``` C hocolate H angovers O rgasms C heese/caffeine O CP L ie-ins A lcohol T ravel E xercise ``` - also bright lights and hormonal changes

Headaches Flashcards by H Jalisi

Tension headache summary card

Dull, tight band, gradual/acute, generalised/bilateral, lasts 3-4 hrs, moderate severity, analgesics help, neck/shoulder pain
= most common, everyday headache
= stress, disturbed sleep
= normal O/E
= keep a headache diary, avoid triggers, increase relaxation, simple analgesia (but beware of med-overuse headache)

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Cluster headache summary card

Neuro disorder of recurrent, severe, headaches on one side of head w/ cyclical pattern
= intense, sharp, penetrating pain, lasts 15 mins - 3 hrs, severely debilitating, unilateral, behind eye
= watery red eye, facial flushing, nasal congestion
= occurs in men, 20-40 yo, may present as partial Horner’s

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Migraine sx and assoc. sx

Unilateral, pulsating/throbbing, paroxysmal/comes on gradually, moderate to severe pain, being in dark room helps

Aura before (flashing lights, tingling), interferes w/ current activities, numbness, tingling, visual changes, photophobia, phonophobia, nausea, vomiting

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Migraine triggers

C hocolate
H angovers
O rgasms
C heese/caffeine
O CP
L ie-ins
A lcohol
T ravel
E xercise

also bright lights and hormonal changes

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Mx of migraines

Conservative
= avoid triggers, keep diary

Acute
= 1) NSAIDs/paracetamol
= 2) triptans

Preventative
= 1) propanolol or topimerate
= 2) amitriptyline

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Trigeminal neuralgia summary card

Facial pain syndrome in > 1 division of trigeminal nerve
= unilateral headache around trigeminal division, numbness, stabbing/shooting pain, paraosmal/lasts for seconds
= triggers: eating/chewing, washing face, burshing teeth, shaving face, talking
= assoc. with MS

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Meningitis presentation

Acute and severe headache, neck stiffness, photophobia, fever, rash, vomiting, seizures, shock!

Non-blanching petechial rash, Kernig’s sign (hips flexed, pain/resistance on passive knee extension), Bruzinski’s sign (flexion of hips and knees when neck is flexed)

RFs: closed communities/crowding, age < 5 or > 65

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Causes of meningitis

Babies = E. Coli, group B strep
Children = H. infulenzae, Strep. pneum.
Young adults = Neisseria meningitidis
Elderly = Strep. pneum., Listeria monocytogenes

Viral = HSV, VZV, HIV, enteroviruses

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Meningococcal disease

Rapid onset fever
Non-blanching rash
Malaise
Sx of sepsis +/- meningitis

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Ix of meningitis

LP for CSF analysis (contraindicated if increased ICP)
Blood cultures
CT head if neurodeficit/decreased consciousness before LP

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CSF analysis for meningitis

Bacterial
= cloudy CSF, increased neutrophils (polymorphic), low glucose, high protein
Viral
= clear CSF, increased lymphocytes (mononuclear), normal glucose, normal/high protein
TB
= fibrin web CSF, increased lymphocytes (mononuclear), low glucose, high protein

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Mx of meningitis

GP
= benzylpenicillin IM
= urgent referral to hospital

A&E
= broad spectrum Abx (ceftriaxone IV/ benzylpenicillin IM, acyclovir if viral)
= consider IV dexamethasone (secondary to reduce cerebral oedema

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Complications of meningitis

Hearing loss, sepsis, impaired mental state => meningoencephalitis, seizures

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Meningitis vs encephalitis

Meningitis
= meninges
= bacterial, viral, TB
= consciousness impaired

Encephalitis
= brain parenchyma
= usually viral
= consciousness altered

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Encephalitis presentation

Acute onset of febrile illness w/ behavioural, cognitive and psychological manifestations
= viral prodrome (rash, lymphadenoatphy)
= fever, headache
= altered mental state (memory disturbances, personality changes, psychiatric manifestations, impaired consciousness)
= FATAL if not treated

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Causes of encephalitis

Viral (most commonly)
= HSV1/2, CMV, EBV, HIV, measles

Non-viral
= legionella, Lyme disease, listeria, malaria, TB, bacterial meningitis

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Ix for encephalitis

LP
Bloods
EEG
CT/MRI
= shows oedemal hyperintense lesions
= bitemporal oedema associated w/ herpes encephalitis

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Presentation of raised ICP

Bilateral, gradual headache, thorbbing/bursting pain, worse in morning and when coughing/sneezing

Vomiting, altered GCS, seizures may also occur

O/E focal neuro sx, papilloedema*, Cushing’s reflex (increased sBP, bradycardia, irregular breathing), Cheyne-Stoke respiration

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Ix for raised ICP

URGENT CT head
?SOL (tumour, abscess, haemorrhage), hydrocephalus

LP is completely contraindicated!!!!
= can cause brainstem herniation

Extradural haemorrhage summary card

Blood pools between dura and bone
= head trauma hx, pterion, young (20-30 males), as bleeding continues leads to ipsilateral pupil dilation as CNIII externally compressed
= headache acute following lucid interval then becomes increasingly severe
= decreased GCS + sx of increased ICP
= urgent CT head shows lemon/lenticular shape that expands medially

Subdural haemorrhage summary card

Blood pools between dural and arachnoid covering of brain
= rupture of bridging veins in elderly and alcoholics
= RFs include head trauma, falls, elderly, alcoholics, anticoagulation
= gradual and continous headaches, sx of increased ICP, personality changes, confusion, fluctuating consciousness
= urgent CT head shows banana/crescent shap

Subarachnoic haemorrhage summary card

Bleed into subarachnoid space, likely due to rupture of saccular/berry aneurysm
= RFs include alcohol, smoking, hypertension*, polycystic kidney disease, Ehler-Danos syndrome
= very severe ‘thunderclap’ headache, occipital/diffuse, meningism, sx of increased ICP
= urgent non-contrast CT head most sensitive within 12 hours
= if CT clear then LP shows xanthochromia and oxyhaemoglobin from 12hrs from onset

Mx of subdural bleeds

ABCDE and neurosurgery referral:
Small (<10mm) + no significant neuro dysfunction
= observe
Large/significant neuro dysfunction
= Burr hole/craniotomy

CNS tumour presentations based on type

Vestibular schwanomma (benign tumour of CNVIII)
= progressive deafness

Frontal lobe tumour
= apathy, impaired intellect, personality disturbance

Right parietal lobe tumour
= left homonymous hemianopia, left sided hemiparesis and sensory loss

Sx of CNS tumours

``` Bilateral and gradual headaches w/ throbbing/bursting pain Focal neurological sx Worse in morning, coughing and sneezing Difficulty walking Seizures Personality changes Weakness FLAWS ```

RFs of CNS tumours

Hx of cancer, ionising radiation, FHx of cancer, neurofibromatosis, immunosuppression

Ix for CNS tumours

CT (quick) MRI (better resolution) CXR, CT thorax, abdo + pelvis to check for mets Biospy (definitive)

Red flags in headaches

SNOOP: S ystemic sx = fever, wt loss, malignancy, HIV, meningism, pregnancy N euro signs + sx = papilloedema, hemiparesis, hemisensory loss, diplopia, dysarthria O nset = thunderclap, worst headache of life O lder = new headache at age >/= 50 P rogression of existing headache = change in quality, frequency or location

How do you manage med-overuse headaches?

Pt must stop all meds Will be worse before it gets better Must advise pts to not take analgesiscs > 2 days/week in order to avoid these headaches

A 40-year-old man complains of a one-year history of 1 to 3 attacks per month of disabling pain over one temple, withnausea and sensitivity to light. He says that his headaches can be triggered by lack of sleep and made worse by physical exertion. He has tried ibuprofen and NSAIDs but they don’t seem to have an effect and the headaches are being debilitating. What’s the next most appropriate step in his management? ``` A Codeine B Diclofenac C Sumatriptan D Topiramate E Amitriptyline ```

C Sumatriptan

A 19-year old medical student presentEd to A & E with headache, fever, and neck stiffness. Once raised ICP is excluded a lumbar puncture is performed and CSF analysis reveals the following: High polymorphs, low glucose and high protein Given the most likely diagnosis, which is the most likely causative organism? ``` A Listeria monocytogenes B HIV C HSV D Neisseria meningitidis E VZV ```

D Neisseria meningitidis

An older man with a longstanding history of AF on anticoagulation with warfarin is brought into A & E by his carer, who is concerned about the patient's confusion at home. The carer describes frequent falls over the last several months. On examination, he has a right-sided pronator drift and is weaker on his right side. His mental status testing reveals poor concentration. ``` What is the most likely cause of his symptoms? A Stroke B Subdural haemorrhage C Alzheimer’s disease D Encephalitis E Parkinson’s disease ```

B Subdural haemorrhage

A 33-year-old woman attends her six-month follow-up appointment for headache. They are migrainous in nature but whereas she used to have them every few months, over the last three months she has experienced a chronic daily headache. She takes co-codamol qds and ibuprofen tds. ``` What is the best medical management? A. Stop all medication B. Start paracetamol C. Start sumatriptan D. Start propranolol E. Continue current medication ```

A. Stop all medication

Plutarch is a 77-year-old male who has come in with a right sided headache. This started yesterday morning and have been getting progressively worse. His memory is a little off because of his dementia, but he says there is a possibility of trauma. His shoulders and neck also feel a little stiff. On examination, there is pain on palpation of the right forehead. ``` A. Intracranial space-occupying lesions B. Meningitis C. Subarachnoid haemorrhage D. Subdural haemorrhage E. Temporal arteritis ```

E. Temporal arteritis

Euclid is a 19-year-old male currently studying Maths at university. He has been very unwell for the last few days with fever and headache and admits to becoming a little confused lately. He is very anxious about his upcoming exams. He has been taking caffeine pills to help him with revision, however this has affected his sleep and for the last couple of nights he has developed a stiff neck. ``` A. Medication overuse headache B. Meningitis C. Migraine D. Tension headache E. Sinusitis ```

B. Meningitis

a Aphrodite, a 19-year-old female sex-worker presents to A&E with a sudden onset headache that is the worst pain she has ever experienced. She occasionally gets mild headaches after sex and has been given some medication by her GP for his. She has some neck stiffness and refuses to open her eyes wide or allow them to be examined. ``` A. Acute glaucoma B. Meningitis C. Migraine D. Subarachnoid haemorrhage E. Trigeminal neuralgia ```

D. Subarachnoid haemorrhage

Leonidas, a 24-year-old male, was fencing and suffered an injury to the head when his rival, Xerxes hit him on the head with his shield. Leonidas recovered quickly and was able to continue to fight for the next 20 minutes. However he quickly developed an excruciating headache, started to lose consciousness and had to stop the fight to go to the nearest A&E. He has had a blocked nose for the last week. ``` A. Epidural haemorrhage B. Intraventricular haemorrhage C. Meningitis D. Subarachnoid haemorrhage E. Subdural haemorrhage ```

A. Epidural haemorrhage epidural = extradural

Homer, a 45-year-old male has had excruciating headaches for the last month. He gets them about 5 times a week and notices his eyes watering. He had a similar episode 6 months ago. They are very disruptive to his poetry. ``` A. Cluster headache B. Intracranial space-occupying lesion C. Migraine D. Subarachnoid haemorrhage E. Meningitis ```

A. Cluster headache

Andromeda, a 32-year-old female presents with recurrent headaches. They are severe, on the right side of her head and often continue for the rest of the day. Before the headaches start, she gets tingling in her arms, and when the headaches start she goes to bed. She is worried they might affect her relationship with her new boyfriend. ``` A. Cluster headache B. Intracranial space-occupying lesion C. Medication overuse D. Migraine E. Tension headache ```

D. Migraine

Helen is a 40-year-old woman with a history of multiple sclerosis. She has developed a headache over the last couple of days. She has travelled the world and rarely had headaches in the past. She has stopped eating, as chewing simply makes her feel worse. ``` A. Meningitis B. Migraine C. Temporal arteritis D. Tension headache E. Trigeminal neuralgia ```

E. Trigeminal neuralgia

Zeus, a 56-year-old man has been complaining of a headache that has progressively worsened over the past three weeks. He has tried taking simple analgesia, but the pain does not seem to go away. On examination he has weakness in his lower right limb. What is the most likely diagnosis? ``` A. CNS Tumour B. Migraine C. Cluster Headache D. Subarachnoid Haemorrhage E. Temporal Arteritis ```

A. CNS Tumour

70-year-old Herodotus is brought in by his daughter to the GP. Over the last week he has developed a headache which lasts most of the day and rarely goes. He lives with his daughter and son-in-law as he is prone to falls due to his recent left hip replacement. The daughter also mentions that his father’s behavior has changed lately and tends to exaggerate some of his stories. What do you think is the most important step in your management plan? ``` A. MRI scan B. Routine CT scan C. Sumatriptan + NSAIDs D. Urgent CT scan E. Watchful waiting ```

D. Urgent CT scan

Alexander, known to his mates as Alex the Great, is a 32-year-old soldier who has just returned from a tour in Iran. He tells you that he has been getting throbbing bilateral head pain and puts this down to lack of sleep. As a general, he has multiple reports to write and is finding this difficult with his four friends constantly bickering about one thing or the other. He hasn’t tried any medication and asks that you prescribe some sleeping pills. What is the most appropriate management? ``` A. Diazepam B. Codeine C. NSAIDs D. Topiramate E. Refer to A&E ```

C. NSAIDs

Pythagoras is a 40-year-old man who suffers from headaches. 3 weeks ago he was prescribed ibuprofen and has taken it religiously. Initially these worked well, however now the headaches have returned and are worse than ever. He is very angry and does not think you are taking the right angle towards managing his issue. What is the next course of management? ``` A. Antibiotics B. Add a β-blocker C. Refer to A&E D. Switch medication to carbamazepine E. Ask to stop ibuprofen and see in 2 weeks ```

E. Ask to stop ibuprofen and see in 2 weeks

Hippocrates is a 71-year-old homeopath who presents with a left sided headache which came on yesterday morning. He tried to treat it with a clever paste made of garlic, vinegar and honey. When he applied the paste he was in great pain, and so believed that his remedy was working. However, his skeptical son told him to see “another doctor” for treatment. What is the most important next step? A. Prescribe prednisolone and refer patient to A&E B. Prescribe sumatriptan and send home C. Refer to A&E for urgent CT scan D. Refer to A&E for urgent non-contrast CT scan E. Refer to A&E for MRI

A. Prescribe prednisolone and refer patient to A&E