Headaches Flashcards
Pyramidal distribution
A two-neuron system consisting of upper motor neurons in the Primary Motor Cortex and lower motor neurons in the anterior horn of the spinal cord. Each of these neurons have extremely long axons.
Functional weakness
No wasting, normal tone, normal reflexes, erratic power, non-anatomical loss
Neuromuscular junction symptoms
Fatigable weakness, normal or decreased tone, normal tendon reflexes. No sensory symptoms!
Motor symptoms of median nerve neuropathy
Unable to abduct thumb
Thenar atrophy
Sensory symptoms of median nerve neuropathy
Thumb, 2nd, third and lateral one half of 4th finger
Motor symptoms of ulnar nerve neuropathy
Unable to adduct finger and thumb
claw hand
Sensory symptoms of ulnar nerve neuropathy
Fifth and medial one half of fourth finger
Motor symptoms of radial nerve neuropathy
Unable to extend wrist, thumb and fingers (wrist drop)
Sensory symptoms of radial nerve neuropathy
Sensory loss in dorsum of hand
Motor symptoms of sciatic nerve neuropathy
Ankle doriflexors and plantar flexors (flail ankle)
Sensory symptoms of sciatic nerve neuropathy
Buttocks, lateral calf and most of foot
Motor symptoms of femoral nerve neuropathy
Paralysis of knee extensors
Sensory symptoms of femoral nerve neuropathy
Anterior thigh and medial calf
Motor symptoms of fibular nerve neuropathy
Paralysis of ankle dorisflexors &foot evertors
Sensory symptoms of fibular nerve neuropathy
Dorsum of foot and lateral calf
An example of a median nerve neuropathy
Carpal tunnel syndrome
An example of a radial nerve neuropathy
Saturday night palsy
An example of a fibular nerve neuropathy
Foot drop
Myoclonus
sudden, brief involuntary twitching or jerking movements
Chorea
rapid jerky involuntary movements
Dystonia
Unintentional sustained muscle contractions leading to abnormal postures e.g., clenching teeth
Hypomimia
Is a reduced degree of facial expression
Hypophonia
Weak voice due to incoordination of the vocal muscles.
Ataxia
Lack of muscle control & coordination of voluntary movements.
Dysdiadochokinesis
Clumsy fast alternating movements
Cerebellar signs
Cerebellar gait is broad-based & unsteady Intention tremor Dysdiadochokinesis Nystagmus Dysarthria
Paratonia
Inability to relax muscles
Paraparesis
Partial paralysis of lower limbs
Exacerbating features to ask about in headache history taking.
Posture, Valsalva (sneezing, coughing, straining etc). Diurnal variation.
Valsalva manoeuvre
A breathing method that may slow your heart when it’s beating too fast. To do it, you breathe out strongly through your mouth while holding your nose tightly closed.
Phonophobia
Called ligyrophobia or sonophobia, is a fear of or aversion to loud sounds
Miosis
Excessive constriction of the pupil of the eye
Red flag symptoms in headache history taking
- New onset headache >55
- Known/previous malignancy
- Immuno-suppressed
- Early morning headache
- Exacerbation by Valsalva
Migraine symptoms
Recurrent, severe headache which is usually unilateral and throbbing in nature
May be associated with aura, nausea and photosensitivity
Aggravated by, or causes avoidance of, routine activities of daily living. Patients often describe ‘going to bed’.
Tension headache
Recurrent, non-disabling, bilateral headache, often described as a ‘tight-band’
Not aggravated by routine activities of daily living
Cluster headache symptoms
Pain typical occurs once or twice a day, each episode lasting 15 mins - 2 hours with clusters typically lasting 4-12 weeks
Intense pain around one eye (recurrent attacks ‘always’ affect same side)
Patient is restless during an attack
Accompanied by redness, lacrimation, lid swelling
More common in men and smokers
Cluster headaches are more common in what people?
More common in men and smokers
Temporal arteritis
Typically patient > 60 years old Usually rapid onset (e.g. < 1 month) of unilateral headache Jaw claudication (65%) Tender, palpable temporal artery Raised ESR
Medication overuse headache
Present for 15 days or more per month
Developed or worsened whilst taking regular symptomatic medication
Patients using opioids and triptans are at most risk
May be psychiatric co-morbidity
What drugs are associated with medication overuse headache?
Opioids and triptans
Epidemiology of migraine
3 times more common in women
Prevalence in men is around 6%, in women 18%
Common triggers for a migraine attack
- tiredness, stress, alcohol
- combined oral contraceptive pill,
- lack of food or dehydration
- cheese, chocolate, red wines, citrus
- menstruation, bright lights
Non-pharmacological treatment for migraines
1, Education- avoid triggers
- Headache diary
- Diet- regular intake, avoid triggers
- healthy balanced diet
- Hydration- at least 2 litres day,
- decrease caffeine
- Stress- decrease
- Regular exercise
Acute pharmacological treatment for migraines
Combination therapy of NSAIDs and Triptans
NSAIDs
- Aspirin 900mg,
- Naproxen 250mg
- Ibuprofen 400mg
Triptans
- Rizatriptan= eletriptan > sumatriptan
- Frovatriptan for sustained relief
Prophylactic treatment for migraines
More than 3 attacks month or very severe consider prophylaxis
- Amitriptyline
- Beta blockers – propranolol
- Topiramate
Side effects of Amitriptyline
Dry mouth, postural hypotension, sedation
Topiramate mechanism of action
Carbonic anhydrase inhibitor (Na/ GABA)
Topiramate side effects
Poor side effect profile- start slowly
Weight loss, paraesthesia, impaired concentration, enzyme inducer
NSAIDs used in migraines
- Aspirin 900mg,
- Naproxen 250mg
- Ibuprofen 400mg
Triptans used in acute management of migraines
- Rizatriptan= eletriptan > sumatriptan
2. Frovatriptan for sustained relief
Management of tension-type headache
Acute treatment: aspirin, paracetamol or an NSAID are first line
Prophylaxis: NICE recommend ‘up to 10 sessions of acupuncture over 5-8 weeks’
Management of Cluster headaches
Acute: 100% oxygen (80% response rate within 15 minutes), subcutaneous triptan (75% response rate within 15 minutes)
Prophylaxis: verapamil is the drug of choice.
Paroxysmal hemicrania (PH)
Defined by attacks of severe, unilateral headache, usually in the orbital, supraorbital or temporal region.
These attacks are often associated with autonomic features, usually last less than 30 minutes and can occur multiple times a day.
Hemicrania continua
A chronic and persistent form of headache marked by continuous pain that varies in severity, always occurs on the same side of the face and head and is superimposed with additional debilitating symptoms. on the continuous but fluctuating pain are occasional attacks of more severe pain.
Treatment of Hemicrania continua
indomethacin (Only NSAID that works)
SUNCT Headaches
- S= Short lived (15-120 secs)
- U=unilateral
- N= neuralgiform headache
- C= conjunctival injections
- T= Tearing
Treatment for SUNCT Headaches
Lamotrigine, Gabapentin
Drugs that cause Idiopathic intracranial hypertension
> combined oral contraceptive pill > steroids > tetracyclines > vitamin A > lithium
Risk factors for Idiopathic intracranial hypertension
o obesity
o female sex
o pregnancy
o drugs*
Features for Idiopathic intracranial hypertension
o headache o blurred vision o papilledema (usually present) o enlarged blind spot o sixth nerve palsy may be present
Management of Idiopathic intracranial hypertension
o weight loss o diuretics e.g. acetazolamide o topiramate is also used, o repeated lumbar puncture o Optic nerve sheath decompression o Lumboperitoneal or ventriculoperitoneal shunt may also be performed to reduce intracranial pressure
What diuretic is used in Idiopathic intracranial hypertension
acetozolamide
What are ways to reduce intracranial pressure?
Lumboperitoneal or ventriculoperitoneal shunt, repeated lumbar puncture
