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 (coughing, sneezing, straining)
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, especially if young
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
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
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
How long do auras typically last in migraine?
20-60 mins
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
List triggers of migraine
Sleep Diet Stress Physical exertion Hormones
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
List pharmacological management of migraine
NSAID (aspirin, naproxen, ibuprofen) + anti-emetic if vomiting
Triptans (5HT agonist/ rizatriptan)
TAKE AS EARLY AS POSSIBLE INTO HEADACHE
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 Gabapentin Sodium valproate Botulinum toxin
What type of drug is topiramate and what are its adverse effects?
Carbonic anhydrase inhibitors
Weight loss, paraesthesia, impaired concentration
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 (stricing circadian rhythm)
Describe a cluster headache
Severe unilateral headache lasting 20mins-3hrs + AUTONOMIC FEATURES
1 to 8 episodes a day
Outline management of cluster headache
High flow oxygen
Sumatripan
Steroids
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 (10-30 minutes typically), more frequent (1-40 a day)
Which drug provides absolute response to paroxysmal hemicranias continua?
Indomethicin
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
