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brs neuro > Headaches > Flashcards

Headaches Flashcards

1
Q

what is headache

A

headache is a symptom
half to 3/4 of adults aged 18-65 in the world have had a headache in the last year
30% of them reported migraines
basis: structural, pharmacological, psychological

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2
Q

what is a migraine

A

periodic attacks of headaches on one or both sides of the head
may be accompanied by nausea, vomiting, increased sensitivity of the eyes to light (photophobia), increased sensitivity to sound (phonophobia), dizziness, blurred vision, cognitive disturbances, and other symptoms

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3
Q

patterns of headache

A 
acute single headache
dull headache, increasing in severity
dull headache , unchanged over months
recurrent headache
triggered headache
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4
Q

red flags

A

onset - thunderclap, acute, subacute
meningism - photophobia, phonophobia, stiff neck, vomiting
systemic symptoms - fever, rash, weight loss
neurological symptoms/ focal signs - visual loss, confusion, seizures, hemiparesis, double vision
orthostatic - better lying down
strictly unilateral

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5
Q

focal signs

A 
double vision
visual loss
3rd nerve (occulomotor) palsy
horner syndrome
papillodoema
seizures
hemiparesis
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6
Q

papillodoema

A

optic disc swelling due to raised intracranial pressure

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7
Q

vascular and circulatory origins

A 
subarachnoid haemorrhages
acute intracerebral bleed
raised intracranial pressure
carotid and vertebral arteries
chronic subdural haemorrhage
temporal arteritis
cerebral venous thrombosis
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8
Q

subarachnoid haemorrhage

A

sudden, generalised headache
50% are instantly fatal
high risk of further bleed

causes:

  • ruptured aneurysms
  • arteriovenous malformations
  • unexplained

management:

  • nimodipine and BP control
  • early neuro assessment will confirm bleed and establish cause
  • CT brain, lumbar puncture (RBC, xanthochromia), MRA, angiogram (confirm location of anuerysm)
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9
Q

aneurysm

A

a bulge in a blood vessel caused by a weakness in the blood vessel wall, usually where it branches

when blood passes through the weakened blood vessel, the blood pressure causes a small area to bulge outwards like a balloon

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10
Q

coiling an aneurysm

A

used to be clipped or wrapped

now filled with platinum coil

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11
Q

acute intracerebral bleed

A

fatal haemorrhage due to coning

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12
Q

coning

A

medullary compression due to tonsillar herniation through the foramen magnum as a result of raised intracranial pressure

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13
Q

carotid and verterbral artery dissection

A

headache and neck pain common
accounts for 20% of ischaemic strokes in people under 45yrs (mean age 40, carotid > vertebral)

cause - linked to trauma or infection
diagnosis - MRI, doppler, angiography
treatment - aspirin or anticoagulation

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14
Q

arterial dissection

A

dissection implies a tear in the wall of a major artery leading to the intrusion of blood within the layers of an arterial wall (intramural haematoma)
this causes stenosis of the lumen when blood collects between the intima and media or an aneurysmal dilatation of the artery when the haematoma predominantly involves the media and adventitia

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15
Q

chronic subdural haemorrhage

A

longer history of headache, can be accompanied by other symptoms e.g unsteadiness, limb weakness

common in elderly:

  • high risk of falls and head injury
  • on anticoagulants so thin blood
  • veins on head very delicate
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16
Q

temporal arteritis

A

presentation:

  • constant unilateral headache
  • scalp tenderness
  • jaw claudication

25% have polymyalgia rheumatica - proximal muscle tenderness
three times more common in females
usually over the age of 55

diagnosis:

  • elevated CRP and ESR
  • temporal artery inflamed and tortuous
  • visible on ultrasound
  • biopsy shows inflammation and giant cells

treatment:
- high dose steroids and aspirin

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17
Q

cerebral venous thrombosis

A

raised ICP and odoema
thrombosis in dural venous sinuses or cerebral vein
unusual amount of headache due to raised ICP
non territorial ischaemia “venous infarcts”
haemorrhage

increased risk in:
thrombophilia, pregnancy, dehydration, Behcets

18
Q

infectious origins

A

meningitis
herpes simplex encephalitis
sinusitis

19
Q

meningitis

A

causes:

  • viral e.g coxsachie, echo, mumps, ebv
  • bacterial e.g meningococci, pnemococci
  • fungal
  • granulomatous e.g sarcoid, lyme, syphyllis
  • carcinomatous

presentation:

  • malaise
  • fever
  • headache
  • neck stiffness
  • photophobia
  • confusion
  • altered conciousness

treatment:

  • treat then diagnose
  • antibiotics
  • blood and urine culture
  • lumbar puncture (increased WCC, decreased glucose, antigens. cytology, bacterial culture)
  • CT or MRI
20
Q

bacterial meningitis

A

can cause cerebral oedema with effacement of ventricles and sulci and inflamed meninges

if lumbar puncture done before scan, high pressure can cause brain to go through foramen magnum

21
Q

herpes simplex encephalitis

A

classic haemorrhagic changes in the temporal lobes due to infection

22
Q

sinusitis

A

presentation:

  • malaise
  • headache
  • fever
  • BLOCKED NASAL PASSAGES
  • anosmia
  • local pain and tenderness

diagnosis:

  • loss of vocal resonance
  • opacification of nasal sinuses on X-ray

frontal pain usually starts 1-2 hours after rising and clears up during the afternoon

23
Q

intracranial pressure origins

A

brain tumour
idiopathic
chiari malformation
obstructive sleep apnoea

24
Q

brain tumour

A

glioblastoma multiforme
cancerous mass causes raised ICP
oedema appears dark on CT head (hyper dense)

25
Q

idiopathic intracranial hypertension

A

pseudotumor cerebri
trigger is commonly weight gain

presentation:

  • often young obese women
  • headaches
  • visual obscurations
  • diplopia
  • tinnitus
  • papilloedema
  • visual field loss

drugs:

  • hormones
  • steroids
  • antibiotics
  • vitamin E

treatment:

  • weight loss
  • diuretics
  • optic nerve sheath decompression
  • lumboperitoneal shunt
  • stenting of stenosed venous sinuses
26
Q

low pressure headache

A

CSF leak due to tear in dura
orthostatic - better when lying down
meningeal enhancement can be seen on MRI

causes:

  • trauma (post lumbar puncture)
  • spontaneous

treatment:

  • rehydration
  • caffeine
  • blood patch
27
Q

chiari malformation

A

causes cough headache
normal brain just sits very low within the skull
cerebellar tonsils descend through foramen magnum
descend further when patient coughs and tugs on meninges

treatment:
- treat cold and cough
- surgery to remodel brain

28
Q

obstructive sleep apnoea

A

characteristic body habitus, history of loud snoring and apnoeic spells

headache causes:

  • hypoxia
  • co2 retention (vasodilator)
  • non refreshing sleep

presentation:

  • depression
  • impotence
  • poor work perfomance

treatment:

  • requires sleep study
  • nocturnal NIV
  • surgery
29
Q

facial pain origins

A

trigeminal neuralgia

atypical facial pain

30
Q

trigeminal neuralgia

A

electric shock like pain in distribution of sensory nerve
often triggered by innocuous stimuli
any division of the trigeminal can be affected
neurovascular conflict (nerve touches vessel causing irritation) at the point of entry of the nerve to the pons
can be symptom of MS

treatment:

  • carbamazepine
  • lamotrigine
  • gabapentin
  • posterior fossa decompression
31
Q

atypical facial pain

A

most common in middle aged women, depressed or anxious

presentation:

  • daily, constant, poorly localised deep aching or burning
  • facial or jaw bones, can extend to neck, ear, throat
  • not lancinating
  • not conforming to anatomical distribution of any nerve
  • no sensory loss

pathology in teeth, TMJ, eye, nasopharynx and sinuses must be excluded

treatment:

  • unresponsive to conventional analgesics, opiates and nerve blocks
  • treat symptoms with tricyclics
32
Q

post traumatic headache

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 headache history
unrelated to post traumatic amnesia duration
depends on nature of injury e.g car accident vs sports injury

multiple mechanisms:

  • neck injury
  • scalp injury
  • vasodilation (autonomic damage?)
  • depression (often delayed)

management:

  • explanation that its not irreversible
  • prevent analgesic abuse
  • NSAIDs e.g ibuprofen, naproxen
  • tricyclics e.g amitryptiline

can take 3-4 years to resolve

33
Q

cervical spondylosis

A

narrowing of intervertebral joint space due to worn disc
commonest cause of new headache in older patients (due to arthritis)

presentation:

  • usually bilateral
  • occipital pain can radiate forwards
  • steady pain
  • no nausea or vomiting
  • worsened with movement

management:

  • rest, deep heat, massage
  • anti inflammatory analgesics
  • over manipulation can be harmful
34
Q

migraine attacks

A

the attacks can have 3 forms:

  • pain
  • focal symptoms
  • pain and focal symptoms

focal symptoms include:

  • speech arrest
  • anaphasia
  • pins and needles
  • weakness
35
Q

migraine phases

A
  1. prodrome - changes in mood, urination, fluid retention, food craving, yawning
    (2. ) aura - visual, sensory (numbness, parasthesia), weakness, speech arrest
  2. haedache - head and body pain, nausea, photophobia
  3. resolution - rest and sleep
  4. recovery - mod disturbed, food intolerance, feeling hungover

48 hours (lots of variability)

36
Q

migraine aura

A

positive (flashes) and negative (black spots) symptoms together:

  • scintillations
  • blindness
  • expanding c
  • elemental visual disturbance
37
Q

migraine treatment

A

acute attack:
- NSAIDs and paracetamol and anti emetics (to stimulate peristalsis)
- soluble preparations to aid absorption
- triptans tablets, melts and nasal spray, subcutaneous injections (vasoconstrictors)
- opiates have analgesic abuse potential
- short nap
TMS (transmural stimulation) to interrupt complex networks that trigger and perpetuate migraines, caused by spreading electrical depression across the cerebral cortex

lifestyle issues:

  • sensitive heads even between attacks
  • over-react any stimulation
  • can be genetic

avoiding triggers:

  • dietary, environmental, dehydration, stress, hormonal, weather
  • drink water
  • avoid caffeine
38
Q

migraine prophylaxis

A

if migraines happen >14 times a month, prevention should be used
cause is so varied that different things work for different people

  • erenumab: injectable monoclonal antibody
  • over the counter: magnesium, nicotinamide, EPO
  • TCAs
  • beta bockers: drop BP and pulse
  • greater occipital nerve bocks: lidocaine
  • botox: crown of thorns distribution to paralyse muscles
39
Q

tension type headache

A

tight muscles around head and neck bilaterally

treatment:

  • NSAIDS preferred
  • paracetamol
  • TCAs (SSRIs less effective)
  • biofeedback and relaxation unproven
40
Q

cluster headache

A

severe unilateral pain lasting 15-180 minutes untreated
classified as trigeminal autonomic cephalgia
forehead and facial sweating
miosis/ptosis
sense of restlessness and agitation
not associated with brian lesion on MRI

also has at least one of the following, ipsilaterally:

  • conjuctival redness, lacrimation
  • nasal congestion
  • eyelid oedema
41
Q

cluster headache treatment

A

acute:

  • inhaled oxygen (inhibits neuronal activity of trigeminocervical complex)
  • s/c or nasal sumatriptan

prevention:

  • prednisolone
  • lithium
  • valproate
  • gabapentin

brs neuro (8 decks)

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