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BRS Year 2 > Headache12/04 > Flashcards

Headache12/04 Flashcards

1
Q

basis for generation of headaches (3)

A
  • structural
  • pharmacological
  • psychological
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2
Q

a drug which can cause headache

A
  • GTN
  • treat angina
  • relaxes blood vessels around heart
  • dilates brain blood vessels - throbbing headache
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3
Q

How to distinguish one headache from another

A
  • history
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4
Q

types of headache (2)

A
  • acute single headache

- dull headache; increasing in severity

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5
Q

type of haemorrhage that can cause an acute single headache

A
  • subarachnoid haemorrhage
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6
Q

what type of tumour causes a dull headache?

A
  • cerebral tumour
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7
Q

what type of venous sinus thrombosis can cause a dull headache?

A
  • cerebral
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8
Q

headache onset patterns (3)

A
  • dull headache; unchanged over months
  • triggered headache
  • recurrent headache
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9
Q

what can cause a dull headache which is unchanged over months

A
  • chronic tension headache
  • depressive
  • atypical facial pain
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10
Q

what can cause a recurrent headache which is unchanged over months (4)

A
  • migraine
  • cluster headache
  • episodic tension headache
  • trigeminal or post-herpetic neuralgia (severe pain due to irritated or damaged nerve)
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11
Q

what can trigger a triggered headache which is unchanged over months (3)

A
  • coughing
  • coitus
  • food and drink
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12
Q

what are the more worrying types of headache?

A

acute single headache

- dull headache, increasing severity

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13
Q

onset red flags (4)

A

thunderclap,
acute (hours or days),
subacute (Days or weeks),
orthostatic

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14
Q

meningism red flags (4)

A

photophobia, phonophobia, stiff neck, vomiting

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15
Q

systemic red flags (3)

A

fever, rash, weight loss

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16
Q

neurological symptoms or focal signs red flags (8)

A 
visual loss,
confusion,
seizures,
heimparesis,
double vision, 
3rd nerve palsy,
horner syndrome,
papilloedoma
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17
Q

red flag for placement of headaches

A

strictly unilateral

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18
Q

which cranial nerves control the eyes?

A
  • 3rd, 4th, 6th
  • damage can cause double vision, horner syndrome, and oculomotor palsy (no control of eyelid and eyeball pointing outwards)
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19
Q

what is horners syndrome

A

damage to sympathetic innervation of eye

- looks droopy (Ptosis), enophthalmos, anisocoria

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20
Q

another scary red flag

A

orthostatic headache

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21
Q

subarachnoid haemorrhage features

A
  • sudden generalised headache - blow to the head
  • meningism - stiff neck and photophobia
  • most cause by a ruptured aneurysm; few from arteriovenous malformations and some unexplained
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22
Q

How should a subarachnoid haemorrhage be diagnosed and treated?

A

Around 50% of SAH are instantly fatal:

vasospasm (vasoconstriction) may stop leak
nimodipine (vasodilates to prevent cerebral ischaemia) and BP control
early neurosurgical assessment confirm bleed and establish cause
CT brain, lumbar puncture, MRA (does not need catheter) and angiogram (needs catheter)

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23
Q

how to treat an aneurysm

A

filled with platinum coils

- aneurysms used to be clipped or wrapped

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24
Q

acute intracerebral bleed is called?

A

coning

- fatal

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25
Q

what is the mechanism of coning?

A

raised intracranial pressure

  • brain starts to seep under weak areas
  • -> falcine herniation
  • -> tentorial herniation
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26
Q

What is seen on the retina with a papiloedema

A

optic disc swelling due to raised ICP

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27
Q

what neck artery pathology can cause headache?

A

large arteries - carotid and vertebral

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28
Q

Carotid artery dissection causes what type of pain?

A
  • phantom of the opera mask distribution pain
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29
Q

how to diagnose artery dissection?

A

MRI/MRA. doppler (USS which measures blood flow), angiography

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30
Q

how to treat artery dissection - first line

A

aspirin or anticoagulation

Tear can lead to clot, which can lead to ischaemia and then stroke

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31
Q

what can turbulent flow cause the blood to become?

A

stick - it can clot

- hence why given anticoagulants when artery dissection occurs

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32
Q

are arteries of veins more easily damaged?

A

veins

- can shear veins to form a subdural.

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33
Q

what does it mean when blood in a subdural is dark on a CT?

A

blood is hyperdense has began to degrade -> chronic bleed

- may see falcine herniation. Midline moves and ventricles squashed

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34
Q

who is temporal arteritis most common in and what are common symptoms?

A

women (3x more likely than men)

  • over the age of 55
  • constant unilateral headache, scalp tenderness and jaw claudication
  • 25% see polymyalgia rheumatica: proximal muscle tenderness
  • see disruption of the internal elastic lamina
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35
Q

what can happen if the posterior ciliary arteries are involved in temporal arteritis?

A

blindness

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36
Q

what are markers elevated in temporal arteritis

A

ESR
CRP
- temporal artery usually inflamed and tortuous

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37
Q

what type of imaging can be used to visualise temporal arteritis?

A

ultrasound

biopsy shows inflammation and giant cells

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38
Q

how to treat temporal arteritis?

A

high dose steroids and aspirin for 3/4 weeks

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39
Q

what is cerebral venous thrombosis?

A

thrombosis in dural venous sinus or cerebral vein

  • unusual amount oh headache due to raised ICP
  • blood coming in but can’t leave
  • non-territorial ischaemia
  • haemorrhage
  • caused by thrombophili, pregnancy, dehydration, Behcets
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40
Q

what viral infections can causes meningitis?

A
  1. coxsackie
  2. ECHO
  3. Mumps
  4. EBV
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41
Q

what bacterial infections can causes meningitis?

A
  1. Meningococci
  2. Pneumococci
  3. Haemophilus
  4. TB
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42
Q

what fungal infections can causes meningitis?

A
  1. cryptococci
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43
Q

what granulomatous infections can causes meningitis? (4)

A
  1. sarcoid
  2. Lyme
  3. Brucella
  4. Syphilis
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44
Q

Seeding of what can cause meningitis?

A

Carcinomas

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45
Q

Presenting symptoms of meningitis (6)

A 
malaise
headache
neck stiffness
photophobia
confusion
alteration of consciousness
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46
Q

how can herpes simplex affect the brain?

A

haemorrhagic changes to the temporal lobes

+ encephalitis

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47
Q

How to treat and diagnose meningitis?

A
  1. AB
  2. Blood/urine culture
  3. CT/MRI
  4. lumbar puncture:
    * increased WCC
    * low glucose
    * antigens
    * cytology
    * bacterial culture
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48
Q

why do you give AB before diagnosis of meningitis?

A

Because meningitis kills very quickly

49
Q

Why do you do CT/MRI before lumbar puncture for meningitis?

A

Need to ensure its not bacterial meningitis:

  • bacterial meningitis makes the brain swell
  • cerebral oedema with effacement (disappearance of) of ventricles and sulci and inflamed meninges
  • If you were to put a needle in here then you’d get sudden decompression if the brain
50
Q

Symptoms of sinusitis? (8)

A
  • malaise
  • headache
  • fever
  • loss of voal resonance
  • anosmia
  • nasal/postnasal catarrh
  • local pain and tenderness
  • frontal pain characteristically starts 1/2 hours after rising and clears up during the afternoon
51
Q

how do you see sinusitis on imaging?

A

opacification of paranasal sinus

52
Q

what does a glioblastoma multiforme cause loss of?

A

sulci markings on imaging

- this tumour has cystic features

53
Q

What is also known as pseudotumour cerebri?

A

intracranial hypertension

54
Q

who are likely to suffer from pseudotumour cerebri?

A
  • young obese women
55
Q

symptoms of pseudotumour cerebri?

A
  • headache, visual obscurations, diplopia, tinnitus

- papilloedema, +/- visual field loss

56
Q

drug causes of pseudotumour cerebri? (4)

A
  • hormones
  • steroids
  • ABs
  • vitamin e
57
Q

treatment of pseudotumour cerebri (5)?

A
  • weight loss – may even give bariatric surgery
  • diuretics
  • optic nerve sheath decompression
  • lumboperitoneal shunt
  • stenting of stenosed venous sinuses
58
Q

what do you see on a scan in pseudotumour cerebri?

A

raise ICP but still no tumour even if presents similarly

59
Q

what is a low pressure headache caused by and how would it show on scans?

A

CSF leak due to tear in dura

- on scans see meningeal enhancement

60
Q

causes of CSF leak in low pressure headache?

A
  • traumatic post lumbar puncture or spontaneous
61
Q
  • treatment for CSF leak?
A

rehydration,
caffeine - seal the hole
blood patch - take out blood and put into epidural space. Fibrin makes it act like glue

62
Q

what is chiari malformation

A
  • normal brain that sits low within skull
  • cerebellar tonsils descending through the foramen magnum
  • descend further when patient cough; causes tugging on the meninges -> headache
63
Q

why do people with obstructive sleep apnoea get headaches?

A

hypoxia
CO2 retention (vasodilator so causes banging headache)-> non-refreshing sleep
- causes depression, impotence, poor performance at work
- require sleep study

64
Q

how to treat obstructive sleep apnoea?

A

nocturnal NIV, surgery

65
Q

symptom of trigeminal neuralgia

A
  • electrical shock like pain in the distribution of a sensory nerve
  • Affects any division of the trigeminal nerve (provides sensory innervation of face)

Triggers:

  • there are trigger zones -> can be caused by wind on face or trying to shave
  • often triggered by innocuous (non-harmful) stimuli

Causes:

  • neurovascular conflict (contact between blood vessels and CN) at the point of entry of the nerve into the pons
  • can be symptom of MS
66
Q

treatment of trigeminal neuralgia (4)

A

carbamazepine
lamotragine
gabopentin
posterior fossa decompression

67
Q

atypical facial pain most common in who?

A

middle aged women

- depressed or anxious

68
Q

characteristics of atypical facial pain?

A
  • daily constant poorly localised aching or burning
  • affects facial or jaw bones; may extend to neck
  • not lancinating
  • not conforming to strict anatomical distribution
  • no sensory loss
  • pathology in teeth, temporomandibular joints, eye, nasopharynx and sinuses must be excluded
69
Q

what is atypical facial pain unresponsive to>

A
  • conventional analgesics, opiates and nerve blocks

- mainstay of management - tricyclics

70
Q

can trauma cause a headache?

A

yes - post traumatic headache

- 1/3 people in accidents come back with headache

71
Q

mechanisms of post traumatic headache?

A

neck injury
scalp injury
vasodilation -> autonomic damage
depression -> often delayed

72
Q

is the incidence of post traumatic headache high in victims of sport injuries and perpetrators of car accidents

A

no

73
Q

is the incidence of post traumatic headache high in victims of car accidents

A

yes

74
Q

management of post traumatic headache

A

NSAIDs - avoid opiates as addictive
tricyclic antidepressants e.g. amitriptyline (pain modulators)
Be patient - 3/4 years
Explain to patient that there’s no structural damage and it’s not irreversible damage- full recovery can be made

75
Q

cervical spondylosis

A

narrowing of jointspace due to worn disc

  • usually bilateral
  • occipital pain can radiate forwards to frontal region
  • steady pain
  • no nausea or vomiting
  • worsened by moving neck
76
Q

management of cervical spondylosis

A
  • rest, deep heat, massage
  • NSAID
  • over manipulation may be harmful
77
Q

three forms or migraine attacks

A
  1. pain
  2. focal symptoms
  3. pain and focal symptoms
78
Q

Symptoms of migraine disorder

A
  • tendency to repeated attacks
  • usually hemicranial
  • triggers (people get to know theirs)
  • easily hungover
  • visual vertigo
  • motion sickness
79
Q

examples of focal symtoms

A
  • aphasia
  • weakness in the left arm
  • paresis
  • plegia.
80
Q

examples of migraine prodromes (5)

A
  1. change in mood
  2. urination
  3. fluid retention
  4. food craving
  5. yawning
81
Q

features of migraine aura

A
  • can be positive or negative
  • visual (scintillations & blindspot)
  • sensory (numbness/paraesthesia)
  • weakness
  • speech arrest
82
Q

features of migraine headache

A
  • head and body pain
  • nausea
  • photophobia
83
Q

resolution for migraine

A

rest and sleep

84
Q

What does recovery of a migraine feel like?

A

like a hangover

  • disturbed mood
  • food intolerance
  • lasts around 48 hrs
85
Q

what is a negative migraine aura

A

black spots

86
Q

what is a positive migraine aura

A

bright spots

87
Q

why do people hold-off on prescribing opiates?

A
  • analgesic abuse potential
88
Q

how does TMS help relieve migraine?

A

interrupts complex networks that trigger and perpetuate migraine, which is caused by spreading electrical depression across the cerebral cortex

89
Q

what do triptan tablets synergise with?

A

NSAID

90
Q

what medication is given first to treat migraines?

A

aspirin/ibuprofen and paracetamol and metoclopramide (anti-emetic)

  • soluble preparations to aid absorption
  • can also take a short nap
91
Q

what are lifestyle issues for people who suffer from migraines?

A
  • they have sensitive heads even in between attacks
  • overreact to any sort of stimulation
  • Can’t ignore the world around them , overstimulates their brain
92
Q

migraine triggers (5)

A 
dietary
environmental
hormonal
weather (biometric pressure change)
stress
93
Q

Lifestyle changes recommended for if you suffer from migranes

A
  • dont skip meals and eat fresh food (avoid preservatives and sulphates in alcohols)
  • Don’t oversleep - electronics downstairs
  • no analgesic abuse
  • drink 2l water/day
94
Q

what is prophylaxis?

A

treatment given/action taken to avoid disease

95
Q

examples of migraine prophylaxis

A

Over the counter meds: feverfew, coenzyme Q10, riboflavin, magnesium, EPO, nicotinamide

Tricyclic antidepressants (TCAs): amitriptyline 7pm
Beta-blockers - Propranolol, Atenolol
Serotonin antagonists: pizotifen, methysergide
Calcium channel blockers: flunarazine, verapamil
Anticonvulsants: valproate, topiramate, gabapentin
Greater occipital nerve blocks
Botox: crown of thorns like distribution
Suppress ovulation: (progesterone only pill or implant/injection)
Erenumab:
- Injectable drug erenumab (Aimovig)
- cut number of days people had migraines from an average of 8 a month to between 4 and 5 a month.
- Monoclonal antibody
disables calcitonin gene-related peptide or its receptor (CGRP mAbs)
- Episodic migraine, chronic migraine, or cluster headache.

96
Q

what causes tension headache?

A
  • tight muscles around head and neck bilaterally, as though head is in a vice
97
Q

how to treat headache tension?

A
  • NSAIDS preferred (ibuprofen, naproxen, diclofenac)
  • paracetamol
  • tricyclic antidepressants
  • Amitriptyline 50-75mg daily
  • 30-60% derive some symptomatic relief
  • SSRI’s probably less effective
  • Biofeedback and relaxation unproven
98
Q

what is a cluster headache?

A

severe unilateral pain last 15-180 mins untreated

  • classified as a trigeminal autonomic cephalgia
  • at least one of the following, ipsilaterally
  • Conjunctival redness and/or lacrimation
  • Nasal congestion and/or rhinorrhoea
  • Eyelid oedema
99
Q

features of cluster headache

A
  • Forehead and facial sweating
  • Miosis and/or ptosis
  • A sense of restlessness or agitation
  • Frequency between one on alternate days to 8 per day - diurnal pattern
  • Not associated with a brain lesion on MRI (primary headadches)
100
Q

examples of primary headaches? (3)

A
  • cluster headaches (phantom of the opera distribution)
  • migraine
  • tension
101
Q

Cluster headache: treatment

A
  • acute

- prevention

102
Q

acute cluster headache treatment

A
  • Inhaled oxygen. Oxygen inhibits neuronal activation in the trigeminocervical complex
  • S/C or Nasal Sumatriptan
103
Q

Prevention cluster headache

A
  • Verapamil
  • Prednisolone
  • Lithium
  • Valproate
  • Gabapentin
  • Topiramate
  • Pizotifen
104
Q

migraine distribution - more common in m/f

A

f

105
Q

migraine distribution - more common in m/f

A

m

106
Q

duration of migraine

A

3-12hrs

107
Q

duration of cluster headache

A

45min-3hrs

108
Q

frequency of migraine

A

1-8 attacks monthly

109
Q

frequency of cluster headache

A

1-3 attacks daily

110
Q

remission of migraine

A

long remissions unusual

111
Q

remission of migraine

A

remission is common

112
Q

nausea migraine - is this common?

A

frequent

113
Q

does nausea occur in a cluster headache?

A

nausea rare

114
Q

How would you describe the pain in migraine?

A

Pulsating hemicranial pain

115
Q

How would you describe the pain in a cluster headache?

A

Steady, exceptionally severe, well localised pain, unilateral in each cluster

116
Q

What are visual symptoms of a migraine

A

visual or sensory auras seen

117
Q

symptoms of cluster headache

A

Eye waters, nose blocked, ptosis etc

118
Q

What can a patient do whilst having a migraine to help them?

A

Patient can lie in the dark

119
Q

cluster headache behaviour by patients

A

Patients pace about

BRS Year 2 (110 decks)

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