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Neurology > Headache/SAH > Flashcards

Headache/SAH Flashcards

1
Q

How can headaches be categorised into two groups?

A

primary e.g. migraine, cluster headache, tension headaches

Secondary- SAH, brain tumour, meningitis

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2
Q

What are the red flags for a headache?

A
  1. first/worst headache with acute onset
  2. postural association
  3. > 50
  4. systemic symptoms e.g. fever, weight loss
  5. neurological signs
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3
Q

Unilateral headache. What are the differentials?

A

cluster headache, migraine

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4
Q

Bilateral headache. Differentials?

A

tension headache, migraine

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5
Q

Ocular headache. Differentials?

A

cluster headache, migraine

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6
Q

Occipital headache. Differentials?

A

haemorrhagic, meningitis

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7
Q

Diffuse headache differentials?

A

raised ICP

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8
Q

Sudden onset headache differentials?

A

SAH

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9
Q

Acute headache differentials?

A

meningitis, migraine, venous sinus thrombosis, temporal arteritis, intracranial haemorrhage

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10
Q

Differentials for chronic headache?

A

migraine, medication overuse, tension

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11
Q

Patient with headache has facial pain. What are the differentials?

A

trigeminal neuralgia, ENT/dental causes

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12
Q

Patient with headache and jaw claudication. What is the likely cause?

A

temporal arteritis

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13
Q

What are associated symptoms of migraine?

A

N/V, photophobia/phonophobia, sensory aura

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14
Q

Headache last a few seconds and is recurrent. What is the likely cause?

A

trigeminal neuralgia

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15
Q

Headache lasts <4 hr. What is the likely cause?

A

cluster headache

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16
Q

Headache 4-72hr, what is the likely cause?

A

migraine

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17
Q

Headache worse on awakening. Differentials?

A

raised ICP, obstructive sleep apnoea

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18
Q

Headache worse during night. Likely source?

A

cluster headache

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19
Q

Headache worse at the end of the day/work. Which headache is this?

A

tension headache

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20
Q

Which headaches can worsen during menstruation?

A

migraine

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21
Q

Which specific questions should you ask about in the history of headache?

A

HTN, analgesia, alcohol/cocaine, sleep, diet, caffeine intake, travel history (infective causes), fam hx migraine and SAH

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22
Q

Which specific things can you do to examine for temporal arteritis and meningitis, SAH?

A

neck stiffness for meningitis and SAH

scalp tenderness- temporal arteritis

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23
Q

What is a key question to ask when querying SAH?

A

when did the headache reach its peak onset? SAH reach peak pain within 5 mins.

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24
Q

What percentage of SAH are observable on CT?

A

99%

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25
Q

If SAH is suspected but the CT is normal, what is the next investigation?

A

lumbar puncture at least 12 hours after onset of headache to detect xanthochromia

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26
Q

Which meningeal layer houses CSF?

A

subarachnoid space

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27
Q

What are the risk factors for SAH?

A

smoking, cocaine use, HTN, fam hx SAH, connective tissue disorders, (AD polycystic kidney disease)

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28
Q

What are complications of LP?

A

headache (most common, improves with lying), infection, bleeding, nerve damage, back pain

29
Q

Management of post LP headache?

A

IV fluids, bed rest, simple analgesia, caffeinated drink?

30
Q

Acronym for headache differentials?

A 
VITAMIN CDEF
vascular- SAH
infection- meningitis
trauma- traumatic brain injury 
autoimmune- temporal arteritis 
metabolic- DKA/HHS
iatrogenic- post LP
neoplastic- brain tumour
functional- stress
31
Q

In suspected meningitis, what is the first step of management/investigation?

A

start antimicrobials

32
Q

Differentials for sudden onset headache

A

Raised ICP, encephalitis, meningitis, SAH

33
Q

When should LP be performed in patient with sudden onset headache and nil findings on CT brain

A

After 12 hours of headache onset and within 12 days of symptoms onset

34
Q

List two checks that should be made for safety prior to commencing LP

A

fundoscopy/CT head (to show evidence of raised ICP)

Clotting and platelets

35
Q

Which findings in LP would indicate positive result?

A

xanthochromia if SAH, positive gram stain/PCR if meningitis

36
Q

List three complications from LP

A

headache, introduction of infection, nerve injury, meningeal herniation

37
Q

Differential for acute headache?

A

VICIOUS
Vascular: SAH, intracranial, sinus thromboembolism

Infection/inflammation: meningitis, encephalitis, abscess

Compression: tumour

ICP

Opthlalmic: acute glaucoma

Unknown: cough, exertion

Systemic: phaochromocytoma, sinusitis, tonsilitis, CO

38
Q

Differential for chronic headache?

A

MCD TINGS

Migraine
Cluster headaches
Drugs
Tension headaches
ICP
Neuralgia (trigeminal)
Giant cell arteritis
Systemic: HTN
39
Q

List three drug classes that can cause headaches

A

analgesics
caffeine
vasodilators: CCB, nitrates

40
Q

Patient with acute headache and papilloedema. What are you worried about?

A

venous sinus thrombosis

41
Q

Which sign is positive in meningism?

A

kernig’s

42
Q

Name two features of tension headache

A

bilateral, non-pulsatile, band-like

43
Q

What is the distribution of headache in migraine?

A

unilateral

44
Q

Patient with rapid onset pain around one eye. The attack lasts 2 hours and happens every day for 5 weeks. Which type of headache do they have?

A

cluster headache

Rapid onset very severe pain around/behind one eye.
 Red, watery eye, nasal congestion
 Miosis, ptosis
 Attacks last 15min–3hrs, 1-2x/day, mostly nocturnal
 Clusters last 4-12wks, remission lasts 3mo-3yrs. Can
be chronic vs. episodic.

45
Q

Treatment for cluster headache?

A

oxygen and sumitriptan

46
Q

Name two triggers for trigeminal neuralgia

A

washing area, shaving, eating, talking

47
Q

What are the symptoms of trigeminal neuralgia

A 
Paroxysms of unilateral intense stabbing pain in 
trigeminal distribution (usually V2/3)
48
Q

Name a treatment for trigeminal neuralgia

A

gabapentin

49
Q

What worsens increased ICP headaches?

A

worse in AM, stooping, worse sitting or standing

50
Q

Name a risk factor for migraines

A

obesity

51
Q

Describe the pathophysiology of migraine

A

Vascular: cerebrovascular constriction → aura,
dilatation → headache.
 Brain: spreading cortical depression
 Inflammation: activation of CN V nerve terminals in
meninges and cerebral vessels.

52
Q

List four triggers for migraine

A 
CHOCOLATE 
  CHeese 
  OCP (oral pill)
  Caffeine 
  alcohOL 
  Anxiety 
  Travel 
  Exercise

Lack of sleep, stress, hunger, mesntruation

53
Q

Describe three symptoms of migraines?

A

Prodrome-> aura -> headache

Prodrome: hours-days

Aura: mins before headache

Headache- unilateral throbbing

54
Q

What are the features of prodrome?

A

yawning, food cravings, changes in sleep/appetite/mood

55
Q

What are the types of auras?

A

 Visual: distortion, lines, dots, zig-zags, scotoma,
hemianopia
 Sensory: paraesthesia (fingers → face)
 Motor: dysarthria, ataxia, ophthalmoplegia,
hemiparesis (hemiplegic migraine)
 Speech: dysphasia, paraphasia

56
Q

Differential for migraine?

A 
  Cluster / tension headache 
  Cervical spondylosis 
  HTN 
  Intracranial pathology 
  Epilepsy
57
Q

Treatment for migraine?

A

aspirin, ibuprofen, triptan, amitriptyline

58
Q

When should triptan be taken ideally for migraine if patient has auras?

A

In patients who experience aura with their migraine, it is recommended that 5HT1-receptor agonists are taken at the start of the headache and not at the start of the aura (unless the aura and headache start at the same time).

59
Q

What is the first line prophylaxis for migraine?

A

avoidance of triggers, propranolol and topiramate (antiepileptic), TCAs (amiltiptyline)

60
Q

List three complications of SAH

A
  1. rebleeding
  2. Cerebral ischaemia
  3. Hydrocephalus
  4. Hyponatraemia
  5. Seizures
61
Q

What is Terson’s syndrome?

A

vitreous haemorrhage of the eye associated with SAH

62
Q

Only when should LP be performed for suspected SAH?

A

if negative CT findings, 12 hours after onset

63
Q

Which drug is used to manage delayed ischaemia in SAH?

A

nimodipine

64
Q

Name a cardio complication of SAH?

A

LVF- tako-tsubo cardiomyopathy

65
Q

Who should you image with headache?

A

SNOOP- SSSNOOPPP: systemic symptoms e.g. fever, secondary risk fx, seizures, neuological symptoms, onset, older, progression, papilloedema, precipitated by cough or exertion or sleep.

CSF- change in nature of headache, S- systemic symptoms of signs, F-focal neurological deficit

66
Q

List three features of postdrome migraine?

A

euphoria, depression, poor concentration, fatigue

67
Q

First line triptan for headache?

A

sumitriptan

68
Q

What are examination findings of raised pressure headaches?

A

optic disc swelling, impaired visual acuity, restricted visual fields, 3rd and 6th nerve palsy, focal neurological signs

Neurology (13 decks)

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