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headaches Flashcards

1
Q

what are primary headaches?

A

no identified cause

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2
Q

what are secondary headaches?

A

characteristics attributed to another cause eg infection/ vascular

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3
Q

what are red flags for subarachnoid headache?

A

sudden onset thunderclap headache reaching max intensity in 5 mins

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4
Q

what are red flags for viral/ bacterial meningitis?

A

fever with worsening headache, necks stiffness, photophobia, change in mental status

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5
Q

what is red flag for haemorrhagic/ ischaemic stroke/ space occupying lesion?

A

new onset focal neuro deficit, personality change or cog dysfunction

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6
Q

what is red flags for ICP?

A

headache worsening on lying down and coughing

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7
Q

what are red flags of angle closure glaucoma?

A

: severe eye pain/ blurred vision/ red eye/ vomiting

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8
Q

what are general red flags for headaches?

A

decreased level of consciousness
head trauma within last three months

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9
Q

what are concerns within past medical history?

A

compromised immunity, malignancy, systemic illness, current pregnancy

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10
Q

what are concerns within drug history for headaches?

A

previous headache meds, anticoags/ anti-platelets, glucocortoids, methamphetamines, coke, GTN, combined oral contraceptive pill. Allergies

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11
Q

what are features of low risk headaches? - 6 things

A
  1. > 30 yrs
  2. Typical features of primary
  3. History of similar episodes – no change in usual pattern
  4. No abnormal neuro findings
  5. No high risk co-morbidities
  6. No new, concerning history or physical examination
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12
Q

what is S on headache history?

A

S: site – bilateral, unilateral, symmetrical

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13
Q

what is O on headache history?

A

O: onset – speed, aura (migraines – lines, zig zag, not focused vision, smell/ taste change)

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14
Q

what is C on headache history?

A

C: character: sharp/ dull/ boring/ electrical (nerve), pressure

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15
Q

what is R in headache history?

A

R: radiation: face (trigeminal neuralgia), eye- glaucoma, neck- meningitis

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16
Q

what is A in headache history?

A

A: associated symptoms: autonomic (tearing, drooping, swollen eyelid, pain around one eye – cluster), meningitis triad, SOL (neuro deficits, weight loss, visual disturbance)

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17
Q

what is T within headache history?

A

T: timings: episodic, daily, duration, unremitting

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18
Q

what is E on headache history?

A

E: exacerbation factors: posture, Valsalva, medication, caffeine

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19
Q

what examinations would you do within headache history?

A
  • Basic obs
  • GCS
  • Features: photophobia, eyes – redness/ pupils, feel sinuses, neck stiffness – passive as well as active
    brudzinki sign
    kernigs sign
    cranial nerve examinations
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20
Q

what is brudzinkis sign?

A

passive flexion of neck causing involuntary FLEXION OF KNEE AND HIP

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21
Q

what is kernigs sign?

A

:pain on passive knee extension with hip fully flexed - lie on back lift leg up and then bend knee

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22
Q

how do you distinguish primary and secondary headaches?

A

SSNOOP

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23
Q

what is SSNOOP?

A

to differentiate between 1st and 2nd headaches
- S: systemic symptoms
- S: secondary risk factors eg HIV or immunocompromised
- N: neurological symptoms/ findings
- O: onset – sudden, thunderclap
- O: older age – 50+
- P: progression pattern: change form usual headache

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24
Q

what is 1st investigations of headaches?

A

headache diary

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25
Q

what is most common age for tension headache?

A
  • Age: 20-50
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26
Q

how would a tension headache be described as?

A
  • Location: bilateral and symmetrical  band around head
  • Severity: mild-moderate – worsens during day
  • Duration: 30mins to 7day
  • Character: band like – not pulsatile, more pressure
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27
Q

what are RF for tension headaches?

A
  • Risk factors: mental tension, stress, fatigue, missing meals, dehydration
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28
Q

where would tension headaches pain radiate?

A
  • Pain: sternocleidomastoid, trapezius and temporalis commonly tender
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29
Q

how do you manage a tension headache?

A
  • Simple analgesia – NSAIDS/ paracetamol
  • If chronic (7-9 headache days per month)  prophylactic low dose amitriptyline.
  • Acupuncture
  • Relaxation therapy
  • Advise: medication overuse
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30
Q

what do you do with amitriptyline in tension headaches?

A
  • If chronic (7-9 headache days per month)  prophylactic low dose amitriptyline. Want to attempt to withdraw after 4-6months
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31
Q

what is a medication overuse headache?

A

Medication overuse headache: analgesia rebound
- Due to regular OVERUSE eg > 3months per year

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32
Q

how often of taking NSAIDS/ paracetamol could trigger medication overuse?

A
  • NSAIDS/ paracetamol if taken >15 days/ mth
  • Headache must be present for >15 days a month in a patient with pre-existing headache disorder
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33
Q

what drugs can cause medication overuse?

A

Aetiology drugs: analgesics, birth control (usually on inactive days eg break days), nitrates, CCB, digoxin, corticosteroids, HRT, alcohol, caffeine

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34
Q

what ages are most common for migraines?

A
  • Age: 10-40
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35
Q

describe the character of a migraine headache?

A
  • Location: usually unilateral – can become bilateral
  • Severity: moderate to severe
  • Duration: 4hrs to 3days
  • Character: throbbing, poundings, pulsating
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36
Q

what are the associated symptoms of a migraine?

A
  • Associated symptoms: prodromal symptoms  irritable, cravings, yawning, aura. During headache: N+V, photophobia, allodynia
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37
Q

what is allodynia?

A

pain that shouldnt be caused by a non painful stimulus

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38
Q

what is atypical migraine?

A

Atypical: no aura – can be known as common migraine  can diagnose after 5 attacks

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39
Q

what are the 4 phases of migraine?

A
  1. prodrome
  2. aura
  3. headache
  4. postdrome
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40
Q

what is prodrome?

A

Prodrome (preheadache): problems concentrating, difficulty speaking, trouble sleeping, nausea, fatigue, sensitivity to light, increased urination, muscle stiffness

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41
Q

what is aura?

A
  1. Aura: seeing bright flashing lights, blind spots in vision, speech changes, ringing in ears, temporary vision loss, funny feeling, changes in taste/ smell
    - Reversible stage
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42
Q

what is scintillating scotoma?

A

(shimmering oddly shaped area of visual deficit) - seen in aura

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43
Q

how long can aura last?

A

can last 5 mins to 1hr before migraine onset

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44
Q

how long can a migraine headache last?

A

Headache: can last 4-72hrs

45
Q

what is postdrome?

A

Postdrome (hungover like) : unable to concentrate, feeling depressed, not being to be able to understand things, euphoria

46
Q

how can you manage headaches via lifestyle modifications?

A
  • Lifestyle: headache diary – find triggers, stress management, hydration, regular meals, exercise, healthy BMI
47
Q

how do you manage an acute attack of migraine?

A
  • Acute attack: NSAID/ paracetamol + triptan, anti-emetics, AVOID OPIOIDS
  • These meds should be taken early to avoid progression and triptans should be taken at start of headache not aura
48
Q

what medication is contra-indicated within migraine?

A

combined oral contraceptive pill

49
Q

what prevention medication can be taken if severely impacted?

A
  • Meds: propranolol, amitriptyline, topiramate (contra-indicated in pregnancy  need contraception
50
Q

what non pharmacological preventative therapies can be used in migraines?

A
  • Non pharma: relaxation therapy/ CBT, acupuncture, riboflavin (vit B2)
51
Q

what can hemiplegic stroke mimic?

A

stroke

52
Q

what are symptoms of a hemiplegic migraine?

A

: typical migraine, sudden/ gradual onset, hemiplegia (unilateral weakness of the limbs), ataxia, changes in consciousness
- Tingling/ numbness across different parts of body

53
Q

what does a hemiplegic migraine respond to?

A

indomegthacin - NSAID

54
Q

what is usual age for cluster headache?

A
  • Age: 20-40
55
Q

what is character of cluster headache?

A
  • Character: sharp, pulsating, boring, burning
  • Associated symptoms: ipsilateral cranial autonomic symptoms  conjunctival injection, lacrimation, eyelid oedema Location: unilateral, peri-orbital
  • Severity: severe
56
Q

when do cluster headaches usually occur?

A
  • Duration: 15 to 180 mins
  • Timimgs: predictable – same time night/ day  typically 1-2hrs after falling asleep
57
Q

what are RF in cluster headaches?

A

RF: More common in men, head trauma, smoking

58
Q

what are triggers in cluster headaches?

A
  • Triggers: alcohol, histamine, exercise, sleep, volatile smells (petrol/ perfume)
59
Q

what are chronic cluster headaches?

A
  • Chronic: attacks occur more than one a year without remission – lasting 1mth
60
Q

what are episodic cluster headaches?

A
  • Episodic: occur in periods typically between 2weeks and 3months  separated by pain-free periods for at least one month
61
Q

how do you manage cluster headache?

A
  • First pres: urgent referral
  • Acute: subcut triptan, nasal triptan, oxygen – 15L non rebreather
62
Q

what preventative therapies can be used for cluster headaches?

A
  • Preventative: verapamil (CCB), ECG monitoring , pred in short periods
63
Q

what should not be used to manage cluster headaches?

A
  • DO NOT USE: paracetamol/ NSAIDS/ opioids
64
Q

what is trigeminal neuralgia like?

A
  • Chronic, debilitating, intense and extreme electric shock like
  • Lasts seconds to minutes  can have hundreds attacks per day
65
Q

what can trigger trigeminal neuralgia?

A

Triggers: light touch, eating, cold wind, vibrations, brushing teeth

66
Q

what imaging is needed in trigeminal neuralgia?

A

MRI - rule out other pathology

67
Q

how do you manage trigeminal neuralgia?

A
  • 1st line: carbamazepenine – withdraw after 1 month
  • Gabapentin, botox
  • Surgery: sever trigeminal nerve root, microvascular decompression
68
Q

what are sinus headaches?

A

Sinus headaches: headaches due to inflammation of mucosal lining of nasal cavity and paranasal sinuses
- Tender to palpation over sinuses

69
Q

what is the aetiology of sinus headaches?

A

Aetiology: viral/ bacterial  usually 2 to URTI but if lasting more than 10 days  bacterial

70
Q

how do you manage sinus headaches?

A
  • NSAIDS/ paracetamol/ codeine, nasal corticosteroids
  • Bacterial: symptomatic treatment, watchful waiting – up to 10days , AB depending on bacteria (phenoxymethylpenicillin) or co-amox if worsening
71
Q

what causes subarachnoid haemorrhages?

A

aneurysms - no trauma

72
Q

where is the bleeding within subarachnoid haematoma?

A

bloods vessels - usually within circle of willis

73
Q

what condition is linked to aneurysm at circle of willis?

A

polycystic kidney disease

74
Q

what is sentinel headaches?

A
  • 30% have sentinel headache (progressive worsening headache leading up – 2wks prior) before subarachnoid headache
75
Q
A
76
Q

what is the clear sign of subarachnoid headache?

A

thunderclap sudden onset headache

77
Q

what are RF for aneurysms?

A
  • RF: hypetension, smoking, headache, genetic conditions (PKD, ehlers danlos, sickle cell, marfan) coke, black ethnicity, female, aged 45-70n
  • Antiplatelets/ anticoags increase severity of bleed
78
Q

how would you diagnose subarachnoid haemorrhage?

A

Diagnosis: FBC, U&E, clotting, CT head- hyperdence white following shape of skull – crescent

79
Q

what would be seen on a lumbar puncture after subarachnoid haemorrhage?

A
  • LP: 12hrs after symptom onset : if bleeding not seen on CT but still highly suspicious – look for xanthochromia (faint, yellow tinge)
80
Q

what medications can be used to manage subarachnoid haematoma?

A

Medical: nimodipine – prevent cerebral ischaemia due to vasospasm, analgesia, antiemetics, anticonvulsants

81
Q

what neurosurgery may be used to manage subarachnoid haematoma?

A

Surgical: occlude aneurysm if risk of bleeding, coiling – endovascular titanium coils inserted into aneurysm, clipping_ direct neurosurgery

82
Q

what is hydrocephalus and link to SAH?

A

There is a risk of hydrocephalus following SAH  disruption of CSF driange and treated with LP or shunt

83
Q

what is normal Intracranial pressure?

A

: should be between 7 and 15mmHg

84
Q

what is the aetiology of raised ICP?

A

mass effect (tumour/ haemorrhage, oedema, abscess), brian swelling, venous sinus thrombosis, obstruction of CSF flow/ absorption, increased CSF production, idiopathic

85
Q

what are signs of raised ICP?

A

Signs: headache – postural changes  worse on lying down. Valsalva/ coughing/ sneezing makes it worse
- Vomiting with/without nausea
- Ocular palsies
- LOC
- Back pain
- Papilledema

86
Q

what can cause space occupying lesions?

A

tumours, haematomas, abscess

87
Q

what are signs of SOL?

A

Signs: new onset headache, progressive or persistent headache, postural changes
- New onset personality changes/ cognitions

88
Q

what is the pathophys of idiopathic intercranial hypertension?

A

Idiopathic intercranial hypertension
- Due to reduced CSF absorption

89
Q

who is most at risk of idiopathic intercranial hypertension?

A

obese women of childbearing age

90
Q

what are signs of idiopathic intercranial hypertension?

A

Signs: headache, neck/ back pain, visual palsy – visual field loss (enlargement of blind spott, dislopia (double vision) due to optic nerve atrophy, papilloedema

91
Q

how is idiopathic intercranial hypertension diagnosed?

A

Diagnosis: based on exclusion, MRI venography with contrast and CT, LP would indicate >25mmHg

92
Q

what drugs can manage IIH?

A
  • Drug: tetracycline, cyclosporine, lithium, OCP, tamoxifen removal
    acetazolamide - visual symptoms
93
Q

what lifestyle options can be used to manage IIH?

A
  • Lifestyle: low sodium, weight reduction
94
Q

what is accelerated hypertension?

A

rapid and sudden increased bP – can cause end organ dam

95
Q

what can cause hypertensive emergencies?

A
  • Hypertensive emergency – maliganant hypetension
  • Hypertensive encephalopathy  neuro symptoms
    Patients with BP of 180/120 + retinal haemorrhages, papilloedema + life threatening symptoms – new onset confusion, chest pain, AKI, signs of HF
96
Q

how do you manage hypertensive emergencies?

A

need to lowe BP slowly over 24hrs to prevent cerebral infarction (watershed areas)  labetalol ?hydrazaline hydrochloride

97
Q

what is temporal giant cell arteritis?

A

Temporal (giant cell) arteritis
- Form of vasculitis caused by inflamedmtempral arteries

98
Q

who does temporal giant cell arteritis mainly affect?

A
  • Mainly affecting women, +50yrs
99
Q

what condition is linked to tempral giant cell arteritis?

A

polymyalgia rheumatica

100
Q

what are signs of temporal giant cell arteritis?

A
  • Frequent severe bilateral headaches
  • Temporal/ occipital pain/ tenderness
  • Scalp enderness
  • Jaw claudication
  • Visual disturbances – diplopia, loss of vision
  • Fatigue. Myalgia
  • Large palpable, non pulsatile arteries of head and face  USS temporal artery
101
Q

how do you manage temporal giant cell arteritis?

A

Management: high dose steroids, may need PPI and bone protection if long term

102
Q

what causes pre-ecalmpsia headaches?

A

raised BP

103
Q

what are cerebral venous sinus thrombosis?

A
  • Blood clot in dural venous sinuses
  • Prevents venous return
  • Causing headache and neurosymptoms, treat with anticoags
104
Q

along with high BP, what else is seen in pre-eclampsia?

A

protein in urine

105
Q

what are RF of pre-eclampsia?

A

RF: previous episodes, hypertension, AI conditions, CKD, diabetes

106
Q

what are symptoms of pre-eclampsia?

A

Symptoms: headache, visual changes, RUQ/ epigastric pain (liver swelling), reduced urine output, N+V, oedema (especially face)

107
Q

how do you manage pre-eclampsia?

A

Management: prophylaxis – aspirin from 12wks if high risk, labetalol, mg sulphate during/ after labour to prevent seizures, birth is only cure

108
Q
A

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