Headaches Flashcards
Primary headaches (4)
Migraine*
Tension*
Cluster
Trigeminal neuralgia
Secondary headaches (7)
Meningitis* Encephalitis Haemorrhages Extradural Subdural* Subarachnoid CNS tumours
Age and gender of tension headaches
Young females more commonly
Site of tension headaches
Generalised, Bilateral
Onset of tension headaches
Gradual or acute onset
Character of tension headaches
Dull – “tight band”
Time it lasts of tension headaches
Lasts 3-4 hours
Alleviating factors of tension headaches
E: Analgesics help
§§
Radiation of tension headaches
Neck/shoulders
RF of tension headaches
Stress
Disturbed sleep
Mx of tension headaches
Conservative: Headache diaries (avoid triggers, relaxation) Medical: Simple analgesia (paracetamol, ibuprofen)
Epidemiology of migraine
Young adult females
Site of migraine
Unilateral
Onset of migraine
Paroxysmal, comes on gradually
Character of migraine
Pulsating/throbbing
Timing of migraine
4 – 72h
Exacerbating factors of migraine (3)
Physical activity/stress, noise, light
Alleviating factors of migraine
lying in a quiet, dark room
Associated symptoms of migraine (8)
Aura: flashing lights, tingling Photophobia, phonophobia Nausea, vomiting Visual changes Tingling Numbness Migraine interferes with current activities
RF of migraine
FHx
How long does a migraine prodrome last
Can last for days
Migraine Mx (conservative, medical 4, preventative 3)
① Conservative: Headache diary, avoid triggers
②Acute Medical
Paracetamol, Ibuprofen, NSAIDs
Triptans
③ Preventative
Propranolol (BB) or topiramate (antiepileptic)
Amitriptyline (antidepressant)
Site of cluster headache
S: UNILATERAL, behind the eye
Onset of cluster headache
: Acute onset, CYCLICAL PATTERN,
Same time each day
Character of cluster headache
C: intense, sharp, penetrating
Timing of cluster headache
T: 15 minutes – 3 hours
Exacerbating factors of cluster headache
E: triggered by alcohol & strong smells
Severity of cluster headache
S: Severe – Can be disabling and cause suicidal thoughts
Associated symptoms of cluster headache (3)
Watery, red eye
Facial flushing
Nasal congestion
Examination of cluster headache
Partial Horners (ptosis, miosis)
What is trigeminal neuralgia associated with
MS
Site of trigeminal neuralgia
S: Unilateral, along the trigeminal division
Onset of trigeminal neuralgia
O: paroxysmal, lasting for seconds
Character of trigeminal neuralgia
C: stabbing, shooting
Exacerbating factors of trigeminal neuralgia
E: brushing teeth, speaking, shaving, talking
Associated symptoms of trigeminal neuralgia
Numbness
What is the common cause of meningitis in babies (2)
E. Coli, Group B Strep
What is the common cause of meningitis in children (2)
H. influenzae,
Strep. pneumoniae
What is the common cause of meningitis in adults
Neisseria meningitidis
What is the common cause of meningitis in elderly (2)
Strep pneumoniae,
Listeria monocytogenes
What does a non-blanching rash suggest
Meningococcal disease
Associated symptoms of meningitis (6)
Meningism Neck stiffness Photophobia Fever Rash Vomiting Seizures
3 signs of meningitis on examination
Kernig’s Sign:
Brudzinski’ s sign
Petechial/purpuric Rash
(non-blanching)
What is Kernigs sign
with the hips flexed, there is pain/resistance on passive knee extension - this is due to severe stiffness in the hasmstrings
What is Brudzinskis sign
- flexion of the hips and knees when the neck is flexed - this is due to severe neck stiffness
Contraindications for lumbar puncture (3)
↑ ICP is a CONTRAINDICATION for LP
CT-head before LP if: neurological deficit or ↓ Consciousness
CSF bacterial: Appearance Cells Glucose Protein
Bacterial Turbid (Cloudy) ↑ neutrophils (polymorphs) ↓ ↑
CSF viral: Appearance Cells (which type) Glucose Protein
Clear ↑ lymphocytes (mononuclear) Normal Normal or ↑
CSF TB: Appearance Cells (which type) Glucose Protein
TB Fibrin web ↑ lymphocytes (mononuclear) ↓ ↑
Meningitis Mx at GP and then at A&E
at GP: benzylpenicillin IM & URGENT REFERAL TO THE HOSPITAL
at A & E: Broad spectrum antibiotics (ceftriaxone IV, benzylpenicillin IM, acyclovir if viral)
Targeted antibiotic Tx depending on sensitivities.
Consider IV dexamethasone
Why use dexamethasone in meningitis
Prevent cerebral oedema
reduces complications such as cerebral oedema
Complications of meningitis (3)
Hearing loss (most common)
Sepsis
Impaired mental status
Usual causes of encephalitis (5)
Usually viral: HSV1-2, CMV, EBV, HIV, measles
Non-usual causes of encephalitis (6)
bacterial meningitis, TB, malaria, listeria, Lyme disease, legionella
Epidemiology of encephalitis
Affects mostly the extremes of age
<1
>65
Symptoms of encephalitis (4)
Viral prodrome Fever Headache ALTERED MENTAL STATE (Memory disturbances Personality changes Psychiatric manifestations Impaired consciousness)
Ix for encephalitis (4)
LP
Bloods
EEG
CT/MRI (oedema/hyperintense lesions
Meningitis vs Encephalitis:
Location
Aetiology
Major symptomatic difference
MENINGITIS
Meninges
Bacterial, Viral, TB
Usually unimpaired
ENCEPHALITIS
Brain Parenchyma
Usually viral
Usually altered
4 causes of raised ICP
SOL (tumour, abscess, haemorrhage)
Hydrocephalus
Raised ICP headache (site onset character timing and exacerbating factors)
S: Bilateral O: Gradual C: throbbing/bursting T: worse in the morning E: coughing, sneezing
Associated symptoms of raised ICP (3)
Associated symptoms:
Vomiting
Altered GCS
Seizures
What is Cushing’s triad and what is it seen in
Raised ICP
↑SBP
Irregular breathing
Bradycardia
Signs of raised ICP (4)
Focal neurological symptoms Papilloedema Cushing’s reflex → Cushing’s triad ↑SBP Irregular breathing Bradycardia Cheyne-stokes respiration
What is Cheynes Stokes respiration
: abnormal pattern of breathing characterised by progressively deeper and sometimes faster breathing followed by a gradual decrease that results in apnoea
Aetiology of extradural haemorrhage
Head trauma
Epidemiology of extradural haemorrhage
Young males
Extradural haemorrhage onset
Acute following a lucid interval
Associated symptoms of extradural haemorrhage (5)
N & V, confusion, seizure, paresis, brainstem herniation
Ix for extradural haemorrhage
Urgent Non-contrast CT head-scan (lemon shape)
MRI
Massive sign of extradural haemorrhage from trauma
Continued bleeding causes ipsilateral pupil dilatation due to haemorrhage compressing parasympathetic nerve fibres
Aetiology of subdural haemorrhage
Rupture of the bridging veins (susceptible in elderly and alcoholics, due to brain atrophy)
What is a subdural haemorrhage bleeding between
Dura and arachnoid mater
RF of subdural haemorrhage (4)
Head trauma & falls (often following minor trauma up to 9 weeks before which patients have forgotten)
Old age
Alcoholics
Anticoagulation
Onset of subdural haemorrhage
Gradual
Timing of subdural haemorrhage
Continuing
Classifications of subdural haemorrhages (3)
Acute: Within 72 hours (younger patients, trauma)
Subacute: 3-20 days (worsening headache, elderly)
Chronic: After 3 weeks (headache, confusion)
Associated symptoms of a subdural haemorrhage (4)
Fluctuating consciousness
Confusion
Personality changes
Symptoms of ↑ ICP
Shape of lesion in a extradural haemorrhage
Lemon
Shape of lesion in a subdural haemorrhage
Banana
Mx of subdural haemorrhage
ABCDE & NEUROSURGERY REFERAL
Depends on size & presentation
If small (<10mm) and no significant neurological dysfunction: observe
If large or significant neurological dysfunction: Burr hole or craniotomy
SAH aetiology
Most commonly due to rupture of a saccular aneurysm
SAH site
Occipital or diffuse
SAH onset
Sudden “thunderclap”
SAH character
Like being hit with a ball
Worst headache ever
SAH timing
Continuous
SAH severity
Very severe, maximum intensity in minutes
Associated symptoms with SAH (2)
Meningism
Symptoms of ↑ ICP
RF of SAH (4)
Polycystic kidney disease
Alcohol, smoking, HTN
Ix for SAH
Urgent CT head within 12 hours
LP after 12 hours
What cells do most brain tumours arise from
Glial cells
Site of headache from brain tumour
Bilateral
Onset of headache from brain tumour
Gradual
Character of headache from brain tumour
Throbbing bursting
Timing of headache from brain tumour
Worse in morning
Exacerbating factors of headache from brain tumour
Coughing sneezing
Associated symptoms of brain tumours (6)
FLAWS Focal neurological signs Weakness Difficulty walking Seizures Personality changes
RF of brain tumours (2)
History of cancer
FHx of cancer
Symptoms of vestibular schwannoma
Progressive deafness
Symptoms of right parietal lobe tumour (3)
L homonymous
Hemianopia, L sided hemiparesis and sensory
loss
Symptoms of frontal lobe tumour (3)
personality disturbance,
apathy, impaired intellect
Ix for brain tumour (4)
CT (quicker)
MRI (better resolution)
CXR, CT thorax, abdo & pelvis to check for metastases
Biopsy (definitive)
