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Neurology > headache and SAH > Flashcards

headache and SAH Flashcards

1
Q

what is the aetiology of SAH?

A

berry aneurysm rupture (80%)

ateriovenous malformations (15%)

5% due to others such as;

  • encephalitis
  • vasculitis
  • neoplasm
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2
Q

where do berry aneurysms form?

A

junction of posterior communicating artery and internal carotid

anterior communicating and anterior cerebral artery

bifurcation of MCA

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3
Q

what are the RFs for SAH?

A 
aneurysms 
smoking 
alcohol 
HTN 
PKD 
Ethlers danos 
Aortic coarctation
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4
Q

what are the differentials for SAH?

A 
meningitis 
migraine 
intracranial bleed 
cortical vein thrombosis 
carotid dissection
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5
Q

what are the S&S of SAH?

A 
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
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6
Q

what are the investigations for SAH?

A

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

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7
Q

how is SAH managed ?

A

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

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8
Q

what are the complications of SAH?

A 
rehaemorrhage 
Hydrocephalus 
Delayed ischaemia 
Hyponatraemia 
Stunned myocardium
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9
Q

what are the classical symptoms of migraine?

A
  • 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
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10
Q

what are the phases of migraine?

A

prodome

Aura - scotoma, flashing lights, fortifications

Headache and associated features

Postdome

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11
Q

what inv should be done in migraine?

A

clinical diagnosis but do cranial nerves, fundoscopy and neuro exam

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12
Q

what are some established migraine triggers?

A

CHOCOLATE

Chocolate 
Hangovers
Orgasms 
Cheese 
OCP 
Lie-ins 
Alcohol 
Tumult 
Exercise
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13
Q

what are some examples of aura?

A

visual - chaotic cascading, distortion, zig zags, scotoma

Somatosensory - paraesthesiae

motor - dyarthria, ataxia, hemiparesis

speech - dysphasia paraphasia

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14
Q

how can migraines be managed?

A

lifestyle changes

NSAID 
Anti-emetic
Paracetamol 
Triptan 
Ergot alkaloid
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15
Q

when are triptans contraindicated?

A

IHD, coronary spasm, uncontrolled HTN, ergot use

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16
Q

what can be given prophylactically for migraines?

A

B-blocker
TCA’s
anti-epilepsy drugs e.g sodium valproate

17
Q

what are cluster headaches

A

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

18
Q

what are the S&S of cluster headaches?

A

repeated attacks of unilateral pain (average 4x day)

Excruciating pain
- boring, sharp, piercing or burning

Lacrimation, rhinorrhoea, partial horners

agitation

N&V

photo/phonophobia

19
Q

what inv are done in cluster headaches ?

A

Brain CT/MRI
- rule out SOL or cavernous sinus pathology

ESR
- rule out giant cell arteritis

20
Q

how is an acute attack of cluster headache treated?

A

oxygen
subcutaneous sumatriptan
zolmitriptan nasal spray is second line
can also give intrnasal lidocaine

21
Q

how are chronic cluster headaches treated?

A

verapimil
lithium
topiramide and gabapentin (2nd line)
melatonin

22
Q

what are the features of tension headache?

A

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

23
Q

how are chronic tension headaches managed?

A

TCA’s
Relaxation tranining or CBT
muscle relaxants
massage or acupuncture

24
Q

what are the causes of raised ICP headaches?

A

mass effect
- SOL, haematoma, infarct with oedema

increased venous pressure
- cerebral venous sinus thrombosis, obstruction of jugular vein

CSF flow obstruction
- hydrocephalus, meningitis

25
Q

what are the S&S of raised ICP headaches ?

A

headache worse on lying flat
headache worse in morning
persistent N&V
headache worse on vulsalva and exertion

26
Q

what examination findings might be seen in raised ICP headaches?

A

papilloedema
impaired visual acuity
III and VI palsy
focal neuro signs

27
Q

what are the inv for raised ICP headaches ?

A

CT/MRI head and spine
- exclude SOL

LP

  • only after imaging
  • raised opening pressure
28
Q

what is the treatment for raised ICP headaches?

A

mannitol or hypertonic saline
shunting or craniectomy
treat underlying cause

29
Q

what are the S&S of trigeminal neuralgia?

A

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

30
Q

what can be the triggers for trigeminal neuralgia?

A

washing or shaving face

eating and talking

31
Q

what are the secondary causes of TN?

A

compression of trigeminal root by aneurysm or tumour

chronic meningeal inflammation

MS

32
Q

what are the treatment options for TN?

A

carbamazepine
lamotrigine
phenytoin

gabapentin

33
Q

what are medication overuse headaches and what are the culprits?

A

headache for >15 days per month associated with frequent use of analgesia

cocodamol
ergotamine
triptans

Neurology (7 decks)

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