Headaches Flashcards
List 10 red flag symptoms in a patient with headache.
Age 50+ yo Thunderclap headache Neurological deficit Worsening with posture/strain/exertion Early morning headaches Systemic symptoms Seizures Meningism Temporal artery tenderness Jaw claudication
In which patients would you always do further investigations for a headache, to detect any underlying cause? (4)
Cancer
Pregnancy
Post-partum
HIV/immunosuppression
Give 3 examples of primary headaches.
Migraine
Tension headaches
Cluster headaches
Which clinical exams are important in a patient presenting with headaches?
Systemic enquiry
Cranial nerve exam
Neurological exam
Visual acuity/fields/fundoscopy
Which 6 systemic signs might be caused by a headache?
Reduced consciousness (GCS) Altered BP/pulse Pyrexia Meningism Skin rash Temporal artery tenderness
List 8 signs you might find on cranial nerve exams in headaches.
Nerve palsies, e.g. CN3, CN6 Horner's syndrome Relative afferent pupillary defect Limited visual fields Blind spots Limited eye movements Papilloedema Sub-hyloid haemorrhage
Describe the following nerve palsies:
a) CN 3 (oculomotor)
b) CN 4 (trochlear)
c) CN 6 (abducens)
OCULOMOTOR NERVE PALSY:
- Eye is paralysed
- Eye points down and out
TROCHLEAR NERVE PALSY:
-Patient tilts head sideways (away from affected eye) to correct vision
ABDUCENS NERVE PALSY:
-Eye cannot move laterally
List 2 features found on fundoscopy relating to headaches, and state what they indicate/
Papilloedema - raised ICP
Sub-hyloid haemorrhage - subarachnoid haemorrhage
List 4 signs indicating upper motor neuron lesions in a neuro exam.
Pronator drift
Increased tone
Brisk reflexes
Extensor plantar response
List 4 cerebellar signs in a neuro exam.
Nystagmus
Past-pointing
Dysdiadochokinesis
Broad-based, ataxic gait
Describe the characteristics of a headache caused by migraine. Consider:
a) Severity
b) Character
c) Onset
d) Duration
e) Exacerbating factors
f) Associated features
Severity: moderate-severe Character: throbbing/pulsatile; unilateral Onset: gradual Duration: 4-72 hours Exacerbating factors: physical activity
Features:
- Nausea/vomiting
- Photophobia
- Phono/osmophobia
- Autonomic disturbance
- Aura
Describe the features of an aura, associated with migraine. Consider:
a) Onset
b) Duration
c) Types of aura
Onset: 5-10 minutes
Duration: <60 minutes
Types of aura: VISUAL AURA -Negative scotoma -Positive scotoma -Flashing llights -Fortification spectrum SENSORY AURA -Tingling
List 2 complications of migraines.
Medication overuse headache
Chronic migraine
Briefly describe the pathophysiology of migraines. (3)
- Primary dysfunction in the brainstem sensory nuclei (CN5, 7-10)
a. Pain comes from sensitive cranial blood vessels - Vascular theory: vasoconstriction causes aura
a. Reflexive vasodilation causes pain - Neurovascular theory: dysfunction on endogenous pain-modulating systems
Describe the management of migraines. Consider:
a) Lifestyle modification
b) Treatment of acute migraine
c) Prophylaxis
Lifestyle:
- Avoid triggers
- Reduce caffeine/alcohol intake
- Regular meals/sleep patterns
Acute treatment:
- Analgesia
- Triptans (e.g. sumatriptan)
- Anti-emetics (e.g. metoclopramide)
Prophylaxis:
- Beta blockers
- Tricyclic antidepressants (e.g. amitriptyline)
- Anti-epileptics (e.g. sodium valproate)
