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Neurology > Headaches > Flashcards

Headaches Flashcards

1
Q

What is the most common neurological outpatient referral?

A

Headaches

- 25% of new referrals

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2
Q

What is a primary headache?

A

The headache itself is the disorder (no underlying cause)

- e.g. migraine tension-type headache and cluster headache

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3
Q

What is a secondary headache?

A

Secondary to an underlying cause - e.g. Subarachnoid haemorrhage, space occupying lesion, meningitis, temporal arteries, high/low intracranial pressure, drug induced…

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4
Q

What is the most important question when assessing a patient?

A

Could this be a secondary headache?

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5
Q

When taking history of a headache, what are the most important features?

A

Onset (time to maximal symptoms and circumstances at onset)
Severity and quality of pain
Location/radiation of pain
Presence of an aura/prodrome
Periodicity
Associated features - photophobia, phonophobia, osmophobia, nausea, movement sensitivity and periorbital autonomic disturbance (common in cluster headaches)
Age at onset (migraine more common in childhood/early adulthood, whereas a secondary cause is more common in the over 50s)
Triggers/exacerbating/relieving factors
Family history
Social/employment history
Medication history
Co-morbid depression and sleep disturbance

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6
Q

What are the ‘red flag’ symptoms of a headache? (indicate a secondary cause)

A

Age >50
Thunderclap headache
Focal/non-focal neurological deficit
Worsening of symptoms with posture (high/low CSF pressure), valsalva (coughing, straining) or physical exertion
Early morning headaches
Systemic symptoms
Seizures
Temporal artery tenderness/jaw claudication
Specific situations
- cancer, pregnancy, post-partum, HIV/immunosupression

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7
Q

What acronym is used to remember red flag symptoms?

A

S - systemic symptoms
N - neurological signs or symptoms
O - older age at onset
O - acute onset (less than 5 minutes)
P - previous headache history is different
T - triggered headache (valsala or postural)

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8
Q

What clinical signs might you find on examination to suggest a secondary cause?

A 
General/systemic
- reduced consciousness
- BP/pulse
- pyrexia 
- meningism 
- skin rash
- temporal artery tenderness
Cranial nerve
- pupillary responses
- visual fields may have a blind spot
- eye movements
- fundoscopy
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9
Q

What abnormal findings might indicate a secondary cause on fundoscopy?

A

Papilloedema - raised ICP

Subhyaloid haemorrhage - raised ICP/SAH

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10
Q

What abnormal findings may indicate a secondary cause when assessing the cranial nerves of the eye?

A

3rd nerve palsy - eye droops down and out
6th nerve palsy - eye can’t move laterally
Horner’s syndrome

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11
Q

Which upper motor neurone signs may indicate a secondary cause?

A

Pronator drift
Increased tone
Brisk reflexes
Extensor plantar response

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12
Q

What cerebellar signs may indicate a secondary cause of the headache?

A

D - dysdiadochokinesis
A - ataxia
N - nystagmus
I - intention tremor (worse during voluntary movement)
S - scanning dysarthria (jerky, explosive, slurred speech)
H - heel-shin test positive

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13
Q

Describe the aetiology of a migraine.

A

More common in women than men
12-16% of population
25-55 years has highest prevalence
Positive family history is common

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14
Q

Give some examples of triggers of migraines.

A 
Hormonal
Weather
Stress
Hunger
Sleep disturbance 
Exertion 
Alcohol excess 
Foods
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15
Q

What is the pathophysiology of a migraine?

A

Neurovascular hypothesis
- disorder of the endogenous pain modulating systems, particularly in subcortical structures (e.g. brainstem and diencephalic nuecli)

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16
Q

What are the phases of migraine?

A

Prodrome - sensation that a migraine is coming for 24/48 hours
Aura - 30% of migraine patients
Headache - persists from 4-48 hours
Postdrome - mild, non-specific headache lasting for 24/48 hours

17
Q

What are the symptoms of a prodrome?

A 
Mood disturbance
Restlessness 
Hyperosmia 
Photophobia 
Diarrhoea
18
Q

What is an aura?

A

Recurrent reversible focal neurological symptoms
- visual, sensory or motor (visual most common)
Develops over 5-20 minutes and lasts less than an hour

19
Q

Describe visual and sensory auras.

A

Visual
- negative scotoma (blind spot)
- positive scotoma (dark spot)
- flashing lights
- fortification syndrome (halo effect around objects)
- visual field loss
Sensory - tingling starting in the thumb and fingers and spreading up the arm

20
Q

Describe a normal headache.

A

Throbbing or pulsatile pain in the head of moderate to severe intensity
Gradual onset, lasting 4-72 hours
60% are unilateral
Aggravated by routine physical activity

21
Q

Name some symptoms associated with a headache.

A 
Nausea and vomiting 
Photophobia 
Phonophobia 
Osmophobia 
Mood disturbance 
Diarrhoea 
Autonomic disturbance 
- e.g. lacrimal, conjunctival, nasal stiffness
22
Q

What investigations can you do if someone presents with a migraine?

A

Good history and normal clinical examination does not require further investigation
Cranial imaging advised if they have red flag symptoms or an aura lasting more than 24 hours

23
Q

What is the most common complication associated with migraine management?

A

Medication overuse headache

  • patient has a headache for at least 15 days of the month associated with frequent use of pain medication
  • e.g. NSAIDs, paracetamol, opiods and triptans
  • to avoid this, patients can’t take medication more than 2-3 times a week
24
Q

What is a chronic migraine?

A

Headache on 15 or more days of a month

25
Q

How can migraines be managed?

A

Lifestyle
- avoid triggers
- reduce caffeine and alcohol intake
- encourage regular meals and sleep patterns
Acute management
- simple analgesia
- triptans (e.g. Sumatiptan)
- anti-emetic (e.g. domperidone and metoclopramide)
Prophylaxis
- beta-blockers
- tricyclic antidepressants (amitriptyline, dosulepin)
- anti-epilepsy drugs (sodium valproate and topirmate)

26
Q

What is the definition of a thunderclap headache?

A

Abrupt-onset of severe headache which reaches maximal intensity within 5 minutes and lasts for over an hour

27
Q

What should you assume the underlying cause of a thunderclap headache is?

A

Subarachnoid haemorrhage

- 15% of tunderclap headaches

28
Q

Name some of the possible causes of a thunderclap headache.

A 
Intracranial haemorrhage 
Arterial dissection (vertebral or carotid)
Cerebral venous sinus thrombosis
Bacterial meningitis
Spontaneous intracranial hypotension 
Pituitary apoplexy 
Primary headache - once no secondary cause can be found
- migraine
- exertional headache 
- cluster headache
29
Q

If someone comes in with a thunderclap headache, what investigations can be done?

A

Primary aim is to identify a subarachnoid haemorrhage

  • bloods (U&Es, LFTs, full blood count, coagulation screen and CRP)
  • blood cultures
  • 12-lead ECG
  • urgent CT brain (over 95% of SAH have blood visible within the first 4 hours)
  • lumbar puncture (performed after 12 hours to look for xanthochromia)
30
Q

What is the normal intracranial pressure?

A

7-15mmHg

31
Q

Why is raised ICP a problem?

A

1) CPP = mean arterial pressure - ICP
So if ICP increases, the global perfusion to the brain decreases, and cerebral metabolism is reduced
2) If the pressure is brain caused by a space-occupying lesion (haemorrhage), the space available in the brain decreases, and the brain herniates

32
Q

What is CPP?

A

Cerebral perfusion pressure is the net pressure gradient causing blood flow into the brain

33
Q

Name some types of brain herniation.

A 
Uncal
Central (transtentorial)
Cingulate (subfalcine)
Transcalvarial
Upward transtentorial (upward cerebellar)
Tonsillar (downward cerebellar)
34
Q

What would you expect to find in the history, if the person has a raised ICP headache?

A

Worse lying flat (improved by sitting up or standing)
Worse in the morning
Persistent nausea/vomiting
Worse on valsalva (e.g. coughing, laughing, straining)
Worse with physical exertion
Transient visual obscurations with change in posture

35
Q

What would you expect to find on clinical examination, if the patient has a raised ICP headache?

A 
Optic disc swelling - papilloedema 
Impaired visual acuity/colour vision
Restricted visual fields/enlarged blind spot
3rd nerve palsy
6th nerve palsy (false localising sign)
Focal neurological signs
36
Q

Name some causes of raised ICP.

A 
Mass effect
- tumour, infarction with oedema, abscess, subdural/extradural/intracerebral haematoma
Increased venous pressure
- cerebral venous sinus thrombosis, obstruction of the jugular venous system
Obstruction to CSF flow/absorption
- hydrocephalus, meningitis 
Idiopathic 
- idiopathic intracranial hypertension
37
Q

What are the features of a low CSF pressure headache?

A

Headache is worse on sitting/standing and relieved by lying down
Results from a CSF leakage
- loss of CSF volume causes traction on meninges, cerebral/cerebellar veins and cranial nerves V, IX and X

38
Q

What are some possible causes of a low CSF pressure headache?

A 
Post-lumbar puncture 
- 1/3rd of cases
- 90% develops within three days
- most resolve spontaneously 
Spontaneous intracranial hypotension
- results from spontaneous dural tear
- can occur following valsalva

Neurology (13 decks)

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