headache and SAH Flashcards
what is the aetiology of SAH?
berry aneurysm rupture (80%)
ateriovenous malformations (15%)
5% due to others such as;
- encephalitis
- vasculitis
- neoplasm
where do berry aneurysms form?
junction of posterior communicating artery and internal carotid
anterior communicating and anterior cerebral artery
bifurcation of MCA
what are the RFs for SAH?
aneurysms smoking alcohol HTN PKD Ethlers danos Aortic coarctation
what are the differentials for SAH?
meningitis migraine intracranial bleed cortical vein thrombosis carotid dissection
what are the S&S of SAH?
thunderclap headache LOC or confusion neck stiffness after 6 hours vomiting seizures eyelid drooping, diplopia, orbital pain - compression of CN III by the aneurysm photophobia
what are the investigations for SAH?
CT head
- hyperdense areas in the subarachnoid space
FBC, U&E’s, Glucose and clotting MAY show;
- leucocytosis
- hyponatraemia
- prolonged coag
- increased glucose
LP
- xanthochromia 12 hours after
Troponin
- elevated in 25% (less than MI levels)
ECG
- arrhythmia and ischaemic changes
CTA/MRA
how is SAH managed ?
Definitive;
endovascular coiling or clipping
Ward management;
- re-examine CNS often - pupils, GCS
- keep hydrated to maintain cerebral perfusion (2-3L of NaCl)
- Nimodipine 60mg/4hrs for 3 weeks. Reduces vasospasm and cerebral ischaemia
Analgesia
Antiembolic stocking
anticonvulsant if seizing
what are the complications of SAH?
rehaemorrhage Hydrocephalus Delayed ischaemia Hyponatraemia Stunned myocardium
what are the classical symptoms of migraine?
- Visual or other aura (see below) lasting 15–30min followed within 1h by unilateral, throbbing headache. Or:
- Isolated aura with no headache;
- Episodic severe headaches without aura, often premenstrual, usually unilateral, with nausea, vomiting ± photophobia/phonophobia (‘common migraine’). There may be allodynia—all stimuli produce pain: “I can’t brush my hair, wear earrings or glasses, or shave, it’s so painful
what are the phases of migraine?
prodome
Aura - scotoma, flashing lights, fortifications
Headache and associated features
Postdome
what inv should be done in migraine?
clinical diagnosis but do cranial nerves, fundoscopy and neuro exam
what are some established migraine triggers?
CHOCOLATE
Chocolate Hangovers Orgasms Cheese OCP Lie-ins Alcohol Tumult Exercise
what are some examples of aura?
visual - chaotic cascading, distortion, zig zags, scotoma
Somatosensory - paraesthesiae
motor - dyarthria, ataxia, hemiparesis
speech - dysphasia paraphasia
how can migraines be managed?
lifestyle changes
NSAID Anti-emetic Paracetamol Triptan Ergot alkaloid
when are triptans contraindicated?
IHD, coronary spasm, uncontrolled HTN, ergot use
what can be given prophylactically for migraines?
B-blocker
TCA’s
anti-epilepsy drugs e.g sodium valproate
what are cluster headaches
very painful condition with a clinical picture consisting of unilateral headache lasting 15-180mins associated with autonomic symptoms secondary to PNS overactivity and SNS underactivity
what are the S&S of cluster headaches?
repeated attacks of unilateral pain (average 4x day)
Excruciating pain
- boring, sharp, piercing or burning
Lacrimation, rhinorrhoea, partial horners
agitation
N&V
photo/phonophobia
what inv are done in cluster headaches ?
Brain CT/MRI
- rule out SOL or cavernous sinus pathology
ESR
- rule out giant cell arteritis
how is an acute attack of cluster headache treated?
oxygen
subcutaneous sumatriptan
zolmitriptan nasal spray is second line
can also give intrnasal lidocaine
how are chronic cluster headaches treated?
verapimil
lithium
topiramide and gabapentin (2nd line)
melatonin
what are the features of tension headache?
generalised head pain that is non-pulsatile and often occurs in frontal or occipital regions
constricting pain - like band around head
normal neuro and autonomic
tenderness in head and neck muscles
how are chronic tension headaches managed?
TCA’s
Relaxation tranining or CBT
muscle relaxants
massage or acupuncture
what are the causes of raised ICP headaches?
mass effect
- SOL, haematoma, infarct with oedema
increased venous pressure
- cerebral venous sinus thrombosis, obstruction of jugular vein
CSF flow obstruction
- hydrocephalus, meningitis
what are the S&S of raised ICP headaches ?
headache worse on lying flat
headache worse in morning
persistent N&V
headache worse on vulsalva and exertion
what examination findings might be seen in raised ICP headaches?
papilloedema
impaired visual acuity
III and VI palsy
focal neuro signs
what are the inv for raised ICP headaches ?
CT/MRI head and spine
- exclude SOL
LP
- only after imaging
- raised opening pressure
what is the treatment for raised ICP headaches?
mannitol or hypertonic saline
shunting or craniectomy
treat underlying cause
what are the S&S of trigeminal neuralgia?
paroxysmal episodes of intense stabbing pain along the distribution of the trigeminal nerve
unilateral, typically affecting the mandibular or maxillary divisions
face screws up with pain
what can be the triggers for trigeminal neuralgia?
washing or shaving face
eating and talking
what are the secondary causes of TN?
compression of trigeminal root by aneurysm or tumour
chronic meningeal inflammation
MS
what are the treatment options for TN?
carbamazepine
lamotrigine
phenytoin
gabapentin
what are medication overuse headaches and what are the culprits?
headache for >15 days per month associated with frequent use of analgesia
cocodamol
ergotamine
triptans
