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neurology clerkship > headache slide > Flashcards

headache slide Flashcards

1
Q

pain sensitive intracranial structures

A
  • dura
  • arteries
  • venous sinuses
  • para-nasal sinuses
  • eyes
  • tympanic membrane
  • cervical spine

*brain parenchyma is sensitive to pain

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2
Q

class of headache

A
  • primary (without underlying abnormality)
  • secondary (Headaches that are associated with some underlying abnormality)
  • painful neuropathies
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3
Q

primary type headache

A

types:

  • migrane
  • tension type headache
  • cluster headache and
  • other trigeminal autonomic cephalalgias
  • other primary headaches
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4
Q

sinus type headache

A

pain is behind brow bone +/- cheekbone

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5
Q

cluster

A

pain is in and around one eye

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6
Q

tension

A

pain is like a band squeezing the head

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7
Q

migrane

A

pain, nausea and visual changes are typical of classic form

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8
Q

5 phases of migraine attack

A
  1. prodrome
  2. aura
  3. headache
  4. resolution
  5. recovery
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9
Q

typical aura ≥ 2 of the following 4 characteristics:

A
  • ≥ 1 aura symptom spreads gradually over ≥ 5 min, and/or ≥ 2 symptoms occur in succession
  • each individual aura symptom lasts 5-60 min
  • ≥ 1 aura symptom is unilateral
  • aura accompanied or followed in <60 min by headache
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10
Q

migrane triggers

A 
Food and food additives  
Bright lights/glare  
Smells/odors  
Dieting/hunger
Loud noises/sounds  
Changes in altitude/air travel  
Stress
Weather changes  
Caffeine
Alcoholic beverages  
Changes in sleep habits
Hormonal fluctuations/menstrual  cycle
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11
Q

release of NT during migrane is triggered by…

A

increase brainstem response from presymptomatic hyperexcitability

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12
Q

names of released NTs

A 
5-HT
NE: norepinephrine
DA: noradrenalin
GABA
glutamate
NO
substance p
estrogen
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13
Q

NT activates…and will lead to…

A

trigeminal nucleus/ vasodilatation and inflammation

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14
Q

trigeminal nucleus activation will lead

A
  1. dilatation of meningeal blood vessels (throbbing)
  2. activation of area postrema
  3. activation of cortex and thalamus (head pain)
  4. activation of hypothalamus (hypersensitivity)
  5. activation of cervical trigeminal system (muscle spasm)
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15
Q

trigeminal nucleus (TNC) will…

*treatment should be done at the stage of Trigeminal vascular activation (before central sensitization) when it reaches to thalamus and cortex its too late

A

transmit pain s,gnals to thalamus and cerebral cortex and cause:

  • allodynia and
  • central sensitization
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16
Q

allodynia

A

you feel pain from stimuli that don’t normally cause pain. For example, lightly touching your skin or brushing your hair might feel painful.

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17
Q

migraine without aura criterias

A
  1. lasting 4-72hr
  2. at least 2 of the following
    - unilateral location
    - pulsatile quality
    - moderate or severe intensity
    - aggravation by routine physical activity
  3. at least 1 of the following
    - nausea +/- vomiting
    - photophobia and phonopobia
  4. at least 5 attacks fulfilling these criteria
  5. no evidence organic disease.
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18
Q

complications of migrane

A
  • status migrainosus ( >72hr)
  • persistant aura thou infarction ( >1 week )
  • Migrainous infarction
  • Migraine aura-triggered seizure
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19
Q

migraine pain treatment

A

ergotamine-triptan
aspirin
acetaminophen
NSAIDs

20
Q

Ergotamine

A

cause vasoconstriction

avoid if patient has CAD

21
Q

triptans

A

bind seratonin receptror and cause vasoconstriction, particularly at cerebral and dura arteries.
Also inhibit inflammation of vessels of the dura matter

22
Q

preventive medics for migrane***

A
  1. Antidepressants
    - amitriptyline
    - cymbalta
  2. Beta blockers
    - propanolol
  3. Ca channel blockers
  4. Depakin (valproic acid)
  5. Epilepsy meds
    - topiramate
    - gabapentin
23
Q

tension type headache

69% prevelance***

A
  1. Affects mostly adults, F>M
  2. Lasting from 30 min to 7 d
  3. ≥2 of the following 4 characteristics:
    - bilateral location
    - pressing or tightening (non-pulsating) quality
    - mild or moderate intensity
    - not aggravated by routine physical activity
  4. Both of the following:
    - no nausea or vomiting,
    - no more than one of photophobia or phonophobia
24
Q

tension type headache treatment

A
  1. episodic treatment
    - simple analgesics
  2. chronic ( > 15 ay) type treatment
    - sypmtomatic treatment may give short time relief
    - Amitriptyline is the prophylactic of choice
    - stress management
25
Q

Trigeminal Autonomic Cephalgias TACs***

A

ipsilateral symptoms or signs:

  • conjunctival injection and/or lacrimation;
  • nasal congestion and/or rhinorrhoea;
  • eyelid edema;
  • fore-head and facial sweating;
  • forehead and facial flushing;
  • sensation of fullness in the ear;
  • miosis and/or ptosis
26
Q

Cluster Headache

A

Onset generally between 20 - 40 yrs
More common in men (3:1 ratio)*
Accompanied by ipsilateral autonomic symptoms
Unilateral, periorbital localization
Very severe, suicide headache
Occurs at night 1-2 hours following sleep onset
Last 15 – 180 minutes,
a sense of restlessness or agitation during an attack*

27
Q

tension type headache subgroups

A

infrequent episodic tension type (<1 d/mo (<12 d/y))
Frequent episodic tension-type (1-14 d/mo for >3 mo)
Chronic tension-type headache (>15/ month)
Probable tension-type headache

28
Q

Secondary TACs

A

Internal carotid artery dissection, pituitary adenoma, tm, cerebellopontine angle AVM, CPA epidermoid tm, posterior fossa lesions…..

29
Q

cluster headache

A

Strictly unilateral pain wth ipsilateral autonomic features
Attack duration less then 4 h
Restlessnes during attack

30
Q

other primary headaches

A

Primary cough headache Primary exercise headache
Primary headache associated with sexual activity Primary thunderclap headache
Cold-stimulus headache External pressure headache Primary stabbing headache Nummular headache Hypnic headache
New daily persistent headache

31
Q

cranial neuropatihes fascial pain

A

Trigeminal Neuralgia
Glossopharyngeal Neuralgia
Occipital Neuralgia

32
Q

maneuver for glossopharyngeal neuralgia pain relief

A

pain releasing right ear lob maneuver

33
Q

secondary headaches

A
  • vascular disorders (hemorrhages…)
  • intracranial infection
  • intracranial tumour
  • trauma
  • disease of extracranial structures (glaucoma)
  • csf abnormalities
  • systemic disease
  • substance abuse / withdrawal
  • hangover
  • fever
34
Q

headache red flags***

A
  1. Systemic symptoms (fever, weight loss) or secondary risk factors (HIV, systemic cancer)
  2. Neurologic symptoms (confusion, impaired alertness)
  3. Onset (sudden, abrupt)
  4. Older (new onset and progressive esp >50 age: giant cell arthritis )
  5. Previous headache history
35
Q

triggered headache by***

A

valsalva maneuver
sexual intercourse
exertion

36
Q

subarachnoid hemorrhage (SAH)

A 
Rupture of aneurysm or AVM
Sudden onset, maximal within 1 minute
Thunderclap headache  
40 years or older
Neck pain and stiffness  
Witnessed loss of conciousness  or acc by confusion
Onset during exertion
37
Q

pitfalls of SAH

A 
not the worst headache in their lives
neural exam is normal
pain can get better w/...
CT is negative
decreased RBC count
skip LP and do always MRI
38
Q

utility of CT/MRI/LP

A

CT
-92-100 % sensitivity within 24h
MRI
-equally sensitive to CT in the acute phase and more sensitive after the acute phase
LP***
-may be negative the first 2 hours after the bleed;
-most sensitive at 12 hours after symptom onset
-Xanthochromia (yellow-to-pink CSF supernatant) usually is seen by 12 hours

39
Q

Headache and Brain Tumor

A

Usually gradual onset

Worse in the morning, before standing

40
Q

Temporal Arteritis

A
  • Recent onset headache
  • > 50 years old,
  • localized tenderness over one temporal area,
  • ESR!…………….
  • Positive bx
41
Q

Emergency of temporal arteritis

A

may affect the retinal arteries and cause bilateral blindness

42
Q

Pseudotumor Cerebri

A 
- Idiopathic intracranial hypertension:
continuous, dull headache, generally unresponsive  to analgesics.
- Obese women
- Hormonal disturbances,
- May cause visual loss,
43
Q

Thunderclap Headache

A

mostly seen at reversible cerebral vasoconstriction syndrome***
most common cause is aneurysmal subarachnoid hemmorhage

44
Q

common causes of thunderclap headache

A
  • aneurysmal subrachnıid hemorrhage
  • reversible cerebral vasoconstriction syndrome
  • carotid and vertebral artery dissection
  • cerebral venous sinus thrombosis
  • spontaneous intracranial hypotension
45
Q

Reversible Cerebral Vasoconstriction Syndrome

A
  1. Recurrent thunderclap headaches
    - 2-10 over 2 weeks
    - Often provoked by urinating, bending, sexual activity, emotions
  2. Monophasic course,
    - No new symptoms after 1 month
  3. Normal Neurological Examination
  4. MRI-CT 30-70 % N
  5. Normal or near CSF
  6. Multifocal, multivessel segmental vasoconstriction of cerebral arteries that normalizes within 12 weeks
46
Q

Spontaneous Intracranial Hypotension

A
  1. Orthostatic headache
    - Worse sitting or standing
    - Relieved lying down
    - 15 % thunderclap headache
  2. Tinnitus, nausea, vomiting, neck stiffness, dizziness, visual changes
  3. Brain MRI with contrast
    - Diffuse, smooth, continuous pachymeningeal enhancement,
    - Cerebellar tonsil and optic chiasmal descent,
    - Flattening of the anterior pons and tectum

neurology clerkship (2 decks)

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