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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
Investigation following confirmation of subarachnoid haemorrhage?
CT - do this ASAP (BMJ called this CT intracranial angiogram) LP/CSF, MRI brain, angiography
26
Management for subarachnoid haemorrhage?
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
27
CSF findings in subarachnoid haemorrhage?
High protein WCC not raised Glucose normal Xanthochromia
28
Complications of aneurysmal subarachnoid haemorrhage?
Re-bleeding Vasospasm Hyponatraemia Seizures Hydrocephalus Death
29
Prognosis of subarachnoid haemorrhage?
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
Presentation of space occupying lesion?
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
Investigation for space occupying lesion?
MRI of brain (+/- contrast) CT head and spine (if can not have MRI)
32
Management of space occupying lesion?
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
Presentation of meningitis?
Symptoms: Headache Fever Nausea and vomiting Photophobia Drowsy Seizures Signs: Neck stiffness Purpuric rash
34
Investigation for meningitis? (With regard to main investigation, what would findings be for causes of meninigits?)
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
Management for meningitis?
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
When is IV dexamethasone not given in meningitis management?
DO NOT give IV dexamethasone in: Septic shock Meningococcal septicaemia Immunocompromised Meningitis following surgery
37
What are complications of meningitis?
Sensorineural hearing loss Seizures Focal neurological deficit Infective —> sepsis —> intracerebral abscess Pressure —> brain herniation —> hydrocephalus
38
Risk of what syndrome with meningococcal meningitis?
Waterhouse-Friderichsen syndrome = adrenal insufficiency secondary to adrenal haemorrhage
39
Presentation of idiopathic intracranial hypertension?
Headache Blurred vision Papilloedema Enlarged blind spot Sixth nerve palsy
40
Risk factors for idiopathic intracranial hypertension?
Obesity Female Pregnancy Drugs = COCP, steroids, tetracyclines, Vit A, lithium
41
Investigations for idiopathic intracranial hypertension?
MRI brain +/- contrast Visual field testing Dilated fundoscopy - may see papillodema Visual acuity Lumbar puncture at spinal L3/L4
42
Management for idiopathic intracranial hypertension?
- 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
Presentation of temporal arteritis?
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
Investigations for temporal arteritis?
Raised inflammatory markers - ESR and CRP Temporal artery biopsy CK - normal
45
Treatment for temporal arteritis?
- 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
Presentation of post traumatic headaches?
* 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
Investigations for post traumatic headaches?
non-contrast CT head - rule out any bleeds in the brain FBC, CRP, U+Es XR /MRI - skull fractures?
48
Management for post traumatic headaches?
Pain killers - ibuprofen, naproxen Triptans assess GCS Manage any other issues - e.g. drug intoxication
49
Complications for post traumatic headaches?
death intracranial lesions depression and anxeity
50
Presentation of sinusitis?
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
Management for sinusitis?
Acute: - analgesia. - intranasal decongestants - intranasal steroids if 10+ days - abx for v severe presentations Chronic: - avoid allergen - intranasal steroids - nasal irrigation with saline
52
Red flags for sinusitis?
Unilateral Sx Persistent Sx despite compliance with 3 months of treatment Epistaxis
53
Presentation of acute angle closure glaucoma?
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
Predisposing factors for acute angle closure glaucoma?
Hypermetropia = long sighted Pupillary dilatation Lens growth with age
55
Investigations for acute angle closure glaucoma?
Gonioscopy = to visualise the anterior chamber angle Slit lamp examination/fundoscopy Tonometry - to assess intraocular pressure
56
Management for acute angle closure glaucoma?
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
Complications for acute angle closure glaucoma?
Adverse reactions to glaucoma medication Post-trabeculectomy complications: - anterior uveitis/iritis - blebitis - sudden changes in IOP
58
Red flags for headaches?
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
What is GCS?
Initially used for head injury, now reproducible way to measure consciousness.
60
Outline GCS
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
What are the characteristics of a migraine?
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
Migraine triggers?
Stress Too much sleep Too little/ poor/broken sleep Missing meals alcohol dehydration strong smells
63
Criteria for a headache to be medication overuse headache?
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
What is a primary headache?
migraine, cluster, tension.
65
What is a secondary headache?
Caused by a separate underlying pathological process that may be amenable to treatment
66
Causes for secondary headaches?
Vascular Haemorrhage Infective Neoplastic Drugs Inflammation Raised ICP Trauma Metabolic Toxins Glaucoma Sinus disease HTN
67
CT scan for SAH: - what is sensitivity of scan in first 24hrs? - what is sensitivity of scan in 72hrs?
24 hrs = 90% 72hrs = 50%

YEAR 4 NEURO (37 decks)

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