections Tearing ```

What is the treatment for SUNCT?

Lamotrigine | Gabapentin

Who gets trigeminal neuralgia more - men or women?

Women | Typically elderly

What typically triggers trigeminal neuralgia and how is it described?

Touch in V2/V3 region e.g. shaving, eating | Severe stabbing unilateral pain

How long does an episode of trigeminal neuralgia usually last?

1-90 seconds | 10-100 episodes a day

List the main investigation and treatments for trigeminal neuralgia

MRI brain ``` Carbamazepine Gabapentin Phenytoin Baclofen Surgical abltation/decompression ```

List the 3 main spontaneous intracranial haemorrhage disorders

Subarachnoid haemorrhage Intracerebral haemorrhage Intraventricular haemorrhage

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 (typically at the junctions in the Circle of Willis) 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/stiffness Focal neuro deficit (dysphasia, hemiparesis) Reduced conscious level

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? What is the typical appearance on CT?

True Depends on delay - once blood spills out bleeding may stop White blood in SAS ('spidery')

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. What must you consider?

Xanthochromatic or bloodstained (ensure not traumatic tap - do three samples)

What investigation is gold-standard for identifying bleeding location of a subarachnoid haemorrhage? How does a Berry's aneurysm appear?

Cerebral angiography with/without CT/MR | 'Mushroom-like'

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 are the signs? What is the drug of choice to treat?

3-12 days Altered conscious level or focal deficit Nimodipine

What is the H triple therapy used for delayed ischaemic neurological deficit?

Hypervolaemia Haemodilution Hypertension

How does hydrocephalus arise? What are the main signs?

Increase in intracranial CSF pressure | Transient worsening headache or altered conscious level

How is hydrocephalus treated?

CSF drainage - lumbar puncture, ventricular drain, shunt

What should you not do to someone with hyponatraemia as a complication of subarachnoid haemorrhage? Why? What is the management?

Fluid restrict - Will cause hypovolaemia, predisposing to vasospasm and cerebral ischaemia Supplement sodium intake and give fludrocortisone

What is the most common aetiology/risk factor for intracerebral haemorrhage?

Hypertension leading to microaneurysms on small perforating arteries (Charcot-Bouchard)

Typically where does a hypertensive intracerebral haemorrhage affect anatomically? What are the presenting signs?

Basal ganglia (haematoma or AV malformation) Headache Focal neuro deficit Reduced conscious level

List the main investigations for intracerebral haemorrhage

``` CT scan (urgent if decreased consciousness) Angiography (suspicious of vascular anomaly) ```

What is an aura?

Fully reversible, visual, sensory, motor or language symptom, typically with a headache following less than 1 hour later

What is the first line management for uncomplicated headache?

Symptomatic OTC medications

What type of drug is propranalol and when should it be avoided?

B blocker | In asthma, HF, PVD

What type of drug is amitryptiline and what are its adverse effects?

Try-cyclic antidepressant | Dry mouth, postural hypotension, sedation

What are the two types of tension type headache?

Episodic or chronic

Which symptoms are present, and which are not in tension type headache?

Mild - moderate blateral pressing tingling quality | No N+V, photophobia, phonophobia

What are the management options for tension type headache?

Relaxation physiotherapy Antidepressant - diothiepin or amitriptyline for 3M Reassurance

What investigations must be carried out in new onset unilateral cranial autonomic features?

Imaging | MRI brain and MR angiogram

Idiopathic intracranial hypertension is more common in...

Obese females

What are the features of idiopathic intracranial hypertension?

Headache Diurnal variation Morning N+V Loss of vision

What investigations should be carried out in idiopathic intracranial hypertension?

MRI brain with MRV sequence (should be normal) CSF (increased pressure with normal constituents) Visual fields

What are the management options for idiopathic intracranial hypertension?

Weight loss Acetazolamide Ventricular atrial/ lumbar peritoneal shunt Monitor visual fields and CSF pressure

List differential diagnoses of sudden onset headache

SAH Migraine Bening coital cephalgia (occurs whilst having sex, before orgasm)

Why does hyponatraemia occur as a complication of SAH?

SIADH | Cerebral salt wasting

Outline the management options for SAH

``` Bed rest Analgesia Anti-emetic IV fluids Refer to neurosurgeons ```

Outline the management options for intracerebral haemorrhage

Surgical evacuation of haematoma +/- treatment of underlying abnormality Non-surgical management

How does an intraventricular haemorrhage arise? How does it appear on CT?

Rupture of subarachnoid or intracerebral bleed into ventricle White pockets in ventricle

What are the presenting signs of AV malformation?

Seizure Haemorrhage Headache Steal syndrome

Outline the management options for AV malformation

Surgery EV embolisation Stereotactic radiotherapy Conservative

List atypical causes of haemorrhage, not vascular pathology

Bleeding diathesis Anticoagulants (warfarin, heparin) Tumour

What is the diagnostic technique used for AV malfromation? What is the characteristic sign?

Catheter angiography | Tangle of vessels with large feeding artery and draining vein

What is the gold standard imaging used in suspected SAH?

CT scan

Triptans are contraindicated in...

Heart disease