Headaches Flashcards
- tension,
- migraine,
- cluster,
- raised ICP (SOL, hydrocephalus),
- temporal arteritis,
- drugs (nitrates, nifedipine, withdrawal)
all cause what type of headaches?
chronic / recurrent
- trauma,
- cerebrovascular (SAH/ICH/infarction),
- meningitis,
- systemic infection,
- acute angle-closure glaucoma
all cause what types of headaches?
acute headaches
Headaches are divided into primary and secondary.
What is a primary headache and give 4 examples?
Primary = disturbance of pain networks in the absence of damage i.e. no other identifiable cause
- migraine
- tension
- cluster
- analgesia overuse
What is a secondary headache?
2o headaches have an underlying cause identifiable on LP / scans etc
there is activation of nociceptors on pain sensitive structures around the brain…
SAH, meningitis, GCA, idiopathic intracranial HTN, low pressure headaches, malignant HTN, sinusitis
which secondary headache does this describe:
thunderclap, sudden onset, first and worst?
SAH
which secondary headache does this describe:
fever, seizures?
meningitis
which secondary headache does this describe & how do you Rx if?
jaw claudication, >50y/o, visual disturbance
is GCA
–> ESR as emergency –> Rx steroids
What secondary headache does this describe & how Rx it?
young fat females, high pressure headaches + visual loss + papilledema
Idiopathic intracranial HTN
Rx –> lose weight
What secondary headache does this describe & ow Rx?
After LP / epidural
= Low pressure headaches
Conservative management: caffeine, hydration, analgesia
What is the SOCRATES for raised ICP?
S - generalised
O - Gradual
C - ache
R - none
A - N&V, photophobia (meningism signs), vision change, worse leaning forward, seizures, parasthesia
T: progressively worsening
E: worse on walking (gravity, CO2 retention), coughing, bending forward
S: mild to severe
After Ix for headaches e.g. CT head & lumbar puncture
the LP results come back as raised lympocytes, normal glucose and protein. What kind of infection is this?
viral
After Ix for headaches e.g. CT head & lumbar puncture
the LP results come back as raised neutrophils, low glucose and high protein. What kind of infection is this?
bacterial
After Ix for headaches e.g. CT head & lumbar puncture
the LP results come back as xanthochromia. What causes this?
Subarachnoid haemorrhage
A red flag for headaches is unilateral with eye pain what else could this be?
glaucoma/cluster
what are the red flags for headache?
- Sudden onset -SAH
- “Thunderclap” - SAH
- First & worst - SAH
- Unilateral with eye pain - glaucoma/cluster
- Neurological deficit
- Meningism (photophobia, neck-stiffness)
- Decreased consciousness
- Not usual pattern of headaches
- Scalp tenderness in >50s -GCA
- Worse on coughing/in the morning/bending forward -raised ICP
What is the socrates for tension headache?
S - bilateral
O - chronic, usually at end of the day
C - tight band, non-pulsatile
R -
A - scalp muscle tednerness
T - chronic
E - stress
S - mild-to-moderate (able to continue with ADLs)
What is the SOCRATES for a cluster headache?
S - unilateral, around one eye
O - quick develops, 1-2x/day, 15m-2hr
C - sharp stabbing pain
R -
A - facial/eyelid swelling/redness, Horner’s syndrome, runny nose, watery eyes, conjunctival injection/ redness, restlessness/agitation
T - clusters lasting several wks, clusters ~1yrly
E - ?alcohol may trigger, hyperbaric chamber relieves
S - severe (pt restless & agitated)
What is the SOCRATES for migraine?
S- Unilateral
O - Sudden or ~1hr onset, lasts 4-72hrs
C - Throbbing pain
R - Back of head & down neck (rule out meningism - infection, SAH)
A - N&V, photophobia, phonophobia, aura
T - Some constant, some wax & wane
E- physical activity, improved with rest
S - severe
Stabbing shooting pain down the face/jaw line
Triggered by chewing, talking
– What does this describe?
Trigeminal neuralgia
How do you Ix & Rx this?
Young woman, sudden headache, visual loss or change
?venous sinus thrombosis
- bloods
- MRI venogram to diagnose
= thromboembolism management
How do you Ix and Rx this?
S- Unilateral
O - Sudden or ~1hr onset, lasts 4-72hrs
C - Throbbing pain
R - Back of head & down neck (rule out meningism - infection, SAH)
A - N&V, photophobia, phonophobia, aura
T - Some constant, some wax & wane
E- physical activity, improved with rest
S - severe
- Ix of migraine is nothing
- can do CT if uncertain
Rx:
- Abortive: NSAIDS or sumatriptan (SSRI for migraine & cluster headache)
- prophylaxis: beta blockers, Calcium Channel Blockers etc. Topiramate (ca &Na blocker + inc gaba) , carbamazepine (na blocker)
- can use STEROID/BOTOX injections
What is the Ix and management of this headache:
S - unilateral, around one eye
O - quick develops, 1-2x/day, 15m-2hr
C - sharp stabbing pain
R -
A - facial/eyelid swelling/redness, Horner’s syndrome, runny nose, watery eyes, conjunctival injection/ redness, restlessness/agitation
T - clusters lasting several wks, clusters ~1yrly
E - ?alcohol may trigger, hyperbaric chamber relieves
S - severe (pt restless & agitated)
- cluster headaches Ix:
- CT done to rule out SOL
DDx = acute glaucoma
Rx:
- Acute: 100% oxygen & Sumatriptan (SSRI for migraine and cluster headaches)
- Prophylaxis: Verapamil (CaChannelBlocker)
What are the Ix and management of this headache?
S - bilateral
O - chronic, usually at end of the day
C - tight band, non-pulsatile
R -
A - scalp muscle tednerness
T - chronic
E - stress
S - mild-to-moderate (able to continue with ADLs)
Ix & Rx for tension headache:
Ix: none needed
Rx:
- Stress relief & rest
- Paracetamol / NSAIDs
- Prevention: Amitriptyline 10mg (a TCA)
What is the Ix and Rx of this?
Stabbing shooting pain down the face/jaw line
Triggered by chewing, talking
Trigeminal neuralgia:
Ix: MRI necessary to exclude secondary cause
Rx:
- Medical: Carbamazepine (na blocker)
- 2ndLine: Topimarate (ca and na + gaba blocker)/ Gabapentin (inhibs Ca2+)
Or Surgical: Ablative surgery
overallt migraines are 3x more common in women and often co-exist with a 2nd type of headache
What is the pathophysiology of migraine that we can glean from its Rx?
Migraine had been found to be a genetic disorder - there is 40 DNA sequence variant, the pathophysiology is not exactly understood
There is vasodilation of extracranial and intracranial vessels –> tryptans treat (sumatriptan - SSRI, vasoconstrict)
there is vascular inflammation which - NSAIDs treat
What is a migraine with typical aura vs with brainstem aura?
typeical aura can be with or without headache
brainstem syndrome in brainstam aura = double vision, slurred speech, drowsiness, vertigo
what is “aura” ?
E.g if migraine with typical aura can happen with or without headache.
Aura is a separate phenomenon:
- it is fully reversible,
- develops over ~5 mins - lasts 5-60mins
Visual > sensory > speech > motor
in order of most common > least common.
- cause is ?altered cerebral blood flow & ?channels
- –> (dilation/inflam of BV)
- –> cortical spreading depression 3mm/min
- –> activates trigemino-vascular loop & trigger headache
What sub-classifications of migraine are there?
- migraine with typical aura (+/- headache)
- migraine with brainstem aura (double vision, slurred speech, drowsiness, vertigo)
- hemiplegic migraine (familial or sporadic)
- retinal migraine
- vestibular migraine
What is notable about the severity of migraine symptoms?
they are severe and the person is unable to continue with ADLs
–> this is important for diagnosis
You can get allodynia in migraines. What is allodynia?
- you can feel pain from stimuli that dont normally cause pain
The stages of migraine attack are:
- Vulnerability –>
- attack initiation –>
- prodrome –>
- aura –>
- headache –>
- post-drome
when does attack initiatino occur before headache?
what can happen in the prodrome?
how long does headache last?
what symptom do you get in post drome?
Vulnerability –>
attack initiation (~24hrs before headache) –>
prodrome (go to toilet more, eat differently due to cravings, more irritable) –>
aura –>
headache (4-72hrs) –>
post-drome (fatigued, still not at best even though headache gone)
What conditions is migraine associated with?
- Obesity - excess E3
- Patent foramen ovale
The acronym for triggers of migraine = CHOCOLATE. what does this stand for?
- Chocolate
- Hangovers/ tiredness/ stress
- Orgasms
- Cheese/ caffeine
- Oral contraceptives (COCP) or menstruation
- Lie ins/ lack of food or dehydration
- Alcohol
- Tumult (loads of noise; clubbing) & bright lights
- Exercise
Due to photophobia and phonophobia where do patients with migraine characteristically go?
to a darkened, quiet room during an attack
how many migraines have aura and what are they often like?
- aura (1/3rd) -
- visual (most commothen sensory, speech, motor)
- progressive,
- 5-60mins,
- transient hemianopic disturbance or
-
a spreading scintillating scotoma
- is 1x visual field zig-zag/shimering.coloured lines/enlarging over 10-20mins –> symptoms “building up” over 20 mins is characteristic of migraine - much longer than would occur in a seizure
What are RFs/indications to migraine?
- FHx
- travel sickness
- cyclical vomiting as a child
- bad hangover after mininmal ETOH
for migraines there is criteria by who? what is the threshold?
criteria by the international headache society
need at least 5 attacks fulfilling criteria B-D
which means the headache attack lasts 4-72h, has 2 of the 4 given characteristics and includes N&V or photo/phonophobia
In the international heachache societies criteria for migraine are:
- A = at least 5 attacks fulfilling criteria B-D
- B = headahce attacks lasting 4-72 hours (untreated or unsuccessfully treated)
- C = ???
- D = during headache at least one of the following:
- nausea and/or vomiting (gastroparesis)
- photophobia and phonophobia
- E = not atrributed to another disorder
- e.g. hx and exam do not suggest a 2o headache disorder
- or if they do it is ruled out by appropiate Ix.
- or headache attacks do not occur for the first time in close temporal relation to the other disorder e.g. something happens but time-wise get an “unrelated” headache
What is C???
C = Headache has at least two of the following characteristics:
- unilateral location*
- pulsating quality (i.e., varying with the heartbeat)
- moderate or severe pain intensity
- aggravation by or causing avoidance of routine physical activity (e.g., walking or climbing stairs) [trigger/interruption of ADLs]
When does a migraine illness become chronic?
>15 days of headache a month
e.g. at least 8 proper migrane attacks (they last 4-72hrs)
When does a patient become eligible for migraine prophylaxis?
if >2 migraine days a month
What are the aims of migraine prophylaxis?
they are 5-HT antagonists e.g. inhibit 5HT reuptake from synaptic cleft
- to reduce attack frequency, severity & duration
- improve responsiveness to acute attack treatment
- prevent disability
Which drugs are used for migraine prophylaxis?
- Propanolol
- Topiramate 25-100mg
- Candesartan (1st or 2nd line)
- Amitriptyline (can cause drowsiness so take at night time)
What drug is recommended for paeds migraine control - no longer recommended for adults?
Pizotafen
(anti-histamine)
What are the SE of propanolol?
- premature ejaculation
- dizziness + fainting due to hypotension in young women
propanolol causes hypotension in young women = dizzines + fainting what other phrophylactiv medication for migraine also causes hypotension in young women?
candesartan
(ang 2 receptor blocker)
otherwise has good side effect profile = 1st or 2nd line
Topiramate is a ca, na inhib and gaba enhancer (AED). used in prophylaxis for migraines.
What are its side effects?
- teratrogenic possibility
- INTERACTS WITH POP
- conta-indicated in glaucoma and renal stones
- weight loss, parasthesia (hypocalcaemia) and confusion
(e.g. hyper calcaemia = stones, bones, abdominal groans, thrones & psychiatric overtones)
NB: the side effects of topiramate can put people off
While for prophylaxis/chronic migranes (>2 d vs >15d a month) you use 5-HT antagonists to inc in synaptic cleft. For acute managment of migraines you use 5-HT agonists.
What do you use for mild-moderate migranes?
stat (within 30mins)
NSAID/aspirin 800-1000mg + metoclopramide (for gastroparesis causing N&V)
What do you give in moderate to severe acute migraines?
Zolmitriptan 2.5mg + NSAID/paracetamol
(NSAID works TF ?inflammation pathophy of migraines)
(Triptan - oral or SC/nasal if nausea or a child)
2nd line: Non-oral metoclopramide or prochlorperazine (anti N&V) +/- non-oral NSAID or triptan - a 5HT receptor agonist (Rx of migraine)
NB: avoid opiates –> risk overuse headache
What are triptans?
5-HT1 agonists
take these straight after a headache comes on (not aura)
5HT vasoconstrict painfully dilated cerebral blood vessens and inhibit trigeminal nerves vasoactive neuropeptides and stop nociceptive NT.
What are the side effects and contraindications of triptans?
S/E of triptans are “triptan sensations” e.g. tingling, heat, tightness (e.g. throat and chest), heaviness, pressure
CI in pts w/hx of or significant RF’s for IHD or Cerebrovascular disease
What are the non-pharmacological treatmnets for migraine?
- Acupuncture is on the NHS now! - 10 sessions over 5-8wks
- Meditation
- Massage therapy - although pts head are often very sensitive to touch so not always recommended
- NOT CHIROPRACTOR as carotid dissection risk - not worth this risk for headache
Injections
-
greater occipital nerve injections from C1,2,3 behind ear, inject the most tender spot usually both
- –> lignocaine w.depomedreone (LA and steroid injected) –> 3 monthly injections
- supra-orbital nerve block if headaches only frontal
- botox for chronic migraine –> 3 monthly injections
Is there an association between migraine and stroke?
there is an association between migraine and stroke/cvs disease
however, no trial done to look at migraine prevention/treatment reducing incidence of stroke/CVD
Why is the COCP CI’d if migraine?
CI’d in migraine due to increased stroke risk (RR 8.72)
If COCP is CI’d if migraine due to increased stroke risk
is HRT safe?
yes, safe if migraines
but may worsen them
What painkillers are recommended for migraines in pregnancy?
- 1st line: Paracetamol 1g
- 2nd line: Aspirin 300mg or ibuprofen 400mg in T1/2
What should be given for mensturation associated migraines?
- Mefanamic acid or aspirin
- paracetamol & caffeine
- triptans also recommended acutely
What is the pathophysiology of a tension headache?
occurs in occipito-frontalis;
a tightening of aponeurosis between frontal & occipital belly
This headache
- lasts 30 mins to 7 days
- >2 of the following bilateral,
- not throbbing,
- mild or moderate,
- not aggravated by movement,
- no nausea or vomiting,
- one or neither of photophobia or phonophobia
What headache is this?
tension headache
what is the socrates for tension headache?
- S - bilateral
- O - chronic, usually at end of the day
- C - tight band, non-pulsatile (tightening of occipito-frontalis)
- R -
- A - scalp muscle tednerness
- T - chronic
- E - stress
- S - mild-to-moderate (able to continue with ADLs)
How do you manage tension hadaches acutely?
(aka a headache that lasts 30 mins to 7 days >2 of the following bilateral, not throbbing, mild or moderate, not aggravated by movement, no nausea or vomiting, one or neither of photophobia or phonophobia )
use caffeine with simple analgesia
First line: aspirin, paracetamol or nsaids
What is the prophylaxis to manage tension hadaches acutely?
(aka a headache that lasts 30 mins to 7 days >2 of the following bilateral, not throbbing, mild or moderate, not aggravated by movement, no nausea or vomiting, one or neither of photophobia or phonophobia )
up to 10 sessions of acupunture over 5-8 weeks (NICE
NB: low-dose amitryptyline is widely used in UK for tension type headache prophylaxis but 2012 NICE guidelines do not support this
(there was not enough evidence to recommend pharmacological prophylactic treatment for tension type headaches. The GDG conidered that pure tension type headache requiring prophylaxis is rare. Assessment is likely to uncover coexisting migraine symptomatology with a possible diagnosis of chronic migraine)
What is the name given to a group of conditions characterised by autonomic symptoms:
including cluster headache, paroxysmal hemcrania, short lived unilateral neualiform headache with conjunctival injection and tearing (SUNCT)
trigeminal autonomic cephalalgia
- group of conditions characterised by autonomic symptoms
autonomic symptoms include: ptsosis, tearing, conjunctival injection, flushing and rhinorrhoea, red/water eye, horner syndrome, salivataion
does cluster affect male or females most?
cluster heachage is the most common trigeminal autonomic caphalalgia (out of paraoxysmal hemicrania and SUNCT)
it affects M>F in 3:1
What headache do these symptomr describe?
- classically wakes patient up at 2am with severe pain
- (pacing around in pain; “suicide headache”),
- can be triggered by smells, paints, perfumes
Cluster headaches!
What is the socrates for cluster headache?
S - unilateral, around one eye (at time of cluster)
O - quick develops, 15m-3hr, 1-8x/day
C - sharp stabbing pain
R -
A - facial/eyelid swelling/redness, Horner’s syndrome, runny nose, watery eyes, conjunctival injection/ redness, restlessness/agitation
T - clusters lasting 4-12wks, clusters ~1yrly
E -
?alcohol may trigger, hyperbaric chamber relieves
S - severe (pt restless & agitated)
A cluster headache attack can develop within 15mins-3hrs and occur 1-8x per day and last 4-12wks annually of clusters.
What is the acute treatment for cluster headache?
-
100% oxygen
- (80% response rate within 15 minutes)
-
Subcutaneous triptan
- (e.g. 5-HT agonist: 75% response rate within 15 minutes; NNT is 2.5 patients)
A cluster headache attack can develop within 15mins-3hrs and occur 1-8x per day and last 4-12wks annually of clusters.
What is the prophylactic treatment for cluster headache?
-
Verapamil is the drug of choice (ECG as risk arrhythmia).
- [blocks vg Ca2+ channels –> dilates BV[
- There is also some evidence to support a tapering dose of prednisolone
NICE recommend seeking specialist advice from a neurologist if a patient develops cluster headaches with respect to neuroimaging
Besides acute rx w/ oxygen and triptan and verapamil as prophylaxis for cluster headache. What other options are there?
- greater occipital nerve injections
- occipital nerve stimulation (implantable device)
- Deep Brain Stimulation (posterior inferior hypothalamus)
What is paroxysmal hemicarnia?
(is with cluster headachesand SUNCT as part of trigenimal autonomic cephalgia (TACS) group of conditions characterised by autonomic symptoms.)
Paroxysmal hemicarnia is similar to cluster headaches but you get more frequent attacks, around 50 attacks per day (not 1-8x) and they are shorter being mins-hrs
paroxysmal hemicarnia as Dx criteria responds to indomethacin (NSAID)
What is short-lived unilateral neural inform headache with conjunctival injection and tearing (SUNCT)?
(is with cluster headaches and paroxysmal hemicarnia as part of trigenimal autonomic cephalgia (TACS) group of conditions characterised by autonomic symptoms.)
- with SUNCT you get 100x attacks a day! (hundreds of attacks a day)
- Very short duration, sharp stabbing (few secs)
- Milder autonomic symptoms
- Multiple cutaneous stimuli can trigger it
Rx: lamotrigine (or another anti-epileptic)
What headache type is this?
- 5-10 seconds,
- comes in one spot,
- pierces,
- very very severe when it happens,
- once or twice a day only
Primary stabbing headache
What headache type is this? What causes it?
- sudden, severe, stabbing-like pain, unilateral face which can be triggered by sensory stimulus e.g. brushing her hair
- pain is commonly evoked by light touch, including washing, shaving, smoking, talking, and brushing the teeth (trigger factors), or occurs spontaneously
- small areas in the nasolabial fold or chin may be par
Chiari I malformation & syringomyelia …
mayfieldclinic.com
ticularly susceptible to the precipitation of pain (trigger areas)
- unilateral disorder
- brief electric shock-like pains
- abrupt in onset and termination
- the pains usually remit for variable period
- limited to one or more divisions of the trigeminal nerve
Trigeminal neuralgia
Cause:
- idiopathic or compression of trigeminal roots
- by tumour or aneurysms/vascular problems,
- chronic meningeal inflammatinon,
- MS,
- VZ zoster,
- skull base malformation e.g. Chiari
If someone with trigeminal neuralgia normally experiences
sudden, severe, stabbing-like pain, unilateral face which can be triggered by sensory stimulus e.g. brushing her hair, unilateral disorder, brief electric shock-like pains, abrupt in onset and termination, limited to one or more divisions of the trigeminal nerve…
What are the red flags?
- sensory change,
- deafness,
- hx skin lesions,
- pain only in V1,
- optic neuritis (eye pain, vision loss)
- FHx MS,
- <40yrs
What will blood tests in trigeminal neuralgia show?
blood tests including ESR will be NORMAL!
What is the Rx for trigeminal neuralgia?
- 1st line: carbamazepine (Na channel blocker) –>
- failure to respond to treatment or atypical features should prompt neurology referral –>
- 2nd line: gabapentin
- Normal pressure hydrocepalus is an Abnormal condition of hydrocephalus, with ventricular dilatation,
- WITH normal CSF pressure. drainage.
What are the clinical signs for normal pressure hydrocephalus?
wet, wacky & wobbly: the clinical signs for normal pressure hydrocephalus
- Urinary incontinence
- Dementia
- Ataxia
- Normal pressure hydrocepalus is an Abnormal condition of hydrocephalus, with ventricular dilatation,
- WITH normal CSF pressure. drainage.
What are the Ix and Rx and prognosis for normal pressure hydrocephalus?
Investigations:
- CT Scan: hydrocephalus
Treatment:
- Intermittent LPs
- Ventriculperitoneal (VP) shunt –> relief of symptoms
Prognosis: Usually good.
A fertile female presnets with headache worse on coughing, nausea, CN6 (abducens) palsy, increased blind spot (papilloedema) and diplopia. Name and define this condition?
idiopathic intracranial hypertension also called pseudotumor cerebri
is raised ICP with papilloedema and no other features on imaging
+ get raised ICP headache signs e.g. worse on coughing/in morning e.g. after being laid flat/bending forward
NB: CN6/abducens palsy is often the only focal deficit
What are the risk factors for idiopathic intracranial hypertension / psuedotumour cerebri?
- obesity
- female sex
- pregnancy
- drugs: COCP, steroids, tetracycline, vitamin A, lithium
e.g. think an obese pregnant female (already 3 RF’s alone!!!) who was talking the COCP and is now taking steroids and has to be aware of lithium because shes pregnant
What investigations do you do into Idiopathic Intracranial Hypertension?(also called psuedotumour cerebri due to headaches and vision problems sx being similar to those caused by brain tumours)
- MRI Brain = Slit like ventricles = normal otherwise
- LP = opening pressure>20mmHg/high (normal = 10-20) = everything else NORMAL
as by definition of IIH = raised ICP w.papilloedema & no other features on imaging
What is the treatment for Idiopathic intracranial hypertension/psuedotumourcerebri?
conservative: Encourage weight loss and fluid restriction
Pharmacology: Acetazolamide (Carbonic anhydrase inhibitor decreases production of body fluids/in eye) or diuretic
3rd Line: Surgery including serial LPs or optic nerve sheath decompression (if visual complaints)
Spontaneous intracranial hypotension can cause headaches.
What is/causes spontaneous intracranial HYPOtension?
very rare cause of headaches that results from a CSF leak.
The leak is typically from the thoracic nerve root sleeves.
–> RF’s are connective tissue disorders such as marfans syndrome
–> it has a strong postural relationship with the headache generally being much worse UPRIGHT - therefore patients can be bed bound.
A contrast MRI shows patchy meningeal enhancement. How do you Rx this condition?
patchy meningeal enhancement is a sign of spontaeneous intracranial hypotension.
Rx: is usually conservative or epidural blood patch
[blood patch = uses autologous blood (from pt) in order to close one or many holes in the dura mater of the spinal cord, usually as a result of a previous lumbar puncture. The procedure can be used to relieve post dural puncture headaches caused by lumbar puncture.]
A patient >55y/o presents with headache, scalp tenderness, jaw claudication (tired @ end of meal), amaurosis fugax (transient vision loss, en route to blind).
What other symptoms may you expect with this condition?
What Ix do you do?
What Rx do you expect to work?
PMR symptoms (overlap condition) - stiffness in shoulders & hips esp. after resting and in mornings, weakness, fatigue, malaise, weight loss
–> this is temporal arateritis/GCA
Ix: superficial temporal artery biopsy (take several due to skip lesions) - gold standard
- ESR (LT marker of inflammation)
Rx: high dose prednisolone provides immediate relief - if not reconsider diagnosis
in temporal arteritis you should get immediate relief (of headache, scalp tenderness, jaw claudication etc) with high dose prednisolone. If not the you should reconsider the Dx.
What are the S/E of high dose prednisolone?
SE’s:
- immunosuppression,
- DM,
- osteoporosis,
- cushingoid,
- HTN,
- cataracts
