headaches Flashcards
name some red flags for headaches
new onset > 50
known/previous malignancy
immunosuppressed
early morning headache
exacerbation by valsalva
what may a new onset headache in patients over 50 suggest
temporal arteritis
space occupying lesion
what may a headache exacerbated by valsalva suggest
chiari malformation type 1
space occupying lesions
what is a chiari malformation type 1
a herniation of the cerebellar tonsils
what might a headache worsened on standing suggest
CSF leak
what should we rule out as a cause for a headache in an immunosuppressed patient
CNS infection and malignancy
what is the most common cause of an episodic headache
migraine
who is more likely to get a migraine
females
what can trigger a migraine
stress, diet, sleep, hormonal imbalance, physical exertion
how frequent are migraine attacks usually
once a month
what are tension headaches associated with
stress, depression, alcohol, skipping meals and dehydration
clinical presentation of a tension headache
bilateral, non-pulsatile pain
tightness sensation
scalp muscle tenderness
NO N+V, photophobia or phonophobia
management of a tension headache
paracetamol + NSAIDs
stress management
massages and muscle relaxation exercises
what is used to manage severe chronic tension-type headaches
trial amitriptyline or dothiepin for 3 months
what is trigeminal neuralgia
long-term pain disorder that affects the trigeminal nerve
who is usually affected by trigeminal neuralgia
women >60
what may trigger an attack of trigeminal neuralgia
washing, shaving, cold wind, chewing
what is the suggested cause of trigeminal neuralgia
compression of the trigeminal nerve
clinical presentation of trigeminal neuralgia
severe stabbing unilateral facial pain, lasting 1-90s, occurs many times a day
investigation for trigeminal neuralgia
usually a clinical diagnosis, but MRI can be used to exclude secondary causes
first line management of trigeminal neuralgia
carbamazepine
secondary management of trigeminal neuralgia
phenytoin, lamotrigine, gabapentin
microvascular decompression, ablation
what is venous sinus thrombosis
occlusion of venous vessels in sinuses of the cerebral veins
risk factors for venous sinus thrombosis
oral contraceptives, dehydration, clotting disorders
who is more likely to get venous sinus thrombosis
young females
clinical presentation of venous sinus thrombosis
progressive headache - worsens when lying down or bending over
visual changes
seizures
focal neurological deficits
investigations for venous sinus thrombosis
non-contrast CT shows hyper density in affected sinus
CT venogram looks for a filling defect
empty delta sign on CT venogram
venous sinus thrombosis
where is most commonly affected in dural venous thrombosis
superior sagittal sinus
management of venous sinus thrombosis
anticoagulation with low molecular weight heparin
monitoring for neurological deterioration
what are trigeminal autonomic cephalgias
primary headache syndromes that are associated with paroxysmal facial autonomic symptoms
what are some autonomic features associated with trigeminal autonomic cephalgias
ptosis, miosis, nasal stuffiness, N+V, tearing, eye lid oedema
what is ptosis
droopy eyelids
what is miosis
excessive constriction of the pupil
who usually presents with a cluster headache
men aged 20-50, often smokers
how are cluster headaches described
alarm clock headaches
clinical presentation of a cluster headache
severe, unilateral headache
felt in or behind the eye - with watery, bloodshot eyes
patients become agitated during attacks
facial swelling, nasal congestion
acute management of cluster headache
high flow oxygen for 20 mins
+ subcutaneous or nasal triptans
prophylaxis of a cluster headache
verapamil
how does paroxysmal hemicrania different to a cluster headache
shorter in duration (10-30 mins) and occur more frequently
how long do cluster headaches usually last
20 mins - 3 hrs
who usually presents with paroxysmal hemicrania
women aged 50-60s
clinical presentation of paroxysmal hemicrania
very similar to cluster headaches
severe unilateral headache
investigation for paroxysmal hemicrania
MRI brain and MR angiogram in new onset unilateral cranial autonomic features
management of paroxysmal hemicrania
absolute response to indomethacin
how does paroxysmal hemicrania differ to hemicrania continua
constant duration in hemicrania continua
what is SUNCT syndrome
short-lasting unilateral neuralgiform headache with conjunctival injection and tearing
what are the main 4 trigeminal autonomic cephalgias
cluster headache
paroxysmal hemicrania
hemicrania continua
SUNCT syndrome
how does SUNCT syndrome present
severe unilateral headache + autonomic symptoms
very brief (15-120 seconds) and occur very frequently
management of SUNCT syndrome
lamotrigine or gabapentin
what is ICP
intracranial pressure
the pressure exerted by the cranium onto brain tissue, CSF and intracranial circulating blood volume
what can cause a raised ICP
SOL
brain swelling
increased central venous pressure (venous sinus thrombosis)
problems with CSF flow
what are the 3 main problems you can have which disrupt CSF flow
obstruction
increased production
decreased absorption
what can cause obstructive hydrocephalus
masses, Chiari syndrome
what can cause increased production of CSF
choroid plexus papilloma
what can cause decreased absorption of CSF (communicating hydrocephalus)
subarachnoid haemorrhage
meningitis
malignant meningeal disease
what is the normal range for ICP at rest
7-15 mmHg
where is CSF secreted from
choroid plexus
how does CSF move through the brain (4)
choroid plexus - ventricular system - subarachnoid space - venous system (arachnoid granulations)
how do we calculate cerebral perfusion pressure
mean arterial pressure - intracranial pressure
name some early signs of raised ICP
decreased level of consciousness, headache, pupil dysfunction +/- papilledema, changes in vision, N+V
name some late signs of raised ICP
coma, fixed dilated pupils, bradycardia, hyperthermia, increased urinary output
who usually gets normal pressure hydrocephalus and why
elderly, due to decreased brain elastance
hakim’s triad indicates what condition
normal pressure hydrocephalus
what is hakim’s triad
abnormal (magnetic) gait, urinary incontinence, dementia
what does a magnetic gait look like
feet appear to be stuck to the floor
mnemonic to remember symptoms of normal pressure hydrocephalus
wet, wacky and wobbly
investigations for normal pressure hydrocephalus
lumbar puncture
CT/MR imaging can show enlarged lateral ventricles
management of normal pressure hydrocephalus
therapeutic lumbar puncture
then ventriculoperitoneal shunt if responsive
who usually presents with idiopathic intracranial hypertension
young, overweight female patients
(possibly PCOS)
clinical presentation of idiopathic intracranial hypertension
headache, double vision, tinnitus, radicular pain, morning N+V, papilledema
what is radicular pain
pain along a dermatome due to a pinched nerve
investigation for idiopathic intracranial pressure
elevated pressure on lumbar puncture
normal CT
management of idiopathic intracranial hypertension
wight loss, carboanhydrase inhibitor
give some examples of carboanhydrase inhibitors
acetazolamide, topiramate
medical management of raised ICP
hypertonic saline, barbiturate coma or antiepileptics
surgical management of raised ICP
surgical decompression
what triad of symptoms suggest raised inctracranial pressure
cushings triad
hypertension, bradycardia and irregular breathing
what is an aura
sensory disturbance that occurs before or during a headache
what is the most common type of aura
visual
clinical presentation of a migraine
unilateral, throbbing headache
causes avoidance of routine activities of daily life
how long do migraines usually last
4-72 hours
name some symptoms associated with a migraine
N+V, photophobia, phonophobia
name some examples of aura
unilateral numbness, dysphasia, teichopsia
what is teichopsia
zigzags in vision
how long does aura usually last
5-60 mins and can present up to an hour before headache
name some red flags for atypical aura
motor weakness, double vision, visual symptoms only affecting one eye, poor balance, decreased level of consciousness
name some prodromal symptoms of a migraine
fatigue, poor concentration, neck stiffness and yawning
name some postdromal symptoms of a migraine
fatigue, elated or depressed mood
how do we differentiate between diagnosing episodic and chronic migraine
episodic: less than 15 days per month
chronic: at least 15 days per month, for more than 3 months
what can be done when investigating migraines
headache diary to identify triggers
acute pharmacological management of migraines
NSAIDs or paracetamol in combination with triptans (at the start of the headache)
special consideration around female patients with migraine with aura
should avoid the combined oral contraceptive due to increased risk of ischaemic stroke
who is considered for prophylactic management of migraines
if the patient is experiencing > 3 attacks per month or they are very severe
what can be added on to acute pharmacological management of a migraine
anti-emetic
what are the 3 main drugs that can be offered for migraine prophylaxis
propanolol
topiramate
amitryptilline
when is topiramate contraindicated
in pregnancy - girls and women would need to be on highly effective contraception prior to initiation
when is propanolol contraindicated
patients with asthma
