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Year 2- Neuroscience > Headaches > Flashcards

Headaches Flashcards

1
Q

what is headache and what are the overaching causes of it.

A
  • is a symptom
  • very common (half to three quarters of adults aged 18–65 years in the world have had headache in the last year and, among those individuals, 30% or more have reported migraine)

Causes:

> structural

> pharmacological (GTN for angina)

> psychological

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2
Q

Give some features and causes of acute onset single headache

A

Acute single headache

> Febrile illness, sinusitis

> First attack of migraine

> Following a head injury

> Subarachnoid haemorrhage

> Meningitis, tumour, drugs, toxins, stroke

> Thunderclap (sudden onset), low pressure

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3
Q

What are some red flags for headaches?

A

Onset

> thunderclap

> acute

> subacute

Meningism

> photophobia

> phonophobia

> stiff neck

> vomiting

Systemic symptoms

> fever

> rash

> weight loss

Neurological symptoms or focal signs

> visual loss

> confusion

> seizures

> hemiparesis

> double vision

> 3rd nerve palsy (ptosis)

> Horner syndrome (droopy, enopthalmos, constricted pupil)

> papilloedema

Orthostatic (better lying down)

Strictly unilateral

Mnemonic: NOS MOS

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4
Q

What is the pathology and presentation of a subarachnoid haemorrhage?

A
  • sudden generalised headache (blow to the back of the head)
  • meningism: stiff neck and photophobia

pathology/causes

  • most caused by ruptured aneurysm
  • some from arteriovenous malformations
  • some are unexplained
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5
Q

What is the treatment and investigations for a subarachnoid haemorrhage?

give relevant details

A

Around 50% are instantly fatal.

  • Vasospasms- may stop the leak
  • Early treatment:
  • Nimodipine and BP control
  • -High risk of a further bleed
  • Early neurosurgical assessment will confirm the bleed and establish the cause.

Investigations

  • CT brain
  • Lumbar puncture (RBC and xanthochromia) and MRA
  • angiogram
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6
Q

How are aneurysms treated?

A
  • clipped, wrapped in the past
  • Now filled with platinum coils
  • aneurysms sclerose and close up
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7
Q

What is the pathology of an acute intracerebral bleed?

A
  • causes fatal haemorrhage due to coning
  • bleeding fills the ventricles
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8
Q

What is the danger of an intracerebral bleed? ICP?

A

raised intracranial pressure (ICP)

  • brain can tolerate a growing mass to a certain point
  • when volume rises above a certain limit brain is no longer compliant
  • pressure rises dramatically
  • brain starts to seep into areas of weakness: coning

> brainstem death

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9
Q

What is papilledema?

A

swelling of the optic disc due to raised ICP

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10
Q

Describe how headache can arise from blood vessels.

give symptoms for each artery

A

Pathology in the large arteries of the neck; carotid and/or vertebral artery dissection.

> layers of tissue in arteries can split

> blood collects here

> turbulent flow in lumen

> common cause of headache

vertebral arteries:

  • occipital and neck pain

carotid arteries:

  • ‘phantom of the opera mask’ distribution
  • eye and forhead
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11
Q

Describe the pathology of arterial dissections. GIVE causes, investigations and treatment

A

Split in arterial wall, and creates a false lumen (less blood comes through the main lumen)

  • 20% of ischaemic strokes <45 years (young stroke).
  • Causes: Traumatic vs. Spontaneous (eg. EDS)
  • Diagnosis: MRI/MRA, Doppler, Angiography
  • Treatment: Aspirin or anticoagulation
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12
Q

Describe a subdural hemorrhage

A
  • common in elderly people due to falls and anticoagulation
  • chronic subdural blood will appear dark (begins to degrade)
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13
Q

Describe the pathology of temporal arteritis. give signs and symptoms and treatment.

A
  • most common in females over 55

Symptoms

  • constant unilateral headache, scalp tenderness and jaw claudication
  • 25% polymyalgia rheumatica-proximal muscle tenderness
  • involvement of the posterior ciliary arteries causes blindness

Signs

  • elevated ESR and CRP
  • temporal artery are usually inflamed and tortuous
  • visible on ultrasound
  • biopsy shows inflammation and Giant Cells.

treatment

  • high dose steroids (anti-inflammatory) and aspirin
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14
Q

Describe cerebral venous thrombosis.

Give causes, signs and symptoms.

A
  • thrombosis in dural venous sinus or cerebral vein

Signs and symptoms

  • unusual amount of headache due to raised ICP
  • non-territorial ischaemia “venous infarcts”
  • haemorrhage

Causes

  • thrombophilia
  • pregnancy
  • dehydration
  • Behcets disease (too much inflammation in ther vessels)
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15
Q

Describe the pathology of meningitis

A

Causes:

  • Viral - Coxsackie, ECHO, Mumps, EBV
  • Bacterial - Meningococci, Pneumococci, Haemophilus (vaccines)
  • Tuberculous
  • Fungal - Cryptococci
  • Granulomatous- Sarcoid, Lyme, Brucella, Behçet’s, Syphilis
  • Carcinomatous

Symptoms:

  • Malaise
  • Headache
  • Fever (septic)
  • Neck stiffness
  • Photophobia
  • Confusion
  • Alteration of consciousness
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16
Q

How is meningitis treated?

A

Antibiotics FIRST

then diagnose:

  • Blood and urine culture
  • Lumbar puncture

> Increased White Cell Count, decreased glucose

> Antigens

> Cytology

  • Bacterial Culture
  • CT or MRI Scan BEFORE (needle in lumbar could cause coning IF there’s ICP
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17
Q

What does herpes simplex encephalitis do to the brain?

A

classic haemorrhagic changes in the temporal lobe

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18
Q

How does bacterial meningitis alter the brain?

A
  • cerebral oedema
  • effacement of ventricles and sulci and inflamed meninges
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19
Q

What are the symptoms of sinusitis?

paranasal.

A

Symptoms:

  • Malaise, headache, fever.
  • Blocked nasal passages.
  • Loss of vocal resonance.
  • Anosmia.
  • Nasal or postnasal catarrh.
  • Local pain and tenderness
  • Frontal pain characteristically starts 1-2 hours after rising and clears up during the afternoon.
20
Q

Describe headaches caused by brain tumours

A
  • swelling around the tumour
  • generates a lot of pressure
  • eg Glioblastoma multiforme
21
Q

What is idiopathic intracranial hypertension.

Give causes, symptoms and treatments

A

Pseudotumor Cerebri

  • Often young obese women

Symptoms:

  • Headache, visual obscurations, diplopia, tinnitus
  • Papilloedema, +/- visual field loss

Causes:

Drugs: hormones, steroids, antibiotics, vitamin E

Treatment:

  • weight loss,
  • diuretics,
  • optic nerve sheath decompression,
  • lumboperitoneal shunt,
  • stenting of stenosed venous sinuses.
22
Q

Describe a low pressure headache

give treatment and causes

A

orthostatic

  • CSF leak due to tear in dura
  • Causes: Traumatic post lumbar puncture or spontaneous
  • Treatment: rehydration, caffeine, blood patch
23
Q

What is a Chiari malformation?

Give details and treatments

A

herniation of the cerebellum more than 5 mm beyond the margin of the foramen magnum

  • brain sits very low in the skull
  • cerebellar tonsils descend
  • descend further when patient cough and tug on the meninges causing cough headache

Treatment:

treat cough/cold,

operation- remodel base of skull by taking away some of the bone

24
Q

Describe the pathology of obstructive sleep apnoea

Give treatments

A

often characteristic physique, history of loud snoring and apnoeic spells

  • signs: hypoxia, CO2 retention, non-refreshing sleep
  • symptoms: depression, impotence, poor performance at work

Treatment:

  • require sleep study
  • nocturnal Non Invasive Ventilation
  • Surgery
25
Q

Describe trigeminal neuralgia

give treatments

A

Electric shock like pain in the distribution of a sensory nerve

Causes:

  • Often triggered by innocuous stimuli (chewing, touching teeth)
  • Any division of the trigeminal can be affected
  • Neurovascular conflict at the point of entry of the nerve into the pons
  • Can be a symptom of M.S.

Treatment:

- anti-convulsants

  • Carbamazepine
  • lamotrigine
  • gabapentin
  • Posterior fossa decompression.
26
Q

Describe atypical face pain

give epidemiology, symptoms and treatments

A
  • Most commonly in middle aged women

Symptoms:

  • Depressed or anxious.
  • Daily, constant, poorly localised deep aching or burning.
  • Facial or jaw bones, but may extend to the neck, ear or throat
  • Not lancinating (shooting)
  • Not conforming to the strict anatomical distribution of any nerve
  • No sensory loss
  • Pathology in teeth, temporomandibular joints, eye, nasopharynx and sinuses must be excluded

Treatment:

  • Unresponsive to conventional analgesics, opiates and nerve blocks
  • Mainstay of management tricyclics
27
Q

Describe post traumatic headaches

A
  • Of people admitted with head injury, headache is present in:
    > 36% at discharge
    > 24% at 6 months
    > 16% at 12 months
  • Correlates with previous history of headache
  • Unrelated to duration of post-traumatic amnesia

Depends on the nature of the head injury
> High in victims of car accidents
> Low in perpetrators of car accidents
> Low in sports injuries

Multiple mechanisms.

> Neck injury
> Scalp injury
> Vasodilation ? autonomic damage
> Depression - often delayed

28
Q

How is post traumatic headache treated?

A
  • Explanation that it will take years to go away
  • Prevent analgesic abuse (use pain modulators)
  • Non-steroidal anti-inflammatories: ibuprofen, naproxen
  • Tricyclic antidepressants: Amitriptyline (3-4 yrs)
29
Q

Describe cervical spondylosis

give presentation and treatments

A
  • Commonest cause of new headache in older patients

Presentation:

  • Usually bilateral
  • Occipital pain can radiate forwards to the frontal region
  • Steady pain
  • No nausea or vomiting
  • Worsened by moving the neck

Management:

  • Rest, deep heat, massage
  • Anti-inflammatory analgesics
  • Over-manipulation may be harmful
30
Q

summaise session review

A
31
Q

draw the 3 forms of attack of migraine and explain how they can present

A
32
Q

State the overall disorders (features) for migraine

A

Tendency for repeated attacks

it has triggers

  • You can become easily hungover
  • visual vertigo
  • motion sickness
33
Q

Explain the phases of migraine

A

Prodrome- include one or more of the following:

  • Changes in mood
  • Urination
  • fluid retention
  • food craving
  • yawning

Aura- can present visually, or as weakness, speech arrest and numbness

Headcahe- head and body pain, nausea and photophobia

Resolution- rest and sleep; with a sweer type of pain

Recovery - mood is disturbed during this perios and you can feel hungover and have food intolerance.

This takes around 48hr but can be varied

34
Q

what do you see when there’s positve and negative symptoms together in.migraine aura?

draw if possible

A

Scintillations and blindspot.

You also see expanding C’s with elemental visual distubances. It moves towards the periphery

35
Q

State the treatment options for acute attacks of migraine

T A S A T O

A
  • Triptan tablets (melts, nasal sprays)- synergise wiht NSAIDS for better therapeutic effects.
  • Aspirin/Ibuprofen AND anti-emetics like metoclopramide which stimulate peristalsis (they have gastric parersis)
  • Soluble preparations to aid absorption.
  • A short nap
  • Opiates given with caution
  • TMS- interrupts networks that can perpetuate migraines

HIT THE HEADACHE HARD AND FAST

36
Q

What are the lifestyle issues those with persistent migraine have?

A
  1. Sensitive head even in between attacks
  2. Over react ton any sort of stimulation. Hence they cannot ignore the world around them as it overstimulates them.
37
Q

What can people with migraine possibly do to avoid triggers, i.e. give me examples of triggers for migraine

A
  • dietary, environmental, hormonal, dehydration, stress
  • Avoid caffenated drinks
  • Dont skip meals and eat fresh food
  • Don’t oversleep or have late nights. Don’t overuse electronics
  • Analgesic abuse- avoid this
38
Q

What are the major prophylaxis of Migraine.

A
  • TCAs
  • Over the counter preparations like Mg or nicotinamide.
  • Beta-blockers
  • Serotonin antagonist- Pizotifen very effective.
  • CCBs
  • Anticonvulsants- valproate- very teratogenic
  • botox
  • Greater occipital nerve block
  • suppress ovulation using POP/implants- dont using OCP as oestrogen can cause headaches
39
Q

what condition do pts with migraine have to fulfil to have prophylaxis.

what is the latest migraine drug and what does it do?

A

Migraine for more than 14 times in a month

New drug: Erenumab (Injectable)

cuts number of migraines in half

it is a monoclonal antibody that disables calcitonin gene- related peptide or it’s receptor

Can be used for episodic migraine, chronic migraine orcluster headache.

40
Q

What happens in tension type headache and how can you treat it?

A

There are tight muscles around head and neck bilaterally, as though head is in a vice.

Treatment

  • NSAIDS preferred
  • Paracetamol
  • TCAs
  • SSRI- less effective
  • Biofeedback and relaxation unproven but anecdote seems to say it helps
41
Q

what is a cluster headache and describe it’s main features.

A

Severe ipsilateral pain that lasts for aroud 3hrs untreated. normally in the face- phantom of the opera

Classified as a trigeminal autonomic cephalgia.

It MUST HAVE atleast one of the following IPSILATERALLY:

  • Conjuctival redness, and /or redness
  • nasal congestion and/or rhinorrhea
  • Eyelid oedema.
42
Q

What are the associated features of the cluster headaches

A
  • Forehead and facial sweating
  • Miosis and /or ptosis
  • A sense of restlesness or agitation
  • symptoms appear diurnally
  • not associated with brain lesion on MRI
43
Q

what are the acute treatment for cluster headches

A
  • Inhaled 100% oxygen- it inhibits neuronal activation in the trigeminocervical complex.
  • Subcutaneous or Nasal Sumatriptan
44
Q

Give the preventative treatments for cluster headaches

A
  • Verapamil
  • Prednisolone
  • Lithium
  • Valproate
  • Gabapentin
  • Topiramate
  • Pizotifen
45
Q

what are the difference between migraine and clusters

A
46
Q

what are the causes of recurrent and triggered (pattern of) headaches

A

Recurrent headaches:

> Migraine

> Cluster headache

> Episodic tension headache

> Trigeminal or post-herpetic neuralgia

Triggered headache

> Coughing, straining, exertion

> Coitus

> Food and drink

47
Q

There are two progression of dull headaches, what are they and give possible causes

A

Dull headache, increasing in severity

> Usually benign

> Overuse of medication (e.g. codeine)

> Contraceptive pill, hormone replacement therapy

> Neck disease

> Temporal arteritis

> Benign intracranial hypertension

> Cerebral tumour

> Cerebral venous sinus thrombosis

Dull headache, unchanged over months

> Chronic tension headache

> Depressive, atypical facial pain

Year 2- Neuroscience (13 decks)

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