Headaches - lectures and tutorial Flashcards
sinusitis, first attack of migraine, following a head injury, subarachnoid haemorrhage, meningitis, tumour, drugs, toxins, stroke can all cause what type of headache?
acute single headache
overuse of medication, contraceptive pill, hormone replacement therapy, neck disease, temporal arteritis, benign intracranial hypertension, cerebral tumour, cerebral venous sinus thrombosis can all cause which type of headache?
dull headache, increasing in severity
which are the most common patterns of headache?
dull headache, unchanged over months, recurrent headaches
Give two examples of dull headaches
chronic tension headache
depressive, atypical facial pain
Give three examples triggers for headache?
coughing, straining, exertion
coitus
food and drink
give four examples of recurrent headaches
migraine,cluster, episodic tension headache, trigeminal or post herpetic neuralgia
Name the 6 red flags for headache
- onset
- meningism
- systemic symptoms
- neurological symptoms or focal signs
- orthostatic - better lying down
- strictly unilateral
what would be the worry of an acute onset headache?
thunderclap/ acute - could be a symptom of something serious
give 4 symptoms of meningism
photophobia, phonophobia (sound), stiff neck, vomiting
visual loss, confusion, seizures, hemiparesis, double vision, 3rd nerve palsy, Horner syndrome and papillodema are all what kind of red flag?
neurological symptoms or focal signs
what causes double vision?
Any of the 3rd, 4th and 6th cranial nerves not working
what causes 3rd nerve (oculomotor) palsy?
posterior communicating artery aneurysm
what are the signs of 3rd nerve (oculomotor) palsy?
A complete third nerve palsy causes a completely closed eyelid and deviation of the eye outward and downward. The eye cannot move inward or up, and the pupil is typically enlarged and does not react normally to light.
What happens in Horner Syndrome? What causes it?
pupil size bigger, eye held open
sympathetic supply to eye is altered
what other symptoms can a subarachnoid haemorrhage cause?
meningism - stiff neck and photophobia
What are subarachnoid haemorrhages caused by?
ruptured aneurysm
What percentage of subarachnoid haemorrhages are fatal?
50%
how do you confirm a subarachnoid haemorrhage?
CT of the brain, lumbar puncture (spinal fluid contains blood), MRA, angiogram
how do you treat an aneurysm?
fill with platinum coil –> causes blood vessel to seal up
is an acute intracerebral bleed fatal?
yes, due to coning
what is coning?
the brain can only handle an increased volume/ pressure up to a certain point. After this, there is herniation due to the brain squeezing out of the skull at certain points. This squashes the brainstem, shutting down cardiorespiratory centres and is fatal.
papilloedema is what?
optic disc swelling at the back of the eye due to raised intracranial pressure
headache in the front of the head and temples could be affected by a problem with which arteries?
carotid
headache from the middle of the head towards the back of the head and neck could be caused by a problem with which artery?
vertebral
what can cause carotid and vertebral artery dissection?
trauma, or a spontaneous dissection with a collagen type that predisposes them
what could happen if you have carotid/vertebral artery dissection?
turbulent flow leading to blood clots which can lodge in the brain and lead to stroke
how would you diagnose carotid and vertebral artery dissection?
MRI/MRA, doppler, angiography
how would you treat carotid and vertebral artery dissection
aspirin or anticoagulation
what can lead to chronic subdural haemorrhage?
banging head - veins are thin and easily traumatised, shearing of veins can lead to haemorrhage
how do you treat chronic subdural haemorrhage?
burr hole surgery
What type of haemorrhage is this?
What is shown in the image as a result of this?
subdural, blood is dark as already begun to degrade (taken at a later stage), ventricles pushed to one side and squashed due to increased pressure, gyri and sulci not visible
What is temporal arteritis?
inflammation of blood vessels
what age group is temporal arteritis most common in?
females over 55
what is the presentation of temporal arteritis headache?
- constant unilateral
- scalp tenderness
- jaw claudication
what do we need to watch out for in temporal arteritis headache?
involvement of posterior ciliary arteries - can cause blindness
which inflammatory markers will be increased in a temporal arteritis headache?
ESR and CRP
which artery will be inflamed in temporal arteritis?
temporal artery
how can you diagnose temporal arteritis?
ultrasound and biopsy showing inflammation and giant cells
how would you treat temporal arteritis?
high dose steroids (inflammation) and aspirin (prevents stroke)
what is central venous thrombosis?
blood clot in the dural venous sinus or cerebral vein
What raises your risk of cerebral venous thrombosis?
thrombophilia, pregnancy, dehydration, behcets
what does cerebral venous thrombosis lead to?
venous infarcts and potentially haemorrhage.
What are the types of meningitis?
- viral
- bacterial
- tuberculous
- fungal (immunosuppressed)
- granulomatous
- syphilis
- carcinomatous
these symptoms indicate which disease?
- malaise
- headache
- fever
- neck stiffness
- photophobia
- confusion
- alteration of consciousness
meningitis
Herpes simplex encephalitis affects which lobes?
temporal
what are the treatments for meningitis?
- Antibiotics straight away
- Blood and urine culture to determine what’s causing it
- Lumbar puncture - look for: increased WBC count, decreased glucose, antigens, cytology, bacterial culture
- CT or MRI scan
This brain scan shows what?
inflamed meninges
cerebral oedema with reduction of ventricles and sulci and inflamed meninges are a sign of what?
meningitis
These symptoms:
- frontal pain starting 1-2 hours after rising and clearing up during the afternoon
- malaise
- headache
- fever
- blocked nasal passages
- loss of vocal resonance
- anosmia
- nasal or postnatal catarrh
- local pain and tenderness
are a sign of what?
sinusitis
what happens to the brain when there is a brain tumour?
What is seen in the scan?
swelling as the tumour takes up space, sulci missing in scan because of increased pressure
low pressure headaches usually come on in which position? They go away in which position?
- standing up
- lying down
what would be seen on an MRI scan with a contrast injection in a low-pressure headache?
meningeal enhancement
what can cause a low pressure headache?
traumatic post lumbar puncture
spontaneous
what is the treatment for a low pressure headache?
- rehydration
- caffeine to seal off hole
- blood patch
what is a blood patch?
venepuncture and inject blood straight into epidural space, acting as a natural glue and patches up the hole
what is a chiari malformation?
normal brain sitting low in the skull
how does chiari malformation cause headache?
cerebellar tonsils descend through foramen magnum - descend further during coughing and tug on meninges
treatment for chiari malformation cough headache
- treat cold or cough
- potentially if that doesn’t help, do operation to remodel skull and prevent snagging
Who is at risk of obstructive sleep apnoea?
obesity or larger people, history of large snoring and apnoeic spells
what happens during obstructive sleep apnoea?
hypoxia, CO2 retention, non-refreshing sleep
What can obstructive sleep apnoea result in?
depression, impotence, poor performance at work
how do we diagnose obstructive sleep apnoea?
sleep study
how do you treat obstructive sleep apnoea?
nocturnal NIV (non-invasive ventilation)
surgery
what sort of pain is present in trigeminal neuralgia?
electric shock-like pain in the distribution of a sensory nerve, triggered by random stimuli
what is trigeminal neuralgia caused by?
neurovascular conflict at the point of entry of the nerve into the pons ie. blood vessel flows too close to nerve
trigeminal neuralgia can be a symptom of what disease?
MS
treatment for trigeminal neuralgia?
- carbamazepine, lamotrigine, gabapentin (anti-convulsants)
- posterior fossa decompression - operation to protect the nerve by separating with surgical sponge
Atypical facial pain is most common in which group?
middle-aged women
what sort of pain is present in atypical facial pain?
daily, constant, poorly localised deep aching or burning
not piercing or stabbing
atypical facial pain is usually treated by?
tricyclic antidepressants
what causes post-traumatic headache?
head injury
what are the mechanisms of post-traumatic headache?
- neck injury
- scalp injury
- vasodilation due to autonomic damage
- depression
what treatment is involved in the management of post-traumatic headache?
NSAIDs eg. ibuprofen, naproxen
tricyclic antidepressants - amitriptyline
what causes cervical spondylosis?
narrowing of joint space due to worn out disc
what sort of pain is present in cervical spondylosis?
bilateral
occipital pain can radiate towards the frontal region
steady pain
no nausea or vomiting
worsened by moving neck
which type of new headache is most common in older patients?
cervical spondylosis
management of cervical spondylosis?
rest, deep heat, massage
anti-inflammatory analgesics
over-manipulation may be harmful
Which type of headache describes these symptoms:
- repeated attacks
- triggers
- easily hung-over
- visual vertigo
- motion sickness
migraines
what are the three phases of a migraine attack?
- Prodrome
- Aura
- Headache
changes in mood, urination, fluid retention, food craving and yawning are signs of?
prodrome of a migraine
visual, sensory (numbness/paraesthesia), weakness, speech arrest are signs of?
aura of a migraine
head and body pain, nausea and photophobia are signs of which stage of what headache?
headache stage of a migraine
how is a migraine resolved?
rest and sleep
what happens during recovery of a migraine? For how long?
mood disturbance, food intolerance, feeling hungover for around 48 hours
during which headache and at which stage does the patient see scintillations around a blind spot
aura, migraine
what are the treatments for migraine?
- aspirin/ibuprofen (non-steroidals)
- paracetamol
- metoclopramide (anti-emetic)
- triptans-tablets
- vasoconstrictors
how do anti-emetics work?
stop sickness, by stimulating peristalsis
(gut slowing down creates nausea)
why should we use opiates with caution on migraines?
analgesic abuse
what other treatments can be used for migraines?
TMS
what caution should we pay attention to when giving vasoconstrictors?
- pregnancy
- people with angina
how does TMS work on migraines?
interrupts complex networks that trigger and perpetuate migraine (caused by spreading electrical depression across cerebral cortex)
what non-medicinal approaches can be used to manage migraines?
- avoid triggers eg. dehydration, dietary, environment
- drink 2 litres of water a day
- avoid caffeine
- eat fresh food without preservatives
- don’t oversleep or have late nights
what can be used for prophylaxis of migraines? (Remember treatment will be different depending on patient and their triggers)
- tricyclic antidepressants
- beta-blockers
- serotonin antagonists
- calcium channel blockers
- anti-convulsants
- greater occipital nerve blocks
- botox - crown of thorns
- suppress ovulation
tension type headaches typically present with?
tight muscles around the head and neck bilaterally
treatment for tension-type headache
- NSAIDs
- paracetamol
- tricyclic antidepressants
cluster headache typically presents as?
severe unilateral pain lasting 15 minutes to 3 hours
what is a cluster headache also classified as?
trigeminal autonomic cephalgia
cluster headache is usually classified if it has at least one of which three signs?
- conjunctival redness and/or lacrimation
- nasal congestion and/or rhinorrhoea
- eyelid oedema
These symptoms relate to which type of headache?
- forehead and facial sweating
- mitosis and/or ptosis
- restlessness or agitation
- frequency between alternating days and up to 8 per day
- not associated with a brain lesion on MRI
cluster headache
cluster headaches commonly present with pain in which areas?
eye, forehead, temple, cheek
what is the acute treatment of a cluster headache?
- Inhaled oxygen - inhibits neuronal activation in the trigeminocervical complex
- subcutaneous or nasal sumatriptan
what 7 drugs are used for prevention of cluster headaches?
- Verapamil
- Prednisolone
- Lithium
- Valproate
- Gabapentin
- Topiramate
- Pizotifen
cluster headache mainly occur in what group?
men
migraines typically last how long?
3-12 hours
how frequently do migraines occur?
1-8 times per month
how often do cluster headaches occur?
1-3 attacks daily, often at night
which group most commonly gets migraines?
women
compare the remission frequency for migraines and cluster headaches
- migraines - long remissions unusual
- cluster headache - long remissions common
what type of pain is present in a migraine?
pulsating hemicranial pain
what type of pain is present in a cluster headache?
steady, severe, well localised pain, unilateral in each cluster
what is the typical behaviour of someone with a migraine versus cluster headache
- migraine - lie in dark
- cluster headache - pace about
