Headaches Flashcards
1
Q
What is a good 3 step approach for taking a history of presenting complaint?
A
- ask questions about the symptoms, using SOCRATES
- ask questions about associated symptoms (symptoms review)
- ask questions about risk factors
2
Q
What is the difference between primary and secondary headaches?
A
Primary headaches:
- there is NO clear underlying cause
- it is thought to be due to pain-sensitive structures in the head (nerves, muscles, vasculature) changing the way the brain processes external stimuli
Secondary headaches:
- the headache has a clear underlying cause
3
Q
What are the 3 different types of primary headaches?
A
- tension headaches
- cluster headaches
- migraine
4
Q
What is the definition of a tension headache?
Why does it occur?
A
the most common type of headache, which is considered a normal, everyday headache
it is not known why it occurs, but it is thought to be due to increased muscle contraction
5
Q
Who tends to be affected by tension headaches?
A
it tends to affect younger people
more commonly affects females
6
Q
What are the symptoms (SOCRATES) for a tension headache?
A
- S - generalised, bilateral
- O - gradual or acute onset
- C - dull - feels like a “tight band” across the forehead
- R - neck & shoulders
- T - lasts for 3-4 hours
- A - analgesics help to relieve pain
- S - moderate severity
there are NO associated symptoms
7
Q
What are the 2 major risk factors for a tension headache?
A
- stress
- disturbed sleep
8
Q
What is involved in the examination and investigations for tension headache?
A
- examination should be normal
- no investigations are carried out
9
Q
What is involved in the conservative and medical management for tension headache?
What must special attention be pain to?
A
- conservative management involves headache diaries to find ways to relax and avoid triggers
- medical management involves simple analgesia (paracetamol, ibuprofen)
- be aware of medication-overuse headaches
- taking too many analgesics can also lead to headache
10
Q
What is the definition of migraine?
What causes it?
A
migraine is a chronic condition that causes attacks of headaches
it is caused by inflammation of the trigeminal nerve, which changes the way in which the brain processes stimuli
e.g. the brain does not usually pay attention to light / sound, but now they are perceived differently as pain
11
Q
Who is more likely to be affected by migraine?
A
- females are 3x more likely to be affected
- more common in young adult females
12
Q
What acronym can be used to remember the triggers of migraine?
A
the acronym CHOCOLATE can be used:
- C - chocolate
- H - hangovers (alcohol, particularly wine)
- O - orgasms (hormonal changes)
- C - cheese / caffeine
- O - oral contraceptives
- L - lack of sleep
- A - alcohol
- T - travel
- E - exercise
also bright lights and stress
13
Q
What are the symptoms of migraine (SOCRATES)?
A
- S - unilateral
- O - paroxysmal, comes on gradually
- C - pulsating / throbbing
- T - lasts for 4 - 72 hours
- E - physical activity / stress, noise, light
- S - moderate to severe (interferes with everyday activity)
- Relieving factors are lying in a quiet, dark room
14
Q
What are the associated symptoms for migraine?
A
- aura - flashing lights, tingling
- photophobia & phonophobia
- nausea & vomiting
- visual changes
- tingling
- numbness
15
Q
What are the risk factors for migraine?
How is it diagnosed?
A
- the only risk factor is family history
- it is a clinical diagnosis and investigations are not usually conducted
- investigations are only performed if something more sinister is suspected
16
Q
What are the 3 stages in the management of migraine?
A
1 - Conservative:
- headache diary (relaxation techniques, good diet & sleep)
- avoiding triggers
2 - Acute Medical Treatment:
- 1 - paracetamol, ibuprofen, NSAIDs
- 2 - triptans are used if simple analgesics are not effective
3 - Preventative Treatments:
- 1 - propanolol (beta-blocker) or topiramate (antiepileptic)
- 2 - amitriptyline (antidepressant) if ^ does not work
17
Q
Why is preventative treatment used for migraines?
What medication must be avoided in migraines?
A
preventative treatment is used for recurrent attacks that interfere with everyday activities
opiates (such as codeine) should be avoided in migraines as they cause dependence
18
Q
What is the definition of a cluster headache?
A
a neurological disorder characterised by recurrent, severe headaches on one side of the head, which occur in a cyclical pattern
the headache comes on at the same time each day and is felt in the same place (usually behind the eye)
the person is then well for couple of months before another cycle of headaches begins
19
Q
Who tends to be affected by cluster headaches?
A
- more common in men
- tends to affect them between the ages of 20 and 40
20
Q
What are the symptoms of cluster headaches (SOCRATES)?
A
- S - unilateral, behind the eye
- O - acute onset, cyclical pattern, same time each day
- C - intense, sharp, penetrating
- T - lasts from 15 minutes to 3 hours
- E - triggered by alcohol and strong smells
- S - severe - can be disabling
21
Q
What are the associated symptoms with cluster headaches?
Why do these occur?
A
there is activation of the hypothalamus, trigeminal nerve and autonomic nervous system
the associated symptoms are related to ANS activation
- watery, red eye
- facial flushing
- nasal congestion
- partial Horner’s (ptosis, miosis)
22
Q
Where is the pain concentrated in each type of primary headache?
A
Cluster headaches:
- pain is in or around one eye
Tension headaches:
- pain is like a band squeezing the head
Migraine:
- pain, nausea & visual changes on one side of the head
23
Q
What further investigations are conducted for primary headaches?
A
no further investigations are carried out for primary headaches as there is no clear underlying cause
24
Q
What are the 6 different types of secondary headaches?
A
- trigeminal neuralgia
- meningitis
- encephalitis
- raised intracranial pressure (ICP)
- bleeds
- CNS tumours
25
What is the definition of trigeminal neuralgia?
What causes it and what condition is it associated with?
**facial pain syndrome** in the distribution of **_\>1 divisions_** of the **_trigeminal nerve_**
it is caused by **_compression_ of the trigeminal nerve** by a **loop or _artery or vein_**
it is associated with **_MS_**
26
27
What can trigger trigeminal neuralgia?
it is triggered by anything that can compress the trigeminal nerve, such as:
* cleaning teeth
* combing hair
* talking
* eating
* shaving
28
What are the symptoms of trigeminal neuralgia (SOCRATES)?
What investigations should be carried out?
* S - **unilateral**, along the **trigeminal division**
* O - **paroxysmal**, lasting for **seconds**
* C - **stabbing, shooting**
* A - associated symptoms are **numbness**
* E - brushing teeth, speaking, shaving, talking
there are **no investigations** for trigeminal neuralgia
29
What is the definition of meningitis?
What can cause it?
meningitis is **_inflammation of the meninges_**, which can be life threatening
it can be caused by **bacteria**, **viruses** or **TB**
30
What bacteria tend to cause bacterial meningitis in different age groups?
***_Babies:_***
* *E. coli*
* Group B streptococci
***_Children:_***
* *H. influenzae*
* *Strep. pneumoniae*
***_Adolescents / young adults:_***
* *Neisseria meningitidis*
***_Elderly:_***
* *Strep pneumoniae*
* *Listeria monocytogenes*
31
32
What viruses can cause meningitis?
What is more common and severe, bacterial or viral meningitis?
* enteroviruses
* herpes simplex virus
* varicella zoster virus
* HIV
* **viral meningitis** is **_MORE COMMON_** and **_LESS SEVERE_** than bacterial meningitis
33
What are the symptoms of meningitis?
***_Headache:_***
* O - **acute** onset
* S - **severe** pain
***_Associated symptoms:_***
* **meningism**
* fever
* rash
* vomiting
* seizures
34
What is meant by meningism?
this is a clinical syndrome of **_headache_**, **_neck stiffness_** and **_photophobia_**
it can be caused by other things, as well as meningitis
35
What are the risk factors for meningitis?
* it is transmitted through respiratory secretions so living in **_close communities_** / **_crowding_** is a risk
* age **_\<5_** and age **_\>65_** have more severe symptoms
36
What 2 signs will be present on examination for meningitis?
**_Kernig's sign:_**
* there is an inability to straighten the leg when the hip is flexed to 90 degrees
**_Brudzinski's sign:_**
* the patient's hips and knees will flex when the neck is passively flexed
37
What type of rash might be present in meningitis?
a **_non-blanching petechial rash_**
when you press on this rash, it should not go white
38
What is involved in the investigations for meningitis?
**_CSF analysis_** is the most important investigation in meningitis
this is acheived through **_lumbar puncture_**
39
What is the main contraindication for lumbar puncture?
**_high intracranial pressure (ICP)_** is a contraindication for lumbar puncture
a **_CT-head_** should be done before LP to look for **neurological deficit / reduced consciousness** to make sure it is safe to continue with LP
40
What is the appearance, cells, glucose and protein like in bacterial, viral and TB CSF samples in meningitis?
***_Bacterial:_***
* CSF appears **turbid (cloudy)**
* increased **neutrophils**
* **reduced glucose**
* increased protein
***_Viral:_***
* CSF appears **clear**
* increased **lymphocytes**
* glucose is normal
* protein is normal or raised
***_TB:_***
* appears like a **fibrin web**
* increased **lymphocytes**
* reduced glucose
* increased protein
41
Why is glucose low in bacterial meningitis CSF samples?
glucose is low in bacterial infection as the bacteria in the CSF use the glucose for their own metabolism, whereas viruses do not
42
What is involved in the management of meningitis at the GP and in the hospital?
***_at the GP:_***
* **_IM benzylpenicillin_** is given and urgent referral to the hospital
***_at A&E:_***
* **_broad spectrum antibiotics_** are given
* ceftriaxone IV
* benzylpenicillin IM
* acyclovir if infection is viral
* **targeted antibiotics** are then given depending on sensitivities
* **_IV dexamethasone_** is considered
* this is a steroid that **reduces the inflammation** that occurs in the meninges
* it can reduce the risk of hearing loss
43
What are the possible complications of meningitis?
* **hearing loss** (this is the most common)
* **sepsis**
* **impaired mental status**
44
What is the definition of encephalitis?
What causes it?
**_inflammation of the brain parenchyma_** that can be fatal
* it is usually **_viral_**
* HSV 1-2
* CMV
* EBV
* HIV
* measles
* there are also non-viral causes
* bacterial meningitis
* TB
* malaria
* listeria
* Lyme disease
* legionella
45
Who tends to be affected by encephalitis?
it affects mostly the extremes of age - **_\<1_** and **_\>65_**
46
What is the presentation of encephalitis like?
What symptoms are present?
it is an **acute onset febrile illness** with **_behavioural_**, **_cognitive_** and **_psychiatric manifestations_**
symptoms include:
* viral prodrome
* fever
* headache
* **altered mental state**
* memory disturbances
* personality changes
* psychiatric manifestations
* impaired consciousness
47
What are the investigations for encephalitis?
* **lumbar puncture** is the investigation of choice
* bloods
* EEG
* CT / MRI to identify **oedema / hyperintense lesions** in the **temporal lobes**
48
How is location, aetiology and consciousness different in meningitis and encephalitis?
49
What is the definition of raised intracranial pressure?
What causes it?
this is an **_increase in the pressure of the skull_**
it is caused by:
* **_space occupying lesions_** (SOL) such as tumours, abscesses and haemorrhage
* **_hydrocephalus_**
50
What are the characteristics of the headache associated with a rise in ICP?
Are there other associated symptoms?
* S - **bilateral**
* O - **gradual** onset
* C - **throbbing / bursting** pain
* T - worse in the **morning**
* E - **coughing and sneezing** (these increase ICP anyway)
* associated symptoms are **vomiting**, **seizures** and **altered GCS**
51
What signs might be present in raised ICP?
* focal neurological symptoms
* **_papilloedema_** (swelling of the optic disc)
* **_Cheyne-stokes respiration_** (deep abnormal irregular breathing)
* **_Cushing's reflex_** demonstrated with **_Cushing's triad_**
* increased systolic BP
* irregular breathing
* bradycardia
52
What is meant by focal neurological symptoms?
these are symptoms caused when there is **damage in a specific part** of the brain
e.g. a pituitary tumour pressing on the optic chiasma causes bitemporal hemianopia
53
What is the investigation performed in raised ICP?
What is contraindicated and why?
an **_URGENT CT-head_** is performed
* raised ICP is a **_contraindication for lumbar puncture_**
* high ICP changes the **pressure gradient** in the brain, so taking CSF and removing fluid from the system can **further alter the pressure** in the brain
* this leads to structures in the brain **moving slightly**
* this contributes to **_brainstem herniation_**, which can be life threatening
54
What are the 3 different types of bleed that can occur in the brain?
* extradural haemorrhage
* subdural haemorrhage
* subarachnoid haemorrhage
55
What is the definition of extradural (epidural) haemorrhage?
a **collection of blood** in the **_potential space_** between the **_dura and the bone_**
there is usually **no space here** as the **dura is attached tightly to the skull**
if there is a high force, the **dura can strip away from the bone** and blood can pool in the epidural space
56
What usually causes extradural haemorrhage?
Who tends to be affected?
* caused by **_head trauma_**
* common in **_young people_** (20-30 year old males)
* common cause is **_rupture to the pterion_** (where the sphenoid, parietal and temporal bones meet)
this is a **weak point** in the skull that is more prone to rupture
* the **_middle meningeal artery_** runs in close proximity to the skull under the pterion
57
58
What are the characteristics of the headache following extradural haemorrhage?
Why?
**_acute onset_** following a **_lucid interval_**
* it is commonly caused by rupture of the **_middle meningeal artery_**
* arteries carry blood at high pressure so the blood will **_accumulate quickly_**
* the lucid interval happens as the brain can **_initially compensate_** for the increase in pressure, then can no longer so the symptoms appear
59
What are the associated symptoms and risk factors associated with extradural haemorrhage?
* headache is **_acute_** following a **_lucid interval_**
* the headache is **increasingly severe**
* there is **_decreasing GCS_** and **symptoms of raised ICP**
* risk factors include **_head trauma_**
60
What investigations are carried out for extradural haemorrhage?
What results does this show?
* urgent **_non-contrast CT head-scan_**
* MRI (more specific, but takes longer)
* shows a **_lemon shape_**
* dura strips away from the bone, but at the **sutures** the dura is **attached tightly** and will not strip away
* there is a **limited space where blood can collect** and it is contained here
61
62
What is the definition of subdural haemorrhage?
What causes it and who is more susceptible?
a collection of blood between the **_dural and arachnoid covering_** of the brain
it is caused by rupture of the **_bridging veins_**
(susceptible in the **_elderly_** and **_alcoholics_**, due to **_brain atrophy_**)
63
Why are the elderly and alcoholics more susceptible to subdural haemorrhage?
this is due to **_brain atrophy_**
the bridging veins come from the cortex up to the bone
when the brain is smaller, but the size of the skull is the same, there is **more space** for the brain to **move around**
**trauma** (even a small one) can put **_pressure on the bridging veins_**, leading to their **_rupture_**
64
What are the symptoms of subdural haemorrhage?
***_Headache:_***
* O - **gradual** onset
* T - continuous
***_Associated symptoms:_***
* fluctuating consciousness
* confusion
* personality changes
* symptoms of raised ICP
65
What are the risk factors for subdural haemorrhage?
* **head trauma** and **falls**
* often following minor trauma up to 9 weeks before which patients have forgotten
* **old age**
* **alcoholics**
* **anticoagulation**
* ****this increases the tendency to bleed
66
How can subdural haemorrhages be classified?
**_Acute:_**
* occurring **within 72 hours** of trauma
* tends to occur in younger patients, trauma
**_Subacute:_**
* occurring **3 - 20 days after** trauma
* tends to affect the elderly
* presents with a worsening headache
**_Chronic:_**
* occurs **3 weeks after** the trauma
67
What investigations are performed for subdural haemorrhage and what signs do these show?
* urgent **non-contrast CT-head**
* this shows a **_banana shape_**
* unlike subdural haemorrhage, there are no suture lines so **more space for the blood to expand**
68
What is involved in the management of subdural haemorrhage?
ABCDE & neurosurgery referral
the treatment depends on the **size** and **presentation**
* if **_small (\<10mm)_** and n**o significant neurological dysfunction**, then it is **_observed_**
* if **large** or **significant neurological dysfunction** then **_Burr hole_** or **_craniotomy_** to drain blood from the brain
69
What is a subarachnoid haemorrhage and what causes it?
this involves **bleeding into the _subarachnoid space_**
it is most commonly due to **_rupture of a saccular aneurysm_**
the aneurysm is a bulging of a blood vessel which does not cause symptoms unless it ruptures
70
What are the symptoms of the headache present in subarachnoid haemorrhage (SOCRATES)?
* S - **occipital** (or diffuse)
* O - sudden ("**thunderclap** headache")
* C - "worst headache ever" / "like being hit by a ball"
* T - **continuous**
* S - **very severe**, maximum intensity within minutes
71
What are the associated symptoms and risk factors for subarachnoid haemorrhage?
***_Associated symptoms:_***
* meningism
* symptoms of raised ICP
***_Risk factors:_***
* **polycystic kidney disease**
* cysts on the kidneys and anerysms present which increases the risk of rupture of aneurysms
* alcohol
* smoking
* hypertension
72
What is the initial investigation performed for subarachnoid haemorrhage?
urgent **non-contrast CT head**
this has to be performed **_within 12 hours_** as the sensitivity of the CT decreases with time
73
When might a lumbar puncture be performed in suspected subarachnoid haemorrhage?
What would the results show?
* **LP** is performed if CT is normal
* This is to look for the presence of **_xanthochromia_** and **_oxyhaemoglobin_**
* these are the products of **RBC breakdown** that **should not be outside the circulaton**
* their **presence in the CSF** indicates that there has been a **_bleed_**
* this test can only be done from **_12 hours after_** symptom onset
74
What is the definition of a CNS tumour?
**_primary_ brain tumours** arising from **_any_ of the brain tissue types**
* a primary tumour arises from the brain tissue
* a secondary tumour arises from metastases
* most commonly from the lung, skin or breast tissue
75
What is the epidemiology of CNS tumours like?
* in general, the incidence of brain cancers increases with age
* medulloblastoma is a paediatric brain tumour that is more common in children
76
What is the general presentation of a CNS tumour headache?
the symptoms depend on the tumour **_type_** and **_location_**
* S - bilateral
* O - gradual
* C - throbbing / bursting
* T - **worse in the morning**
* E - coughing / sneezing
77
What are the general associated symptoms of a CNS tumour?
* **FLAWS - symptoms of cancer**
* fever
* lethargy
* appetite loss
* weight loss
* focal neurological signs
* weakness
* difficulty walking
* seizures
* personality changes
78
What are the risk factors for a CNS tumour?
* history of cancer
* family history of cancer
79
What investigations are performed for a CNS tumour?
* CT (quicker)
* MRI (better resolution)
* CXR / CT thorax, abdo & pelvis to check for metastases
* biopsy (definitive)
80
81
What is the treatment for a medication overuse headache?
* to **_withdraw all analgesics_**
* this will **initially worsen** the headache, but should alleviate it in the long-run
* once off the analgesia, it will be easier to discern the effects of other headaches (e.g. migraines)
82
What recommendation is given to headache patients when taking analgesia?
it is not advisable for headache patients to take **simple analgesia** for **_more than 2 days a week_**
83
