Headache + Intracranial Pathology Flashcards
How are headaches classified? Give examples
Primary vs secondary
1˚: migraine, tension, cluster
2˚: SAH, meningitis, IIH, GCA
What are the important features in a headache history?
SOCRATES -Onset eg thunderclap (SAH) -Character eg pulsating (migraine) -Timing eg discrete episodes (cluster) -Exacerbating eg lying flat (IIH, SOL) Red flags -Systemic: weight loss, fever -Focal neurology- weakness, visual changes -Trauma-related -Hx of cancer or immunosuppression
How does SOL present?
Insidious onset:
- Headache: worse on lying/bending, improved on standing. Waking from sleep.
- Vomiting
- Seizures
- Papilloedema
- Focal neurology
What are some specific features that would make you worry about SOL?
Adult onset seizures esp. post-ictal weakness eg. Todd’s paralysis
Focal neurology evolving over time
Name some causes of SOL
Vascular: AVM
Infection/inflamm: TB granuloma, sarcoid granuloma, toxoplasmosis, abscess
Neoplasm: benign or malignant, 1˚ or 2˚
Which cancers commonly metastasize to the brain?
Melanoma Breast Lung Thyroid Colorectal Renal
What is the best imaging modality for SOL?
MRI
Describe the classic presentation of IIH
Overweight/obese woman, recent weight gain
Raised ICP signs:
-Headache worse on lying/bending
-Pulse-synchronous tinnitus
-Blurry vision, diplopia, visual loss (blind spot large)
-Papilloedema
Describe the approach to diagnosis in someone presenting with features of raised ICP
- History suggestive
- Examination: focal neurology, vision, fundoscopy
- Imaging: CT head if worrying features eg rapid onset. MRI is best
- Visual fields
- LP for opening pressure (above 30 is abnormally high)
Describe the management of IIH
Conservative: -Weight loss is definitive -Analgesia PRN Medical: -Acetazolamide Surgical: -Shunting
Describe the presentation of intracranial haemorrhage
EDH: headache with rapidly progressive decline in cognitive function and altered consciousness after traumatic event
SDH: slowly progressive decline in cognitive function and altered consciousness. Usually elderly, alcoholics, anticoagulated. Possible Hx of trauma
SAH: thunderclap headache, possible Hx of hypertension
Describe the diagnostic process in suspected SDH
- History suggestive
- Examination: focal neurology, GCS, obs
- Imaging: CT head (hyperdensity, midline shift)
What are the indications for CT head?
CT within 1 hour if:
- GCS <15 2 hours after incident or <13 at any time
- Suspected open skull fracture or basal skull fracture
- 1+ episodes of vomiting after incident
- Focal neuro or seizures
Ct within 8 hours if amnesia/loss of consciousness and:
- Age >65
- Dangerous mechanism of injury
- Current anticoagulation
- > 30 mins retrograde amnesia
Describe the management of SDH/EDH
- Generally: reversal of anticoagulation, prophylactic antiepileptics
- Consider severity-> conservative vs surgical Mx, ITU or ward
- Conservative: Prevent raised ICP
- Nurse flat
- Analgesia and sedation PRN
- > Hypertonic saline, osmotic diuretics (mannitol)
- > intubation and ventilation
- Surgical: craniotomy (large, GCS <9)
Describe the aetiology of intracranial haemorrhage
SDH: tear of the bridging veins
EDH: laceration of MMA
SAH: bleeding/ruptured aneurysm, AVM
What are the types of intracranial venous thrombosis? What is the imaging of choice?
Dural venous sinus thrombosis eg. cavernous sinus, sagittal sinus, etc.
Cortical vein thrombosis
Imaging with CT/MR venography
Describe the presentation of migraine
Migraine causes an episodic, unilateral headache often describes as ‘pulsating’ in nature. Lasts 4-72 hours
- Assoc w photophobia, phonophobia, N+V
- Relieved by rest + quiet
- Can be triggered: wine, cheese, stress, menstruation
What are the types of migraine?
Migraine w aura
Migraine wo aura
Ancephalgic migraine
Chronic migraine: 15+ days/month over 3 months
What are some types of migraine aura?
- Most commonly visual: visual fortification
- Sensory disturbance
- Weakness (hemiplegic migraine)
- Vestibular
What are the criteria for migraine diagnosis?
ICHD-3 criteria
1) Migraine wo aura: 5+ attacks, 4-72 hours, has migraine qualities
2) Migraine w aura: 2+ attacks, with classic description of aura
What are the red flags for headache?
SNOOP4 Systemic symptoms Neurological S/Ss: altered MS, focal neuro Onset Older age Pattern change Papilloedema Precipitating factors Positional aggravation
Describe the diagnostic process for suspected migraines
- History suggestive
- Examination for any focal neuro
- > If suggestive Hx, no red flags and normal exam: no further tests needed
- > If any atypical features/red flags -> MRI w contrast. Consider CT or CTA/MRA if urgent
Describe the management of migraine
Acute:
- NSAIDs, aspirin/paracetamol/caffeine, anti-emetics (metoclopramide, prochlorperazine), hydration
- Triptans: sumatriptan 1st line. Take first dose -> second after 2+ hours if the first was not effective or migraine returns
Prophylaxis (if >3 per month):
- Trigger avoidance
- Mg, riboflavin
- Betablockers (propranolol), amitriptyline, anticonvulsants (topiramate), CCBs
Describe the presentation of trigeminal neuralgia
Paroxysms of sharp stabbing pain the distribution of the branches of the trigeminal nerve
<2 minutes
May be triggered by eating, brushing teeth, shaving
What are the causes of trigeminal neuralgia?
Classified as classic (idiopathic) or symptomatic (2˚)
2˚: MS, tumours (compression), post-herpetic neuralgia
Describe the diagnostic process for suspected trigeminal neuralgia
- History and examination (normal in CTN)
- Electrophysiology can distinguish CTN from STN
- Imaging eg. MRI for STN
Describe the management of trigeminal neuralgia
Medical:
-Anticonvulsants (carbamazepine)
Surgical:
-Decompression
Describe the presentation of cluster headache
- Attacks of rapid onset unilateral headache occurring in clusters (8x/day-every other day) over weeks-mos
- Last 15 mins-3 hours
- Occur with ipsilateral autonomic signs (red and teary eye, runny nose, sweating, ptosis)
- Often restless and agitated patient
- Triggered by different stimuli
Describe the management of cluster headache
Acute:
- Parenteral triptans (nasal/SC)
- Oxygen
Transitional treatment (start with preventative for quicker relief): -Prednisolone
Preventative:
- Verapamil
- Topiramate
- > neuromodulation
Describe the presentation of GCA
- Medium vessel vasculitis affecting branches of external carotid
- Temporal headache in >50s
- Worse w chewing, brushing hair
- Can have visual loss
- Assoc w PMR in 1/3
What are the signs of GCA on examination
- Thickened, hard, tender temporal artery
- Visual field loss
Describe the diagnostic process in suspected GCA
- History and examination- vital to know if any visual loss
- Bloods: routine bloods + ESR and CRP
- Imaging: USS
- Extra tests: temporal artery biopsy (can be done within 2 weeks of diagnosis, do not delay treatment)
Describe the management of GCA
- Medical emergency! Same day rheum review. Ophthal if any visual loss
- High dose prednisolone (40-60mg) ASAP
- Taper slowly, usually treatment over 1-2 years
What are the 3 types of herniation? Describe.
Tonsillar: cerebellar tonsils -> foramen magnum. BS compression causes cardioresp failure
Subfalcine: frontal lobe under the falx cerebri
Transtentorial/uncal: temporal lobe under tentorium
What are some causes of cerebral oedema?
- Vasogenic (increased permeability): trauma, infection, neoplasm, etc.
- Cytotoxic (decreased oncotic pressure -> water into cells)
- Interstitial: hydrocephalus
Define epilepsy
Tendency to recurrent, unprovoked episodes of abnormal electrical activity in the brain that manifests as seizures
Name some causes of seizures
Non-epileptic:
- Vascular: ischaemic stroke, haemorrhage
- Infection/inflamm: viral encephalitis, TB, syphilis, HIV, sarcoidosis
- Trauma
- Autoimmune: encephalitis
- Metabolic: hypoxia, hypoglycaemia, electrolyte disturbance, hyperbilirubinaemia (kernicterus), hypothermia
- Iatrogenic
- Neoplastic
- Functional seizures
Epileptic seizures
Describe the presentation of an epileptic seizure
- May have a prodrome for hours/days. May have aura
- Seizure activity, during may have incontinence, tongue-biting
- Followed by post-ictal period of drowsiness, focal neuro etc
What are the types of epileptic seizures?
Simple vs complex: loss of consciousness or not
Focal vs generalised: confined to one area of the brain or more widespread
Focal can be subdivided into location eg
-Frontal lobe: motor eg. Jacksonian march, Todd’s paralysis
-Temporal lobe: automatisms, sensory, deja vu
-Parietal lobe: tingling/numbness
-Occipital lobe: visual phenomena
Generalised can be divided into types:
- Tonic-clonic: tonic phase and clonic phase. Classic.
- Tonic: stiffness
- Myoclonic: jerks
- Atonic: no tone
- Absence
A 22 year old man is brought to ED after having a seizure. Describe the management approach.
-History: elicit if epileptic seizure, head trauma/precipitating factors, PMH, etc. Collateral Hx.
-Examination: look for any focal neuro, listen to heart
-Obs
-Urine drug screen
-ECG
-Bloods: FBC, CRP, U+Es, LFTs, TFTs, glucose
-Imaging if indicated eg. CT head, MRI
Mx:
-First episode: educate on seizure recognition, first aid, reporting further seizures, when to call 999
Name some indications for MRI head in a patient with epilepsy
- New Dx of epilepsy in adulthood
- Evidence of focal onset or focal neuro
- Seizures continue despite first line treatment
Describe the management of epilepsy
MDT approach
Conservative:
-Education
Medical:
-Antiepileptic drugs (AEDs) usually after 2nd seizure or 1st if structural lesion
eg. valproate (men only), lamotrigine (usually 1st line. Worsens myoclonic seizures), levetiracetam (Kepra), carbamazepine
Surgical: refractory cases
Describe the side effects of common AEDs
Valproate: N+V, alopecia, weight gain, abnormal LFTs, enzyme inhibition, teratogenicity
Lamotrigine: rash, SJS, sedation, diplopia
Levetiracetam: psych- irritability, depression, anxiety
Carbamazepine: SIADH, N+V
Describe the management of status epilepticus
Start timer A to E approach: -Airway: consider need for airway Mx -Breathing: high flow O2 -C: IV access and bloods. ECG -D: GCS, pupils -E: check BM, exposure 5 minutes: -Buccal midazolam 10mg -IV/IM lorazepam 4mg -Consider IV glucose (50ml 50%) or Pabrinex (250mg) 15 minutes: repeat loraz 25 minutes: -Phenytoin 18mg/kg at rate of 50mg/min -Phenobarbital Refractory status (60-90 mins): GA eg. propofol, thiopental
Describe the common types of brain tumour
Metastases: commonest of all tumours
Benign:
Meningioma: Commonest.
Astrocytoma
Glioblastoma multiforme: grade IV astrocytoma. Poor prognosis.
