headaches Flashcards
what are primary headaches
disorders where there is no known secondary underlying pathology eg migraine
what are secondary headaches
underlying disease that is causing the headaches
- SOL
- Intracranial hypertension
- Vasculitis
what would you not want to miss on an examination?
- swollen optic discs
- papilloedema = raised ICL requiring emergency brain imaging
- visual field test: peripheral field loss and enlarged blind sports combined with headaches
- test eye movements, failure to abduct/adduct eye = nerve palsy
- abnormal plantar test
- ataxia and headache = lesion in posterior fossa of the brain
- white plaque on tongue = oral hairy leukoplakia
- purpuric rash, non-blancing = meningococcal septeicaemia (medical emergency, requires emergency AB)
what does a blanching rash all over suggest
livedo reticularis = antiphospholid AB syndrome or lupus
- at risk of venous clot in sinuses in brain
- also seen in vasculitis
what investigations could you do for headaches if neurological exam requires it?
CT scan, MRI, CSF monometer (measure ICP when performing LP), spinal fluid, neutrophils in CSF, biopsy (uncommon in headaches)
what do the colours of CSF mean?
clear = normal
yellow fluid = xanthochromic fluid = breakdown of blood in fluid = subarachnoid haemorrhage
what could biopsies indicate
high ESR, and inflammatory infiltrates in histology; common in GCA
what are the emergency symptoms of a headache
thunderclap onset acute onset with papilloedema acute onset with neurological signs head trauma / injury photophobia and nuchal rigidty reduced consciousness acute red eye / acute angle closure glaucoma new onset headache in 3rd trimester pregnancy
what is giant cell arteritis
inflammation of the lining of your arteries, most often in your head
what are the symptoms of GCA
jaw claudication, visual disturbance, temporal arterty is prominent and tender, diminished pulse, other cranial nerve palsies, limb claudication
what is the 2 week suspected cancer referral
-headache with features of raised ICP: wakes from sleep, valsalva manoeuvres, papilloedema, headache present upon waking and easing once up, tinnitus, transient visual loss when changing posture, vomiting, seizures
red flags for secondary headaches
- undifferentiated headache of recent origin and present for >8 weeks
- recurrent headaches triggered by exertion
- orthostatic headache (occurs in upright position, suggesting low CSF pressure)
- new onset headache in those >50, immunosuppressed/HIV
what is the type of pain in a migraine
throbbing pain lasting 4 hours -3 days, mostly unilateral, aggravated by physical activity
can be chronic or episodic
what are the associated symptoms with a migraine?
sensitivity to light, nausea, aura
what is aura
neurological feature preceding headache, may affect one eye only, sensory symptoms: unilateral parasthesia and numbness affecting hand and up the arm, spreading to face, lips and tongue.
visual symptoms = flickering lights, spots etc
20-30% suffer with it
lasts 5-60 minutes
what is a cluster headache
- more common in men
- most severe pain ever
- unilateral - sharp, boring, burning, throbbing or tightening side locked
what are the associated symptoms of cluster headaches
- on the same side as the headache:
- red or water eye
- nasal congestion or runny nose
- swollen eyelid
- forehead and facial sweating
- constricted pupil/drooping eyelid
- restlessness
how do you manage cluster headaches
12-15L O2, using non re-breathe mask
subcutaneous or nasal triptans acutely
prophylactic: verapamil, lithiuum, prednisolone (steroids but max 2 weeks)
how long does a cluster headache last and how often does it occur
15-180 minutes
episodic: 1 every other day to 8 per day, with remission >1 month
chronic: continous remission <1 month in a 12 month period
what is a tension-type headache
band-like ache, mostly featureless, can have mild photo or photobia but no nausea
not aggravated by ADL
how long do tension headaches last
30 mins - continous, >15 days per month for more than 3 months = chronic
what is a menstrual headache
migraine occuring between 2 days before and 3 days after first day of their period, for 2/3 consecutive cycles
what is a medication overuse headache
headaches have developed or worsened while they were taking triptans or opiods >10 days a month
or
paracetamol or NSAIDs >15 days a month
treatment of a tension headache?
- aspirin, paracetamol etc, no opioids
prophylactic: 10 sessions of acupuncture over 5-8 weeks
acute treatment of a migraine?
oral triptan, NSAID, 900mg aspirin (one of them, if not responding, combine NSAID and triptan for 1 dose)
anti-emetic in addition (bc migarines can cause gastric stasis leading to nausea) eg domperidone
if ineffective: non-oral metoclopramide, non-oral NSAID or triptan
prophylactic treatment of a migraine?
topiramate or propanolol
amitryptilline (blocks action of seretonin which is a vasoconstrictor)
riboflavin, 400mg OD, may be effective
what meds are contraindicated in migraine with aura?
the oral CP
if all other treatment is ineffective, what do you give for menstrual related migraine?
frovatriptan, 2.5mg BD or zolmitriptan on days migraine is expected
migraine in pregnancy treatment?
paracetamol, triptan or NSAID
how do you manage a medication overuse headache
stop taking all overused meds abruptly for 4-8 weeks , prophylactic treatment for underlying disorder
what is the pathology of migraines
vascular changes (aura - intracerebral vasoconstrictoin and hence headache due to reactive vasodilation)
arterial vasoconstriction induced by ergotamine = relieves migraine headaches
what triggers migraine attacks
relaxing after stress menstruation bc oestrogen decline jet lag oral cp (oestrogen in pills makes blood easier to clot) cheese - contains tyramine flickering lights
how do triptans work
strong agonist actions at seretonin 5-HT receptor, in arterial smooth muscle causing vasoconstriction
acts on 5-HT receptors in CNS
what is the second line treatment for migraines
ACE-I and ARBs or CCB bc calcium causes vasoconstriction
what is meningitis and what is the main triad of symptoms
medical emergency; inflammation of the meninges (dura, arachnoid and pia mater)
headache, neck stiffness and photophobia
causes of meningitis
irritation due to infection, blood or trauma
viral infection more common but bacterial - higher mortality
RF for meningitis
extremes of age - babies and young adults more commonly get bacterial meningitis
living in close proximity
immunosuppression eg asplenia
absence of vaccination history
impaired blood brain barrier
pathophys of bacterial meningitis
transmitted via droplet spread but requires frequent close contact
can spread from otitis media or URT in susceptible people
entry of bacteria into the CSF
meningococcal disease = neisseria mengitides
differential diagnoses for meningitis?
encephalitis (HSV causes this) - but causes confusion which meningitis doesn’t
subarachnoid haemorrhage
brain malignancy
sepsis from any source
associated symptoms of meningitis?
fever, non-blanching rash, kernig’s sign - stiffness of hamstring (cannot straighten leg when hip is flexed), brudzinki’s sign (neck stiffness causes patient hips and knees to flex when knee is flexed)
how do you examine for meningitis?
look for signs and symptoms fundoscopy for papillodema glass test neuro exam cognitive assessment
if a patient comes in to PRIMARY care with a non-blanching rash what do you do
give benzylpenicillin 1.2g IV before admitting
what investigations do you do for meningitis?
CSF sample blood cultures for organism serology for viruses throat swab for bacteria and virus urine pneumococcal antigen CT or MRI of brain to rule out signs of intracranial pathology
what organisms cause meningitis
meningococcus, pneumococcus, haemophilus influenzae, listeria monocytogenes
also HSV etc
how do you analyse CSF for meningitis?
high protein and low glc: in bacterial (protein leaks out of damaged BBB and bacteria eat glc)
WCC high, no RBC should be present
will be turbid
how do you first manage bacterial meningitis (that is non septic)
if raised ICP = call ICU
LP prior to antibiotics if possible
antibiotics: ceftriazone: 2g/12h, and add amoxicillin 2g/4h if >60 or immunocompromised
give dexamethasone 10mg/6h IV if meningism features
what is the prophylactic treatment for bacteria meningitis
give people in close contant ciprofloxacin 500mg 1 dose
how do you treat viral meningitis
supportive management only
if viral encephalitis suspected, give IV acoclovir
what are the types of intracranial SOLs
tumours; benign or malignant, primary or secondary
infection: presenting with brain abscess, subdural empyema, granuloma, parasitic
vascular: extradural, subdural, arachnoid and parenchymal haemorrhages
hydrocephalus
what causes hydrocephalus
non-communicating or obstructive eg tumours, cycts, intraventricular haemorrhage
communicating: meningitis or SAH
overproduction: choroid plexus papilloma
what are the symptoms of a primary brain tumour
raised ICP leads to:
- headache worse in morning
- vomiting
- blurring of vision
- deterioration of conscious level
- hypertension
- bradycardia
also: symptoms of neurological defecits and hormonal effects, and fatigue
what are the symtpoms associated with the frontal lobe
weakness, dysphagia, personality changes and dementia
what are the symptoms associated with the parietal lobe
sensory symptoms, dressing apraxia, visual field defects
what are the symptoms associated with the temporal and occipital lobes
dysphasia, visual field defects
how does ICP affect the posterior fossa
dysmetria, in-coordination, gait ataxia, cranial nerve palsies, tremors
how do you diagnose a brain tumour
CT, MRI, bloods, neuro exam and CSF
what is a glioma
commonest primary tumour, grade 1-4
rapidly life-threatening if grade 4
management is surgery, steroids, radio and chemo, symptomatic treatment
what is a meningioma
benign tumour of arachnoid cap cells
treatment is surgical excision
cause: trauma, radiation, oncogenic virus and hormones but rest still unclear
what is a vestibular schwannoma
benign tumour arising from nerve sheath of vestibular nerves
very slow growing
presents with ipsilateral hearing problems and tinnitius
affects 5,7th and lower CN
treatment - surgical excision if feasible otherwise radiosurgery
what is a subdural haematoma
bleeding from veins so haematoma in between dura and arachnoid = only gradually raises the ICP so delay between injury and presentation = even upto 9 months
signs and symptoms of SDH
fluctuating levels of consciousness, slow, sleepiness, headache, personality change and unsteadiness
seziures, localising neuro symptoms eg unequal pupils
what are the differentials
stroke, dementia, CNS masses
imaging of a SDH
crescent-shaped but inside the skull on MRI or CT
management of a SDH
reverse clotting abnormalities, larger ones>10mm or midline shift need craniotomy or burr hole washout
what is an extradural haemotoma
collection of blood in potential space between skull and dura mater
what are the causes of an extradural haematoma
traumatic skull fracture
laceration of the middle menigneal artery
how does an EDH present
lucid interval (detiororating consciousness after any head injury that intially presented no LOC)
severe headahce, vomiting, confusion and seizures follow
brisk reflexes
if bleeding continues, ipsilateral pupil dilates, coma etc
what are the tests for an EDH
CT (lens-shaped), broken skull may show up on x-ray
managing EDH
clot evacuation and ligation of BV
how to measure ICP
external ventricular drain with strain-gauge pressure transducer
fibre-optic intra-parenchymal transducer
airpouch balloon
general routine measures to control ICP
-head up tilt, 30-45 degrees
keep neck straight and avoid tight ETT taps
avoid hypotension = use cerebral vaspressors
maintain adequate sedation
maintain euvolaemia (proper amount of blood in body) to reduce cerebral oedema
maintain normal CO2
how do you manage an acute rise in ICP
heavy sedation CSF drainage osmotic therapy hyperventilation barbiturate therapy decompressice craniectomy
what is osmotic therapy
mannitol - osmotic diuretic reduces ICP by reducing brain volume; draws free water out of tissue into circulation so dehydrates brain parenchyma usual bolus dose 100ml effects are: 2-60 mins; last 4-24 hours may be rebound increase in ICP
what are barbiturates
phenobarbitone, thiopentone
reduce brain metabolism and cerebral blood flow - lowers ICP
