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3a neurology > Headaches > Flashcards

Headaches Flashcards

1
Q

What is giant cell arteritis (GCA)

A

Inflammation of large and medium sized arteries

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2
Q

What artery is primarily affected in GCA

A

Branches of the external carotid artery

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3
Q

What is the typical patient profile for Giant Cell Arteritis (GCA), and what condition is commonly associated with it?

A
  • White female over 60
  • commonly occurs in patients with polymyalgia rheumatica
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4
Q

Give 5 common symptoms of GCA

A
  • New constant, throbbing headache
  • Scalp pain or tenderness
  • Aching and stiffness - neck, shoulders, hips
  • Jaw claudication
  • Systemic: fever, weight loss, malaise, fatigue
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5
Q

What are 3 signs of GCA

A
  • anterior ischemic optic neuropathy: fundoscopy will show swollen pale disc and blurred margins
  • Absent temporal artery pulse
  • Reduced visual acuity (+ diplopia/ change to colour vision)
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6
Q

How is GCA investigated

A
  • Vascular ultrasonography of temporal and axillary artery
  • GS: Temporal artery biopsy
  • ESR/CRP - high
  • FBC - may have normocytic normochromic anaemia
  • Fundoscopy - optic disc pallor/ oedema
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7
Q

Give 3 positive finding of GCA on a temporal artery biopsy

A
  • Multinucleated giant cells
  • Granulomatous inflammation (skip lesions)
  • Intimal thickening and narrow lumen
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8
Q

Why are negative biopsies possible in patients with GCA (2)

A

Less helpful in extracranial GCA
* presence of skip lesions along the artery
* Involvement of arteries besides superficial temporal artery

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9
Q

What may a positive vascular ultrasonography for GCA show (2)

A
  • Wall thickening (non-compressible halo sign)
  • Stenosis or occlusion
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10
Q

How is GCA managed

A
  • high dose glucocorticoids as soon as a diagnosis is suspected:
    • no visual loss: oral high-dose prednisolone
    • evolving visual loss: IV methylprednisolone then high-dose prednisolone
  • urgent ophthalmology review
  • low dose aspirin
  • Specialist Tx - SC tocilizumab or Oral methotrexate once weekly
  • bone protection with bisphosphonates
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11
Q

Give 3 complications of GCA

A
  • Glucocorticoid toxicity - osteoporosis, diabetes, HTN
  • Aortic aneurysm
  • Vision loss
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12
Q

What is a migraine

A

Chronic, episodic, primary headache typically presenting in early-mid life (<40)

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13
Q

Give 4 RF of migraines

A
  • Female
  • Family Hx
  • Obesity
  • Sleeping disorders
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14
Q

Give 6 Triggers of a migraine

A

Chocolate
Oral contraception
Alcohol
Bright lights
Exercise
Menstruation

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15
Q

What is aura in relation to migraines

A

Unilateral fully reversible visual, sensory or other CNS Sx that develop gradually and are usually followed by a headache

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16
Q

Describe the 5 stages of a migraine

A
  • Prodromal - 3 days before headache
  • Aura - lasts up to 60mins
  • Headache - lasts 4-72h
  • Resolution - headache relieved
  • Recovery
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17
Q

What is a hemiplegic migraine

A

Migraine with aura including motor weakness

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18
Q

Give 5 ways migraines present

A
  • Severe, unilateral, throbbing headache lasting 4-72h
  • Nausea
  • Photophobia
  • Worse with activity
  • Aura: flashing lights, zigzag lines, Paraesthesia, blind spot
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19
Q

How is a migraine diagnosed

A

Clinical
* A) At least 5 attacks fulfilling criteria B-D
* B) Headache attacks lasting 4-72 hours
* C) Headache has at least two of the following characteristics:
1. unilateral location, 2. pulsating quality, 3. moderate or severe pain intensity, 4. aggravation by or causing avoidance of routine physical activity
* D) During headache at least one of the following:
1. nausea +/- vomiting, 2. photophobia and phonophobia
* E) Not attributed to another disorder - ruled out by history or appropriate investigations

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20
Q

Management of acute migraine

A
  • First line: oral triptan + NSAID or triptan + paracetamol
  • nasal triptan if <17y
  • metoclopramide or prochlorperazine
  • Triptans: should be taken at start of headache not aura - oral sumatriptan
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21
Q

Give 4 pharmacological therapies used to prevent migraines

A
  • Propranolol
  • Topiramate
  • Amitriptyline (25-75mg at night)
  • Riboflavin (B2) 400mg - avoid in pregnancy
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22
Q

What preventative tx for migraines is teratogenic

A

Topiramate

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23
Q

Give 2 non-pharmacological therapies that can be offered to prevent migraines

A
  • Relaxation techniques - mindfulness/ meditation
  • Acupuncture - if both propranolol and topiramate are ineffective
24
Q

Which preventative drug should be prescribed for menstrual related migraines

A
  • Frovatriptan or zolmitriptan (2.5mg twice daily)
25
Q

State 3 characteristics of a tension headache

A
  • Generalised, bilateral
  • Non-pulsatile dull pain
  • Constricting - tight band around head
26
Q

What regions are typically affected by tension headaches

A
  • Frontal
  • Occipital
27
Q

Give 2 characteristics that would favour a diagnosis of a tension headache over a migraine

A
  • Mild/ moderate intensity
  • Not aggravated by routine physical activity
28
Q

What is the most common type of primary headache

A

Tension headache

29
Q

What age range has the peak prevalence of tension headaches

A

20-39 years

30
Q

Give 3 RFs/ aggravating factors of tension headaches

A
  • Stress
  • Missing meals
  • Fatigue
31
Q

How are tension headaches investigated

A
  • Clinical diagnosis - typical headache without associate Sx (N+V) and normal neuro exam
  • CT sinus/ MRI brain - normal
32
Q

How is an acute tension headache managed

A

Simple analgesia ASAP after onset
* Aspirin
* Paracetamol
* Ibuprofen

33
Q

Prophylaxis for tension headaches

A
  • up to 10 sessions of acupuncture
  • low dose Oral Amitriptyline
34
Q

What is a cluster headache

A

severe headache occuring in clusters and lasting several weeks

35
Q

5 RFs of cluster headaches

A
  • Male
  • FHx
  • Head injury
  • Smoking
  • Heavy drinking
36
Q

5 characteristics of cluster headaches

A
  • Unilateral pain
  • Excruciating pain - sharp, piercing, pulsating
  • Duration: lasts 15 mins - 3h
  • Agitation and restlessness - pacing, rock back and forth
  • Autonomic Sx
37
Q

Give 5 autonomic features that may present in cluster headaches

A
  • lacrimation
  • conjunctival infection
  • nasal congestion
  • rhinorrhoea
  • Partial Horner syndrome (ptosis/ miosis)
38
Q

Describe the frequency of attacks in cluster headaches

A
  • pain typical occurs once or twice a day, each episode lasting 15 mins - 2 hours
  • clusters typically last 4-12 weeks
39
Q

What differentiates episodic and chronic cluster headaches

A
  • Episodic: Cluster periods separated by pain-free remission periods lasting at least 3 months
  • Chronic - attacks occur for over a year without remission or remission is <3 months
40
Q

How are cluster headaches diagnosed

A
  • Clinical: 5 or more headaches that fulfil Sx criteria
  • ESR - Exclude GCA
  • Brain/ pituitary MRI with gadolinium contrast - exclude secondary causes
41
Q

How are acute cluster headaches managed

A
  • SC Sumatriptan 6mg , may repeat 1h after initial dose (max 12mg/day)
  • High flow 100% oxygen - flow rate of 12-15L/min via non-rebreather mask for 15-20 mins
42
Q

What is the prophylactic management for cluster headaches

A
  • verapamil
  • tapering dose of prednisolone
43
Q

When are triptans containdicated

A
  • moderate or severe hypertension
  • CAD
  • PVD
44
Q

What is trigeminal neuralgia

A

Facial pain syndrome in the distribution of the trigeminal nerve

45
Q

Is the pain in trigeminal neuralgia typically unilateral or bilateral

A

Unilateral

46
Q

What are the three branches of the trigeminal nerve

A
  • V1 - ophthalmic
  • V2 - Maxillary
  • V3 - Mandibular
47
Q

Give 4 RFs for trigeminal neuralgia

A
  • HTN
  • Multiple sclerosis
  • Female
  • Over 50
48
Q

Give 5 triggers of trigeminal neuralgia

A
  • Shaving
  • Brushing teeth
  • Talking
  • Cold weather
  • Citrus fruits
49
Q

Describe the facial pain in trigeminal neuralgia

A
  • electric shock sensation - sharp, stabbing
  • 90% unilateral
  • Lasts seconds - minutes
  • Triggered by facial/oral mechanical stimulation
50
Q

How is trigeminal neuralgia diagnosed

A
  • Usually clinical
  • MRI brain - rule out other pathology
51
Q

How is trigeminal neuralgia treated

A
  • 1st line: Carbamazepine
  • 2nd line: lamotrigine or pregabalin
  • failure to respond to treatment or atypical features (e.g. < 50 years old) should prompt referral to neurology
52
Q

Give some red flag symptoms of a headache

A
  • Sudden onset thunderclap headache reaching maximum intensity within 5 minutes
  • new-onset cognitive dysfunction
  • impaired level of consciousness
  • personality change
  • vomiting >1 without obvious cause
  • triggered by cough, valsalva, sneeze or exercise
  • orthostatic headache (changes with posture)
53
Q

What could a headache accompanied by visual disturbances indicate (2)

A
  • Glaucoma
  • Temporal arteritis
54
Q

What could a headache that is worse laying down indicate

A

Space occupying lesion

55
Q

What could a headache lined to Valsalva manoeuvres

A

raised ICP

3a neurology (16 decks)

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