Headache+ stroke Flashcards
What are headaches?
Can be sx if underlying disorder
- brain tumour, temporal arteritis
Encephalitis
Or Migraine H Tension H Cluster H SOCRATES- Site, Onset, Character, Radiation, assc, timing, exacerbations, Severity.
Bam? How long inbetween each episode
Different types of H
Migraine: unilateral, retro orbital- above and behind eye- pulsating, made worse by photopobia, phonophobia, assc N+V during event, last to mins to hrs.
Tension: felt around the entire head, esp occibital muscles- back muscles “vice-like”, - quite a while eg 6 hrs- sustained, not aggrevated by light or sound, less severe.
Very rarely assc w/ non H sx
Cluster H: unilateral, non pulsatile, extremely severe but brief.
Assc w/ eye redness, rhinorrhoea, facial swelling on same side as H. May also be accompined by Horners syndrome.
Types
Migraine: provoking- light, sound. Quality: sharp, pulsatile. Radiation: Superorbital, Severity: 6-8, T: hours to days.
Tension: Procoking: stress, insomnia, hunger, eye-strain. Character: wrapping, tight. R: around head. S: 8, minutes, multiple
Migraines: what are they?
B>G, F>M. Onset: 25-50Y (oestrogen??)
Idiopathic, inflammatory response. Hypothesis- expansion of extracranial vasculature (on scalp) - irritates surrounding nerves.
Unilateral ‼️, retro supraorbital, Pulsating‼️, ❌❌Light, sound. Lie in room, dark! N+V.
Aura- visual here, before event happens.
Scintilatinh scotoma- visual deficit. Classic. (Sparkles, halos)
Hx- healthy ppl, B>G, W>M, 30s,
Genetic predisposition- Fhx.
Women > after menarche, less likeley while pregnant or after menopause- oestrogen + migraine correlation?
Migraine sx:
Aura- usually (20%) visual, vertigo-
Pain phase- unilateral, polsatile, sharp, supraorbital
Dx- clinical sx
IHS
IHS criteria-5,4,3,2,1 criteria
5 or more attacks ever
Any of them lasted 4hrs to 3 days duration
2 of more: unilateral, pulsating, moderate ro severe intensity, withdrawal from activities
1 : sensitivity to light or sound
Migraine ID
- Have ur H limited ur acttivities for more than a day in the past 3 M?
- Do ur H cause u to feel N?
- Does light/sound bother u when on ur H?
2/3 Q-> dx made. 81%sensitive, 75% specific.
Migraine H tx
Tx- 1st: triptan derivative- sumatriptan, rizatriptan- sublingual- SEROTONIN AGONISTS- constrict vessels that supposetetly - reduce plexus that is around those vessels
Ergotamines- dihydroergotamine,
NSAIDS- ibuprofen
To prevent: topiramade
If vomiting: Saline IV- dehydration.
Opiods not❌ due to rebound effect. - long term- medication induced .
Best- avoid drugs at alll, then see,
What happens if pt still has 2-4 migraines a Month, every week, what do we do?
Prophylaxis: topiramate, antiepileptic drug,
Divaproex, valproate AED, propranolol - beta blocker
Antiepileptic drugs
But- topamax- cognitive dulling ! Hard to find words.
Pregnant: triptans: acute: sumatriptan, but- acetaminophen -
Not AEDS- only if seizures due to hypoxic complications.
-> but u have less during migraines.
What are complicated migraines?
Residual focal neurological deficits during and after Migraines
Migraine: any neuro deficit will be gradual
Stroke- sudden
Migraine w/ hemiplagia or hemiparesis
Exclude vascular causes- non contrast Ct
Headache: PC - what do different areas mean?
In the morning/when bending/straining (⬆️ICP)
Bilateral, band-like(tension)/unilateral (most others)
Scalp tenderness/jaw claudication(GCA)
Facial Pain (trigeminal neuralgia)
Timing: sudden, severe:SAH, cluster H,/ after fall/trauma (subdural)
Aura/visual disturbance (migraine)
Photophobia/Vomitting (meningitis/migraine/ SAH)
Odd behaviour (encephalitis)
Headache - Disease framework
HPC- exposure to: CO, nitrates, CCB
Witjdrawal from: alcohol, oipoids, oestrogens, corticosteroids, TCAs, SSRIs, NSAIDs
Constitual sx- brain cancer 1o, 2o ,
Exertional onset: -SAH,nduring coitus- coital cephalgia
PMHx Cancer- metastatic Polymyalgia rheumatica (GCA) Angina- nitrates exposure Depression, anxiety , insomnia (tension)
Fhx: close contact has become unwell (meningitis) , familial tendencies (SAH w/ PCOS, migraines)
DHx- anticoagulants, alcoholism (subdural haematoma)
Chronic analgesics: codeine, paracetamol, NSAIDs, triptans
ROS GI Upset/ teuchopsia/ fortification spectra (migraine) Limp-gridle pain /weakness (GCA) Blurred/altered vision (⬆️ICP)/ Transient visual loss
SH
Caffeine, alcohol, dietary precipitants (chocolate, cheese)
Smoking(migrainw, metastatic cancer, SAH)
O/E H
General-
Overwt (IIH)/cachexia (malignancy)
Photophobia (meningitis/SAH)
HTN /fever/signs of sepsis/ drowsiness
Painful scalp on palpation (GCA, trigemina neuralgia)
Lacrimating red eye- cluster H
Kernig’s sign/ pain on straight leg raise- non blanching rash/ cool peripheries; painful legs( meningitis)
Fundoscopy + visual field examination
Investigations
FBC - polycythaemia- cause- anaemia due to eg malignancy
U+Es / Ca2+- (dehydration)/ blood sugar/ TFTs
CRP/ESR-⬆️ in infx, GCA (temporal artery biopsy)
EEG- acute changes in intracranial bleed
CT Head/ LP- eg for meningitis/SAH/IIH
Tx of H?
If meningitis suspected: IV benzylpenicillin before urgent transfer to hosp. 3rd generations cephalosporins are the empirical tx b4 causative organisms are identified.
Lifestyle changes- trigger avoidance:
GCA- Giant cell arteritis- prednisolone 40mg daily-> ophtalmology.
Migraine-> simple analgesia (NSAIDS) +- antiemetic
If no relief- triptans or ergotamine
Cluster- treat cluster w/ high flow O2 , sumatriptan,
Prophylaxis w/ prednisolone, verapamil
Tension: simple analgesia, avoid chronic use.
Neuralgia- neuropathetic painkillers; antiepileptics (AEDs)/ TCAs
SAH- nimodipine 60mg 4-hrly, urgent referral- head CT.
Raised ICP- tx cause- radiotherapy, theraputic LP, shunt (IIH), rarely cranioromy.
What are tension H?
Most commom
Band like distribution around head,
Onset: gradual, less severe than migraine w/o assc sx, respinds to analgaesics.
What are some typical sx of ⬆️ICP?
Pain Vomitting, visual blurrinh. Fundoscopy: optic disc- blurred Causes; intracranial masses, bleeding, Benign (Idiopathic intracranial hypertension)- IIH CT b4 Lp is mandatory.
Migraines??
20% have auras usually visual- flashing lights or fortification spectra.
H, N+V may follow.
Unilateral + severe- assc w/ photophobia + phonophobia.
Temporal arteritits(GCA)
> 50Y, F>W
50% will have polymyalgia rheumatica
❌❌‼️‼️MUST BE TREATED AGGRESIVELY B4 permanent visual loss
Trigeminal neuralgia ?
Can affect any of the 3 divisions- most commonly by mandibulary and maxillary branches.
Pain: brief, sharp, stabbing, shock-like,
Brought on by tough! Eg combing hair.
Cluster H?
Unilateral and are localised around or behind the eye.
Sharp, excruciating pain comes on rapidly, w/o aura, lasts 45-90mins.
H commonly occur within 2 hrs of falling asleep
Periods of remission between clusters of attacks.
Ipsilateral lacrimation or nasla discharge is often presx.
What are analgesia asc H?
Presx for >15D a month or worsens while taking regular painkillers.
Any simple analgesic can cause it.
Tx: withdrawal of analgesics.
SAH
Thunderclap H
Sudden onset, worst pain ever,
Often in occipital area.
What will CO poisoning cause?
H w/ irritability, N, weakness, tachycardia, tachypnoea.
Classic rosy pink appearance assc w/ carboxyHb rare b4 death.
Give high flow O2 + remove from Co
What happens in PD?
Examine: gait, UL, speech, lower cranial nerves (fiacial expression)
Observe: Poor posture (stooping, slumped in chair)
Slow shuffling gait/ reduced arm swing/poor balance
Quiet monotonous speech/pauses
Face: lack of facial expression/drooling of saliva
Glabellar tap- not habituate as normal
Arms: bradykinesia (slow) -> moving thumb to other fingex
Rigidity(stiff)-> wrist best demonstrated
Tremor (shaky)-> Pill rolling, at rest, asymetrical, reduced on movement, brought out by motor distraction,
Ask pt to raise and lower one arm while u watch the other for ⬆️ tremor.
Tx of PD?
L-Dopa-> chorea/dystonic movements, esp on hands and feet. In contrast w/tremor, these movements ⬆️ During action.
Dementia w/Lewy bodies is a clinical overlap b/n Parkinsons + Alzheimers.
Motor Neurone Diseases
MND
Observe: wasting (LMn) esp small Hand/foot miscles, Fasciculations (LMn) (tongue or limbs)
Tone: normal or increase (spastic UMN)
Power: segmental (LMN) or pyramidal (UMN) weakness
Reflexes: exaggerated (UMN) / diminished/ absent- LMN
Sensation, coordination: normal
Extras: Bulbar - pseudobalbar palsies
Some extras for MND
Cause- 90% unknown, 10%idiopathic
Patho: degeneration of: anterior horn cells/ CS tract
Motor cortex(frontal)/ cranial nerve nuclei/ corticobulbar tract
Typically: 45-65/ males>F / median survival 3Y
Progressive muscular atrophy- w/ isolated LMN signs
Progressive lateral sclerosis- UMN signs
Amyotrophic lateral sclerosis (ALS)a mixed signs,
Bulbar/ pseudobulbar palsy- UMN
CVA events- disease framework
Stroke: sudden neurological deficit of vascular origin lasting longer than 24hrs. Resolution within 24hrs is a TIA.
PC: asymetrical weakness of a limb/limbs/face
Speech problems/ sensory upset/visual disturbance
Collapse/H but NOT❌ black out/syncope.
HPC: SUDDEN ONSET, Course: static/resolving/progressing
Hx- previous TIAs/CVAs, Amaurosis fugax, transient sensory/motor probs
RFs- smoking, HTN, Diabtets, Hyperlipidaemia -> Atherosclerosis.
Right or Left handed?
PMHx- Vascular- IHD, angina, MI/PVD: claudication, AF, rheumatic heart /valve disease, MI,
FH- ⬆️vascular disease in family
SH- home, house type, ground floor/stairs
Modifications- stairs?
Carers? Helpers? Wheelchairs?frames/sticks
Dh- antihypertensives, aspitin, dipyridamole, warfarin-> may be cause of hameorrhagic CVa)
ROs- complications- wt loss, swalling diff, comsipation, /bladder sx.
Pneumonia- aspiration / shoulder subluxation
Strokes-O/E??
General A: plethoric/ malar flush
CVS- BP/ signs of hypertensive heart disease (pressure overload)
AF, Heart murmurs, Carotid bruits,
CNS: dysphasia, dysarthria, apraxia, sensory/ visual inattention
Cranial nerves: Homonymous Hemianopia, UMN facial weakness, Pseudobulbar palsy
Peripheral nerves: hemiparesis- spastic if old, unilateral UMN singns+/- sensory loss, (⬆️ tone/reflexes/clonus, Weakness w/o wasting, ⬇️ decreased sensation/coordination, Upgoing plantars/+ve Hoffmans
How would u investigate stroke?
BM: exclude hypoglycaemia
ECG: AF?
CT brain: urgently if being considered for thrombolysis/ depressed GCS
How would u treat a stroke?
Acute CVA:
Early dx + imaging (CT) to confrim
Thrombolysis if: Haemorhage excluded, within 3hrs of onset of sx, blood pressure-
How do u treat a TIA?
Aspirin 300mg -+ dipyridamole, risk stratify, carotid doopler ultrasonography /EEG/ECHO,
CONSIRED eaely endareterectomy if >70% stenosis on side related ro sx
What are some other causes of strokes?
Haem:15% , SAH -5%, intracerebral 10%
Ischaemic/ 85%, thrombotic/embolic from heart/ carotids/ 40% unknown
Classification: anterior from internal carotids or vertebrobasilar - posterior circulations.
What is the classification used ro divide CVAs according to territory, extent and cause?
Bamford Criteria
Total anterior Circulation strokes (TACS) - all 3 of:
- Motor + sensory deficits in 2/3 of face, arm/ leg
- Homonomous hemianopia
- Distirbance of higher fxa dysphasia/neglect
Partial anterior Circ Strokes (PACS)- 2 of above, or higher dysfx alone, or more limited sensory/motor deficits.
Ladunar strokes: LACS- pure motor or pure sensory /ataxic hemiparesis.
Posterior circulation: POCS- any of:
- Cranial nerve-/+ contralateral motor/sensory lesions
- Cerebellar wigns/ Brainstem signs
- Isolated homonymous hemianopia
- Bilateral sensory/motor deficit
