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NEURO (Neurology) > Headaches > Flashcards

Headaches Flashcards

1
Q

What is a Tension Headache?

A

A form of episodic primary headache.

A mild ache across the forehead in a band-like pattern. This may be due to muscle ache in the frontal, temporals and occipitals muscles.

If occurring on more than 15+ days per month, this is a Chronic Tension-Type Headache.

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2
Q

Features of a Tension Headache (3).

A
  1. Gradual Onset and Gradual Recovery.
  2. Recurrent and Non-Disabling.
  3. Not Aggravated by Routine Activities.
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3
Q

Management of a Tension Headache (6).

A
  1. No medical management required.
  2. Basic Analgesia.
  3. Reassurance, Relaxation and Hot Towels.
  4. NICE (Acute Management) : Aspirin, Paracetamol or NSAID.
  5. NICE (Prophylaxis) : Up to 10 Sessions of Acupuncture over 5-8 weeks.
  6. Low-Dose Amitriptyline is used as prophylaxis in the UK but is not supported by NICE.
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4
Q

Epidemiology of Migraines (1).

A

Prevalence - Women : 18%; Men - 6%.

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5
Q

Aetiology/Risk Factors of Migraines (9).

A

Specific triggers individual to the person (CHOCOLATE).

  • Chocolate.
  • Hangovers.
  • Orgasms.
  • Cheese/Caffeine.
  • Oral Contraceptives.
  • Lie-Ins.
  • Alcohol.
  • Travel.
  • Exercise.
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6
Q

Pathophysiology of Migraines - Theories (5).

A
  1. Dilation of Cerebral/Meningeal Arteries : Disproven.
  2. Episodic Cerebral Oedema, Dilation of Intracerebral Vessels and Reduced Water Diffusion (MRI Proof).
  3. Sub-Cortical Disorder affecting modulation of sensory processing (PET Proof).
  4. Resting Interictal Hyperexcitability in Visual Cortex due to a failure of inhibitory circuits (Magneto Encephalographic MEG Proof).
  5. Metabolic : High levels of 5-HT metabolites in urine.
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7
Q

5-HT Management and Migraines (2).

A

Acute Pharmacology : 5-HT Receptor Agonists.

Prophylactic Pharmacology : 5-HT Receptor Antagonists.

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8
Q

Acute Management of Migraines.

A

1st Line : Combination Therapy - Oral Triptans and NSAID/Paracetamol. In young people (12-17), use a Nasal Triptan. If Oral Triptan is inadequate or not tolerated, use a non-oral preparation of Metoclopramide/Prochlorperazine.

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9
Q

Mechanism of Action of Paracetamol.

A

Weak inhibitor of COX. In the CNS, COX inhibition causes a rise in the pain threshold and reduced Prostaglandin E2 concentrations of the thermoregulatory region of the hypothalamus to control fever.

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10
Q

Contraindications/Cautions of Paracetamol (2).

A
  1. People with Risk of Liver Toxicity - Reduce dose.
    (Increased NAPQI Production (due to chronic excessive alcohol use) or Reduced Glutathione Stores (malnutrition, low body weight, severe hepatic impairment).
  2. CYP450 Inducers like Phenytoin and Carbamazepine can increase the rate of NAPQI production.
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11
Q

Adverse Effects of Paracetamol (2).

A
  1. Overdose = Liver Failure.
  2. Metabolised by CYP450 enzymes to NAPQI (toxic metabolite) which is conjugated with Glutathione before elimination. In an overdose, the elimination pathway is saturated so NAPQI accumulates causing hepatocellular necrosis. To prevent hepatotoxicity, use a Glutathione precursor like Acetylcysteine.
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12
Q

Mechanism of Action of Triptans (3).

A
  1. Act on smooth muscle of arteries to cause vasoconstriction (5HT-1B/D/F).
  2. Act on peripheral pain receptors to inhibit activation of pain receptors.
  3. Reduce neuronal activity in the CNS.
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13
Q

Contraindications of Triptans (1).

A

Coronary Artery Disease.

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14
Q

Adverse Effects of Triptans (2).

A
  1. Coronary Vasoconstriction.

2. Dysrhythmias (mainly Sumatriptan).

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15
Q

Mechanism of Action of Ergotamine.

A
  1. 5-HT Partial Agonist.
  2. Vasoconstrictor.
  3. Inhibitor of Trigeminal Nerve Transmission.
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16
Q

Contraindications of Ergotamine (1).

A

Uterine contractions - damage foetus.

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17
Q

Adverse Effects of Ergotamine (1).

A
  1. Peripheral Vasoconstriction.
18
Q

Indication of Migraine Prophylaxis.

A

If a patient experiences 2 or more attacks per month.

19
Q

Prophylactic Pharmacological Management of Migraines (5).

A

ATP Backwards.

  1. Propanolol.
  2. Topiramate.
  3. Amitriptyline.
  4. Supplementation with Vitamin B2 (Riboflavin).
  5. NSAIDs e.g. Mefenamic Acid or Triptans in Menstruation-Related Migraines.
20
Q

Mechanism of Action of Propanolol

A

B2 Adrenoceptors are found in smooth muscle of blood vessels and airways. B-Blocker will cause vasoconstriction.

21
Q

Contraindications of Propanol (3).

A
  1. Asthma (Life-threatening Bronchospasm).
  2. Heart Block.
  3. Patients with non-Dihydropyridine CCBs e.g. Verapamil, Dilitazem (HF, Bradycardia, Asystole).
22
Q

Cautions of Propanolol (3).

A
  1. Heart Failure.
  2. Haemodynamic Stability.
  3. Hepatic Failure.
23
Q

Mechanism of Action of Topiramate.

A

Carbonic Anhydrase Inhibitor.

24
Q

Contraindication of Topiramate.

A

Pregnancy - Teratogenic (Cleft Lip/Palate).

25
Q

What is a Cluster Headache?

A

Severe and unbearable unilateral headaches, usually around the eye. They come in clusters of attacks (lasting 15 minutes-3 hours) and disappear for a while e.g. 3-4 daily for weeks/months and then pain-free for 2 years.

26
Q

Risk Factors of Cluster Headaches (6).

A
  1. Alcohol.
  2. Nocturnal Sleep.
  3. Men (3x Commoner).
  4. Smokers.
  5. Strong Smells.
  6. Exercise.
27
Q

Clinical Features of Cluster Headaches (6).

A
  1. Unilateral Red Swollen and Watering Eye.
  2. Unilateral Miosis (Pupil Constriction).
  3. Unilateral Ptosis (Eyelid Drooping).
  4. Nasal Discharge.
  5. Facial Sweating.
  6. Partial Horner Syndrome (no Anhidrosis).
28
Q

Management of Cluster Headaches.

A

Acute : Triptans e.g. Sumatriptan 6mg injected SC (75% response rate within 15 minutes) and High-Flow 100% Oxygen for 15-20 minutes (80% response rate within 15 minutes).
Prophylaxis : Verapamil, Lithium, Prednisolone (short course for 2-3 weeks to break the cycle during clusters).
| Specialist Referral : Trigeminal Autonomic Cephalgia (Cluster Headache + Paroxysmal Hemicarnia + Short-Lived Unilateral Neuralgiaform Headache with Conjunctival Injection and Tearing). |

29
Q

What is an Analgesic Headache?

A

Non-specific features similar to a tension headache caused by long-term use of analgesia (especially Opioids, Triptans, Psychiatric Patients) presenting for 15+ days each month. This is treated by analgesia withdrawal.

30
Q

What is Cervical Spondylosis?

A

Headache and neck pain caused by osteoarthritis in the cervical spine, after excluding other causes of neck pain.

31
Q

What is Trigeminal Neuralgia?

A

A unilateral disorder characterised by brief electric-shock like pains, abrupt in onset and termination and limited to one or more division of the trigeminal nerve (any combination of the branches) - thought to be due to compression.

32
Q

Red Flag of Trigeminal Neuralgia Symptoms.

A

MS : Sensory Changes, Optic Neuritis, family History, Young (<40). 5-10% of patients with MS have TN.

33
Q

Clinical Features of Trigeminal Neuralgia.

A

90% Unilateral; 10% Bilateral. Intense Facial Pain that can last between seconds to hours and attacks worsen over time.

34
Q

Triggers of Trigeminal Neuralgia (5).

A
  1. Cold Weather.
  2. Spicy Food.
  3. Caffeine.
  4. Citrus Fruits.
  5. Light Touch (especially Nasolabial Folds, Chin).
35
Q

Management of Trigeminal Neuralgia.

A

1st Line : Carbamazepine.
Surgery : Decompress/Intentionally Damage Trigmeinal Nerve.
Prompt referral to Neurology.

36
Q

Mechanism of Action of Carbamazepine.

A
  1. Inhibitor of Sodium Ion Channels.
  2. Control Neuralgic Pain by blocking synaptic transmission in the Trigeminal Nucleus.
  3. Reduce Electrical Kindling in Temporal Lobe and Limbic System to Stabilise Mood in Bipolar Disorder.
37
Q

What is a Hormonal Headache?

A

Non-specific Tension-like Headache that tends to be related to low Oestrogen levels (e.g. 2 days before and 1st 3 days of Menstrual Period; Menopause; Pregnancy). It should improve in the last 6 months of pregnancy - a headache in the 2nd half of pregnancy should prompt investigation for PET.

OCP can improve hormonal headaches.

38
Q

What is Sinusitis?

A

Inflammation of the mucous membranes of paranasal sinuses producing facial pain behind nose, forehead and eyes (with tenderness) accompanied by thick purulent nasal discharge and obstruction.

39
Q

Pathophysiology and Aetiology of Sinusitis.

A
  1. Paranasal sinuses are usually sterile.

2. Common infectious agents : S. pneumonia; H. influenzae; Rhinoviruses (mostly viral though).

40
Q

Management of Sinusitis (4).

A
  1. Resolves within 2-3 weeks.
  2. Nasal irrigation with Saline.
  3. Prolonged symptoms : Steroid nasal sprays.
  4. If antibiotics : 1st - Phenoxymethylpenicillin and Co-Amoxiclav if systemically unwell.

NEURO (Neurology) (54 decks)

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