Headaches and migraines

Question 1

Acute Herpes Zoster

Answer 1

Shingles, reactivation of varicella zoster virus

Question 2

Acute Herpes Zoster Epidemiology

Answer 2

Anyone who has had a natural infection with wild-type varicella zoster virus
Most patients are over 60 or immunocompromised
Cancer- esp leukaemia and lymphoma
HIV
More common in women
Less common in black people

Question 3

Acute Herpes Zoster Patho

Answer 3

Primary infection with VZV causes varicella (chickenpox), once illness resolved virus remains latent in dorsal root ganglia
Can reactivate later in persons life and causes painful, maculopapular rash
Reactivation occurs when immune system is impaired

Question 4

Acute Herpes Zoster S&S

Answer 4

Eruption of rash by 3-7 days (follows one or two dermatomes)
Rash commonly appears on trunk along thoracic dermatome
Does not usually cross body’s midline
Rash can spread widespread and affect three or more dermatomes= disseminated zoster, generally occurs in people with compromised or suppressed immune systems (difficult to distinguish between the two)
Rash is painful, itchy or tingly, onset over several days
Headache, photophobia, general feeling of discomfort
Rash develops into clusters of vesicles
New vesicles form over three to five days and progressively dry and crust over
Usually heal within 2-4 weeks
May be permanent pigmentation changes and scarring

Question 5

Acute Herpes Zoster Investigations

Answer 5

Polymerase chain reaction- can detect VZV DNA rapidly and sensitively

Question 6

Acute Herpes Zoster Management

Answer 6

anger of permanent nerve damage
Opioids, adjuvant, antiviral (shorten length and severity), adjunctive
Recombinant zoster vaccine recommended
Calamine lotion

Question 7

Temporal Arteritis (S)

Answer 7

Persistent, severe headaches, often located in the temples.

Question 8

Migraines with aura

Answer 8

Migraines with any visual disturbances
* Usually accompanied by visual symptoms and tingling
* May also have mild weakness

Question 9

Migraines w aura Epidemiology

Answer 9

Common in women before 40
Stress
Too much or too little sleep
Noise
Irritating lights
Hormonal factors
Alcohol
Skipping meals

Question 10

Migraines w aura Patho

Answer 10

Recurrent headache associated with visual and GI disturbance
Changes in brainstem blood flow leads to unstable trigeminal nerve nucleus and nuclei in basal thalamus
Results in release of vasoactive neuropeptides including calcitonin gene-related peptide (CGRP) and substance P
Then results in process of neurogenic inflammation, of which two components are vasodilation and plasma protein extravasation
Cortical spreading depression is a self-propagating wave of neuronal and glial depolarisation that spreads across cerebral cortex
Proposed to cause aura of migraine and lead to release of inflammatory mediators which impact on trigeminal nerve nucleus

Question 11

Migraines w aura S&S

Answer 11

Unilateral throbbing, onset builds up over minutes-hours
Associated with vomiting, nausea, photophobia
Made worse with physical exertion
Irritability
Premonitory symptoms occur hours-days before
Auras
o Related to depression of visual cortical or retinal function and persists for minutes to hours before headache
o May be scotomata, unilateral blindness, hemianopia field loss, flashes
o Others include aphasia, tingling, numbness and weakness of one side of the body
Most common way to resolve is through sleep

Question 12

Migraines w aura Investigations

Answer 12

ID pattern of headaches

Question 13

Migraines w aura Management

Answer 13

Acute attacks- analgesics (paracetamol), high dose of aspirin, NSAIDs
Moderate- triptans (e.g., sumatriptan, almotriptan)- inhibit release of vasoactive peptides, promote vasoconstriction and block P pathways in brainstem
Prophylaxis- Pt with frequent attacks (more than one a month) or those who respond poorly to treatment for acute attacks
1. Anticonvulsants
2. Beta blockers

Question 14

Migraines without aura

Answer 14

Headache that occurs without the presence of preceding neurological symptoms or aura.
moderate to severe in intensity and often described as a pulsating or throbbing pain on one side of the head. However, the headache can also affect both sides of the head in some cases. The pain is often accompanied by other symptoms, such as nausea, vomiting, sensitivity to light (photophobia), and sensitivity to sound (phonophobia). The duration of the headache can range from a few hours to several days.
Common triggers include stress, hormonal changes, certain foods or food additives (e.g., caffeine), sensory stimuli and changes in sleep patterns, dehydration, and certain medications.

Question 15

Migraines without aura Epidemiology

Question 16

Migraines without aura Patho

Question 17

Migraines without aura S&S

Question 18

Migraines without aura Investigations

Question 19

Migraines without aura Management