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YEAR 4 NEURO > Headaches > Flashcards

Headaches Flashcards

1
Q

Presentation of tension headache?

A

Recurrent, non-disabling, bilateral headache, often described as a ‘tight-band’. Non-pulsatile. Classically every day - can persist for months/years.

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2
Q

Presentation of migraine?

A

Recurrent, severe headache. Unilateral, Throbbing.
Associated with aura, nausea and photosensitivity
Aggravated by routine activities of daily living. Patients often describe ‘going to bed’.
Associated to women during period.

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3
Q

Presentation of medication overuse headache?

A

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

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4
Q

Causes of headache?

A

Tension
Cluster
Migraine
Med overuse
SAH
SOL
Meningitis
Idiopathic intracranial hypertension
Temporal arteritis/GCA
Post traumatic headache
Sinusitis
Acute angle closure glaucoma
Venous sinus thrombosis
Chairi malformation with syringomyelia

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5
Q

Presentation of cluster headache?

A

Male, smoker.
Pain once or twice a day, each episode lasting 15 mins - 2 hours. Clusters typically lasting 4-12 weeks
Unilateral pain
Associated with
- intense pain around one eye (recurrent attacks ‘always’ affect same side)
- restlessness during an attack.
- accompanied by redness, lacrimation, lid swelling/ partial Horner’s syndrome

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6
Q

Pathophysiology of tension headache?

A

Tiredness, anger, stress, tension in muscles of neck or head.

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7
Q

Investigations of tension headache?

A

Clinical Dx usually. (at a push = CT sinus, MRI brain, lumbar puncture)

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8
Q

Management of tension headache?

A

Simple analgesia
Amitriptyline 10mg if chronic
Mindfulness
Relaxation therapy

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9
Q

Differentials for tension headache?

A

Chronic migraine
Medicine overuse headache
Sphenoid sinusitis
GCA
TMJ disorder
Pit tumour / Brain tumour

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10
Q

Investigations for a migraine?

A

Clinical Dx.

ESR, Lumbar puncture, CSF fluid culture, MRI brain, CT head, angiography.

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11
Q

Management for a migraine?

A
  • in ED = Rescue therapy e.g. metaclopramide +adequate hydration + high flow oxygen + IV dexamethasone.
  • acute presentation:
    —> mild to moderate Sx = NSAIDs + anti-emetic
    —> severe Sx = triptan + anti-emetic
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12
Q

Differentials for a migraine?

A

Cluster headache
Med overuse headache
Headache after head or neck trauma
SAH
Brain tumour
Idiopathic intracranial HTN
CNS infection
GCA

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13
Q

Presentation of medication overuse headache?

A

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

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14
Q

Pathophysiology of medication overuse headaches?

A

Regular use of med - paracetamol, NSAIDs, triptans, opiods. Pts develop new type of headache or have deterioration of pre-existing headache

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15
Q

Management of medication overuse headaches?

A

Check for red flags and causes of secondary headache
Withdraw from overused medication for at least 1 month.
Keep headache diary.

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16
Q

Differentials of medication overuse headaches?

A

-Chronic migraine
-Chronic tension headache
-Cluster headache
-Head / Neck trauma
-GCA
-Idiopathic intracranial HTN
-Substance misuse/withdrawal
-Infection - meningitis, encephalitis, cerebral abscess, systemic infection
-Hypoxia, HTN
- ENT differentials too —> Otitis media +/- effusion, TMJ disorder, sinusitis

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17
Q

Investigations of cluster headache?

A

Passmed
* most patients will have neuroimaging - underlying brain lesions are sometimes found even if the clinical symptoms are typical for cluster headache
* MRI with gadolinium contrast is the investigation of choice

Brain MRI without and with IV contrast
ESR
Pit function tests
Brain CT
Polysomnogram - check for sleep apnoea
ECG

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18
Q

Management of cluster headache?

A

Subcut sumatriptan
Oxygen
Intranasal triptan
Lidocaine
Verapamil

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19
Q

Presentation of a subarachnoid haemorrhage?

A

Sudden onset headache - ‘thunderclap’
Nausea and vomiting
Meningism (photophobia, neck stiffness)
Dizziness
Orbital pain
Diplopia
Visual loss
Coma
Seizures
Sudden death
ECG changes - ST elevation

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20
Q

The 2 main groups of causes of subarachnoid haemorrhage are t___ and s______?

A

Head injury (trauma)
Spontaneous

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21
Q

Causes of spontaneous subarachnoid haemorrhage?

A

Intracranial aneurysm aka berry aneurysm
AV malformation
HTN

Other causes:
Pituitary apoplexy
Arterial dissection
Infective/Mycotic aneurysm
Perimesencephalic (idiopathic venous bleed)

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22
Q

Investigations for subarachnoid haemorrhage?

A

1a) CT scan of the head

1b)Lumbar puncture (if CT is negative for showing blood)

2) CT intracranial angiogram - following confirmed Dx of SAH

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23
Q

When is LP done for SAH?

A
  • if CT scan of head is negative for blood
  • at least 12 hours following onset of symptoms
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24
Q

For a SAH, why is a LP done in the time frame suggested?

A

12 hours (at least) following symptoms BECAUSE:
- allow enough time for xanthochromia to develop

xanthochromia = RBC breakdown product. (Gives LP yellow tinge)

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25
Q

Investigation following confirmation of subarachnoid haemorrhage?

A

CT - do this ASAP (BMJ called this CT intracranial angiogram)
LP/CSF, MRI brain, angiography

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26
Q

Management for subarachnoid haemorrhage?

A

Referral to neurosurgery once SAH confirmed for cerebral angiogram

Treatment is based upon causative pathology

Intracranial aneurysms need to be treated within 24 hrs

Treated with a coil
Some pt need craniotomy and clipping by neurosurgeon

Other things:
1) Strict bed rest, well controlled BP (SBP<150), avoid straining to prevent re-bleed.
2) Treat vasospasm with nimodipine ( a CCB)
3) Hydrocephalus is treated with external ventricular drain

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27
Q

CSF findings in subarachnoid haemorrhage?

A

High protein
WCC not raised
Glucose normal
Xanthochromia

28
Q

Complications of aneurysmal subarachnoid haemorrhage?

A

Re-bleeding
Vasospasm
Hyponatraemia
Seizures
Hydrocephalus
Death

29
Q

Prognosis of subarachnoid haemorrhage?

A

V poor.
Up to 15% die before reaching hospital.
25% die in 24hrs
40% die in 1 month
50% overall mortality in 6 months
33% survivors have major neurological defecits

30
Q

Presentation of space occupying lesion?

A

Headache
Worse on walking, worse when lying down or coughing/straining
Associated to vomiting
Visual field defects

Early symptoms are non-specific
Cranial nerve palsies may present

Advanced cases: drowsy, seizures, pupillary abnormalities, papillodema

Cushing’s reflex - raised BP, bradycardia and abnormal breathing

31
Q

Investigation for space occupying lesion?

A

MRI of brain (+/- contrast)
CT head and spine (if can not have MRI)

32
Q

Management of space occupying lesion?

A

Simple measures:
- elevate head of bed
- avoid pyrexia
- analgesia

Specific medical measures:
- anticonvulsants
- sedation / NM blockade
- mannitol or hypertonic saline

Surgical measures:
- ventriculostomy
- decompressive craniotomy

33
Q

Presentation of meningitis?

A

Symptoms:
Headache
Fever
Nausea and vomiting
Photophobia
Drowsy
Seizures

Signs:
Neck stiffness
Purpuric rash

34
Q

Investigation for meningitis?

(With regard to main investigation, what would findings be for causes of meninigits?)

A

LP for CSF - if no signs of raised intracranial pressure
FBC
CRP
Blood culture
Whole blood PCR
Blood glucose
Coag screen
Blood gas

Bacterial = cloudy, low glucose, high protein, 10-5000 polymorphs/mm3 of neutrophils. Culture +ve for bacteria

Viral = clear, normal protein (mildly raised), normal glucose, high lymphocytes. Culture -ve as no bacteria

Tuberculous = fibrin wed/cloudy, low glucose, high protein, 10-1000 lymphocytes/mm3

35
Q

Management for meningitis?

A

Abx:
<3 months old = IV cefotaxime + amoxicillin

3m - 50years = IV cefotaxime

> 50yrs = IV cefotaxime + amoxicillin

Meningococcal meningitis = IV benzylpenicillin or cefotaxime

IV dexamethasone ( in certain circumstances, this is withheld)

Prophylaxis for household and close contacts

36
Q

When is IV dexamethasone not given in meningitis management?

A

DO NOT give IV dexamethasone in:
Septic shock
Meningococcal septicaemia
Immunocompromised
Meningitis following surgery

37
Q

What are complications of meningitis?

A

Sensorineural hearing loss
Seizures
Focal neurological deficit
Infective
—> sepsis
—> intracerebral abscess

Pressure
—> brain herniation
—> hydrocephalus

38
Q

Risk of what syndrome with meningococcal meningitis?

A

Waterhouse-Friderichsen syndrome = adrenal insufficiency secondary to adrenal haemorrhage

39
Q

Presentation of idiopathic intracranial hypertension?

A

Headache
Blurred vision
Papilloedema
Enlarged blind spot
Sixth nerve palsy

40
Q

Risk factors for idiopathic intracranial hypertension?

A

Obesity
Female
Pregnancy
Drugs = COCP, steroids, tetracyclines, Vit A, lithium

41
Q

Investigations for idiopathic intracranial hypertension?

A

MRI brain +/- contrast
Visual field testing
Dilated fundoscopy - may see papillodema
Visual acuity
Lumbar puncture at spinal L3/L4

42
Q

Management for idiopathic intracranial hypertension?

A
  • Weight loss
  • Diuretics - acetazolamide
  • Note: topiramate is also used, and has the added benefit of causing weight loss in most patients
  • Repeated LP
  • Surgery: optic nerve sheath decompression and fenestration. Lumboperitoneal or ventriculoperiotneal shunt
43
Q

Presentation of temporal arteritis?

A

Patient over 50+
Rapid onset <1month
Headache
Jaw claudication
Visual disturbance
-amaurosis fugax
-blurring
-double vision

Tender, palpable temporal artery
PMR in 50% of patients
Lethargy
Depression
Fever
Anorexia
Night sweats

44
Q

Investigations for temporal arteritis?

A

Raised inflammatory markers - ESR and CRP
Temporal artery biopsy
CK - normal

45
Q

Treatment for temporal arteritis?

A
  • Urgent high dose glucocorticoids as soon as Dx suspected (prednisolone if there is no visual loss or IV methylprednisolone if there is visual loss).
  • Urgent ophthalmology review
  • Bone protection with bisphosphanates while steroids are required.
  • Low dose aspirin sometimes given
46
Q

Presentation of post traumatic headaches?

A
  • new headache within 7 days of a head injury - feels like migraine / tension like pain
  • nausea and vomiting
  • dizzy
  • insomnia
  • concentration issues / memory issues
  • sensitive to light
47
Q

Investigations for post traumatic headaches?

A

non-contrast CT head - rule out any bleeds in the brain
FBC, CRP, U+Es
XR /MRI - skull fractures?

48
Q

Management for post traumatic headaches?

A

Pain killers - ibuprofen, naproxen
Triptans
assess GCS
Manage any other issues - e.g. drug intoxication

49
Q

Complications for post traumatic headaches?

A

death
intracranial lesions
depression and anxeity

50
Q

Presentation of sinusitis?

A

Hx of of nasal obstruction, recent local infection, swimming, smoking

Headache/ Facial pain in frontal area, worse on bending forward.
Nasal discharge - thick and purulent.
Nasal obstruction
Post nasal drip (in chronic).

51
Q

Management for sinusitis?

A

Acute:
- analgesia.
- intranasal decongestants
- intranasal steroids if 10+ days
- abx for v severe presentations

Chronic:
- avoid allergen
- intranasal steroids
- nasal irrigation with saline

52
Q

Red flags for sinusitis?

A

Unilateral Sx
Persistent Sx despite compliance with 3 months of treatment
Epistaxis

53
Q

Presentation of acute angle closure glaucoma?

A

Severe pain - headache or ocular type pain
Decreased visual acuity
Symptoms worse with mydriasis (e.g watching TV in dark room)
Hard, red eye
Haloes around eye
Fixed, semi-dilated, oval non-reacting pupil
Coreneal oedema = get hazy cornea
Systemic upset = N+V, abdo pain

54
Q

Predisposing factors for acute angle closure glaucoma?

A

Hypermetropia = long sighted
Pupillary dilatation
Lens growth with age

55
Q

Investigations for acute angle closure glaucoma?

A

Gonioscopy = to visualise the anterior chamber angle
Slit lamp examination/fundoscopy
Tonometry - to assess intraocular pressure

56
Q

Management for acute angle closure glaucoma?

A

EMERGENCY SITU - need urgent referral to optham

Emergency treatment to lower IOP - acetozolomide IV. This reduces aqueous secretions

Topical therapy - pilocarpine = opens trabecular meshwork to increase outflow of aqueous humour. - timolol = decrease aqueous humour production

Definitive management:
- laser peripheral iridotomy = create hole in peripheral iris to allow free flow of aqueous – the contralateral eye is treated prophylactically as it is predisposed to PACG

57
Q

Complications for acute angle closure glaucoma?

A

Adverse reactions to glaucoma medication

Post-trabeculectomy complications:
- anterior uveitis/iritis
- blebitis
- sudden changes in IOP

58
Q

Red flags for headaches?

A

1) Thunderclap headache = severe and sudden onset. ‘sudden means vascular until proven otherwise’.

2)Meningism = Neck stiffness +Photophobia

3)Non blanching purpuric rash = menigococcal septicaemia.

4) Fever = infection, vascular, inflammation, raised ICP or SOL.

5) Characteristics of raised ICP —> present on waking, worse if lying, exacerbated by leaning forward, coughing, valsalva, papillodema

6) Recent onset or change in character = secondary cause

7) Hx of malignancy = mets.

8) Constitutional symptoms = e.g. night sweats, scalp tenderness in pt 50+ = GCA

9) New onset in older person = new pathology

59
Q

What is GCS?

A

Initially used for head injury, now reproducible way to measure consciousness.

60
Q

Outline GCS

A

BEST MOTOR GRADE (6)
1- no response to pain
2-Extensor posturing to pain
3-Abnormal flexion to pain
4- withdraws to pain
5- localises response to pain
6- obeying a comment

BEST VERBAL RESPONSE (5)
1- none
2- incomprehensible speech
3- inappropriate speech
4- confused conversation
5-Orientated

EYE OPENING (4)
1- no eye opening
2-opening in response to pain
3- eye opening in response to any speech
4- spontaneously opening eyes

61
Q

What are the characteristics of a migraine?

A

ICHD CRITERIA

A- At least 5 attacks fulfilling criteria B-D
B- Headache attacks lasting 4-72 hours (when untreated or unsuccessfully treated)
C- Headache has at least 2 of the following 4 characteristic: Unilateral location, pulsating quality, moderate or severe pain intensity, aggravation by or causing avoidance of routine physical activity (e.g. walking or climbing stairs)
D- During the headache at least one of following: N&v or photophobia/phonophobia
E- Not Bette accounted for by another ICHD-3 diagnosis

62
Q

Migraine triggers?

A

Stress
Too much sleep
Too little/ poor/broken sleep
Missing meals
alcohol
dehydration
strong smells

63
Q

Criteria for a headache to be medication overuse headache?

A

Headache occurring on 15 or more days/month in a pt with a pre-existing headache condition and as a consequence of taking analgesia regularly for 15 days/month (simple analgesics) or 10days/month (triptans, opioids, ergotamine)

64
Q

What is a primary headache?

A

migraine, cluster, tension.

65
Q

What is a secondary headache?

A

Caused by a separate underlying pathological process that may be amenable to treatment

66
Q

Causes for secondary headaches?

A

Vascular
Haemorrhage
Infective
Neoplastic
Drugs
Inflammation
Raised ICP
Trauma
Metabolic
Toxins
Glaucoma
Sinus disease
HTN

67
Q

CT scan for SAH:
- what is sensitivity of scan in first 24hrs?
- what is sensitivity of scan in 72hrs?

A

24 hrs = 90%
72hrs = 50%

YEAR 4 NEURO (37 decks)

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