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Headaches / Raised ICP Flashcards

1
Q

What is a primary headache

A

No underlying medical / structural cause

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2
Q

What are examples of primary headaches

A 
Tension type = most common
Migraine
Cluster = only one you need to know
Trigeminal neuralgia 
Drug overuse
Post-coital / exertional - can be thunderclap
- Require CT to exclude structural brain
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3
Q

What are secondary headaches

A

Have a structural cause

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4
Q

What are examples of structural causes

A 
SAH 
Stroke / TIA 
Carotid dissection 
Tumour 
GCA
Meningitis
Venous sinus thrombosis 
Intracranial hypotension
Head injury
Acute glaucoma
Metabolic - CO poisoning 
Drugs
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5
Q

What is a thunderclap headache

A

High intensity reaching max in <1 min

Can be primary or secondary

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6
Q

What do all thunderclap headaches get

A

CT and LP

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7
Q

What must you rule out

A

SAH !

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8
Q

What is important in Hx of headache and give example

A

Onset
SAH = instant
Meningitis = subacute
SOL = progressive

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9
Q

What causes acute single headache

A 
Meningitis / encephalitis 
SAH 
Head injury
Sinusitis
Glaucoma
Tropical illness e.g. malaria
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10
Q

What causes chronic

A

Raised ICP / SOL
Psychological
Paget’s

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11
Q

What is important in Hx of headache

A 
SOCRATES
Sudden or gradual 
Better sitting up or lying flatt 
Any N+V
Vertihgo
Vision / eye pain / photophobia
Neck stiffness 
RED FLAGS
Examination for papilloma suggesting raised ICP
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12
Q

What is important in PMH

A

Previous episode
HTN?
Vasculitis / inflammatory flare
Hx malignancy

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13
Q

What is important in drug Hx and social Hx

A

Anti-coagulant
Anti-hypertensive
Any Rx tried
Medication overuse

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14
Q

What is important to examine

A

Neuro

  • Limb power, tone, reflex
  • Pronator drift
  • CN
  • Visual fields
  • Fundoscopy
  • Cerebellar
  • Gait
  • Calculate GCS
  • PEARL ?

If normal neuro and not a thunderclap headache = usually no more investigations
Otherwise = CT to rule out secondary

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15
Q

What are red flags for secondary headache requiring urgent imaging

A 
New onset
Thunderclap 
Increasing in frequency and severity 
>50
<20 
History of malignancy 
Vomiting with no other cause
Immunosuppressed - HIV 
Change in freq / characteristics + fever  
New onset neurological deficit
Focal neuro signs 
Papilloedema 
Visual disturbance 
Impaired consciousness 
New onset cognitive / personality change 
Recent head trauma 
Neck stiffness / fever / photophobia 
Low pressure - precipitate standing up 
High pressure - worse lying down / cough
Wake from sleep 
Any RF for cerebral venous sinus thrombosis
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16
Q

What are the stages of migraine (don’t have to go through all)

A 
Pre-Aura
Aura
Early headache
Advanced headache
Post headache
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17
Q

What causes aura and what can it present with

A 
Cortical spreading depression evolves over 5-60 minutes 
Mood changes
Fatigue
Muscle pain
Cravings 
Visual loss
Sensory paresthesia
Motor Sx
Speech disturbance
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18
Q

What do you get post head

A

Fatigue

Muscle pain

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19
Q

What is acephalic migraine

A

No headache occurs after aura

Common in elderly

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20
Q

What causes migraine and what can trigger

A 
Primary brain = sensitisation of trigeminal system 
Stress
Hunger
Sleep disturbance
Dehydration
Diet
Alcohol
OCP 
Changes in oestrogen
Bright lights
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21
Q

What are the symptoms of migraine

A 
Headache lasting 4-72 hours
Aura
Nausea
Photo / phonophobia
Functional disability
Confusion / ataxia / aphasia in young
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22
Q

What must headache in migraine have

A 
2+ of
Unilateral
Pulsating
Moderate - severe
Made worse by activity

So can have bilateral and still be migraine if meets other criteria

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23
Q

What must migraine attacks have

A

5+ headaches with features above lasting
4-72 hours
At least one of N+V / photophobia / phonophobia
No other cause

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24
Q

What can aura be confused with

A

TIA

Migraine tends to have more +ve sx e.g. tingling rather than loss

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25
Q

When would you further investigate aura

A 
Motor weakness
Double vision
Only one eye
Poor balance
Decreased GCS
Migraine tends to have +Ve Sx where as stroke = -ve
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26
Q

How do you treat migraine

A

Paracetamol / NSAID / aspirin
Triptans (5HT3 agonist) - MAXALT MELT
If <18 nasal
Anti-emetic

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27
Q

When are triptans CI

A

IHD

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28
Q

What is used as prophylactic medication

A

If 2+ attacks per month
Propranolol - not if asthma
Toperimate - not 1st trimester as cleft lip / women child bearing
Canderstartan

2nd line 
AED
TCA - amitryptilline = off-license
Venlafaxine
Acupuncture
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29
Q

How do you treat migraines in pregnancy

A 
Often improves 
Paracetamol = 1st line
NSAID in 1st or 2nd trimester
Avoid aspirin / opiates
Propranolol or amitriptyline
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30
Q

What is CI in migraine with aura

A

Combined OCP due to risk of stroke

CVS RF worsen risk

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31
Q

What is tension type headache

A

Bilateral headache
No associated features
Not worsened by exercise

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32
Q

What is episodic vs chronic

A

Chronic if >15 days per month

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33
Q

How do you treat

A

Paracetamol / aspirin = 1st month
NSAID
Amitryptilline / sodium valproate for long-term
Acupuncture if chronic

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34
Q

What causes medication overuse

A

Simple analgesia used >15 days
Triptans / opioids >10
Caffeine overuse

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35
Q

How does medication overuse present and who is prone

A

Headache >15 days
Usually migraine like
Improves when analgesia stops
Common if get migraine

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36
Q

What are the trigeminal autonomic cephalgia’s

A

Cluster headache
Paraoxysmal hemicrania
SUNCT
Trigeminal neuralgia

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37
Q

What are the autonomic symptoms

A 
Conjunctival haemorrhage / injection
Nasal congestion
Eyelid oedema
Sweating
Miosis 
Ptosis
Facial flushing
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38
Q

How do cluster headaches present

A 
Intense sharp stabbing pain 
Orbital + temporal (around one eye) 
Usually unilateral 
Restless / agitated 
Can be thunderclap 
Cluster into bouts which usually occur once a year
Circadian rhythm 
Autonomic Sx = common
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39
Q

How long do attacks / bouts of cluster last

A

15minutes - 3 hours
Rapid cessation
Get 1-8 per day
Lasting 4-12 weeks

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40
Q

Who is at risk and what triggers

A

Men
Smoking
Alcohol
FH

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41
Q

What should you do

A

Refer for neuro imaging

Beware of acute angle closure glaucoma but usually eye signs

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42
Q

How do you treat

A

Triptan nasal spray
SC triptans
OXYGEN = respond to high flow

Long term
Avoid trigger eg. alcohol
Verapamil for long term
Depomedrone injection on same side during bout

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43
Q

What do paroxysmal hemicranial headaches present

A 
Orbital and temporal headache
Unilateral 
Migraine Sx
Autonomic Sx
No circadian
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44
Q

How long do they last and how many

A

2-30 minute
Rapid onset and cessation
Usually 5. day

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45
Q

How do you treat paroxysmal

A

Indomethacin

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46
Q

What causes trigeminal neuralgia

A 
Something touching trigeminal nerve
Blood vessel ?
Aneurysm
Tumour
Chronic inflammation
MS
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47
Q

How does trigeminal neuralgia present

A 
Unilateral stabbing pain - extreme pain 
Lasts seconds
Maxillary more common than opthalmic
Autonomic uncommon
Refractory period present
If no refractory - may be SUNCT
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48
Q

What can trigger

A 
Wind
Cold
Touching
Washing area
Shaving
Eating
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49
Q

What investigations

A

MRI to exclude secondary causes

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50
Q

How do you treat

A

Carbamazepine = 1st line prophylaxis
Other AED - gabapentin / lamotrigdine
Refer to neuro if don’t respond
Decompressive surgery

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51
Q

What are red flags of underlying cause

A 
NEURO DISTURBANCE
Sensory change
Deafness
Hx skin / ora lesion
Pain bilateral or only in ophthalmic region
Optic neuritis
FH MS
<40
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52
Q

Meningitis / encephalitis

A

SEE INFECTION

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53
Q

What are common infectious causes of meningitis

A

Nesseria meningitides
S.pneumonia
Enterovirus

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54
Q

What are non infectious causes

A

Sarcoid
Drugs
Malignancy - leukaemia / lymphoma

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55
Q

How does meningitis present

A 
Unwell 
Gradual onset / thunderclap headache
Neck stiff
Fever
Flu like symptoms / viral illness 
Vomiting
Photo / phonophobia 
Rash - purpuric
GCS <14
Confusion
CN palsy / seizure / focal Sx may occur
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56
Q

What signs if meninges involved

A

+ve Kernig

57
Q

How do you investigate

A

General exam + neuro
Blood culture
LP
CT prior to LP to look for SOL

58
Q

What are CI to LP

A 
Focal deficit suggest brain mass 
Seizure
Papilloedema
Abnormal consciousness suggesting raised ICP 
Immunocompromised
Unstable bleeding disorder
59
Q

What can meningococcal disease cause

A

Thrombocytopenia so don’t LP if meningococcus

60
Q

How do you Rx

A

IV Ax - ceftriaxone (give without delay)
Add amoxicillin if very young or old
Fluids
Oxygen
Viral = self limiting
Add IV acyclovir if any suggestion of encephalitis e.g. cerebral signs

61
Q

What are complications of meningitis

A 
Sepsis
Permanent brain / nerve damage
Sensorineural hearing loss - screen 
Visual loss 
Epilepsy
Paralysis 
Abscess 
Brain herniation
Hydrocephalus
62
Q

What does CSF show if bacterial

A

Increased opening pressure
High neutrophil
Reduced glucose
High protein

63
Q

What does CSF show if viral and encephalitis

A

Increased pressure
High lymphocytes
Normal glucose
Slightly increased protein

64
Q

Wha is encephalitis

A

Inflammation / infection of brain substance

65
Q

What causes encephalitis

A

HSV
Arbovirus if travel related
Autoimmune

66
Q

Where does typically affected

A

Temporal lobe

67
Q

What are the symptoms of encephalitis

A 
Headache
Fever
Meningism
Flu prodrome
Vomiting
Altered mental state
Altered consciousness
Focal S+S 
Seizures
Psychiatric
68
Q

How do you Dx

A

Blood cultures
LP inc PCR for HSV
CT / MRI may show changes

69
Q

What do you give if suspect

A

IV acyclovir

70
Q

What causes raised ICP and how does It cause headache

A 
Malignancy / tumour
SOL 
Haemorrhage 
Aneurysm
Abscess
Chronic haematoma
Cyst

Headache

  • Raised ICP
  • Vascular
  • Meningeal involvement
71
Q

What can tumour be

A 
Metastatic 
Astrocytoma
Glioblastoma
Olidogendroglioma
Mengioma
Primary CNS lymphoma
72
Q

Where are mets common from

A 
Lung 
Breast
Colon 
Kidney 
Melanoma
73
Q

What are symptoms of raised ICP

A 
Gradual progressive headache
Worse in the morning
Worse lying flat or with valsalva
Vomiting 
Paplloedema - bilateral
Falling GCS 
Seizures
Bheaviour change
Focal neuro 
Pulsatile tinnitus
6th nerve palsy
3rd nerve palsy due to uncle herniation 
- Dilated pupil 
Cushing's reflex
74
Q

What causes vomiting

A

Compression of VRZ

No nausea

75
Q

What are focal signs

A

Hemiparesis
Dysphasia
Hemianopia
CN palsy

76
Q

What are symptoms of Cushing’s

A

Hypertension
Tachycardia
Irregular breathing
Bradycardia

77
Q

How do you Dx raised ICP

A 
Neuro exam
Fundoscopy 
Assess for primary
CT head
Consider biopsy 
LP 
Routine bloods
78
Q

How do you assess for primary

A

CXR?
Biopsy of LN to find tumour type
Easier than biopsy intra-cranial lesion

79
Q

What should you avoid before imaging

A

LP as risk of coning

80
Q

What is 1st line

81
Q

What are new methods of monitoring raised ICP

A

Brain tissue oxygen monitoring - o2 levels drop before ICP goes up

Micro-dialysis to investigate brain metabolism

82
Q

How do you initially manage raised ICP

A 
Analgesia
Mannitol
Dexamethasone - if oedema 
Raise head 45
Hyperventilate so less blood needed
Maintain O2 sats
Low CO2 as acidic = oedema 
Reduce metabolism = coma
83
Q

How do you treat

A 
Shunt to relive pressure
Remove tumour if possible 
Surgery 
RT
Chemo
84
Q

What suggests benign cause

A

Progressive headache with no other signs

85
Q

What makes up ICP / Munro Kelly

A 
Volume intracranial = 
V Brain tissue 
V Blood
V CSF 
= a constant
86
Q

How do adapt to raised ICP

A

Shift in CSF
Autoregulation
Will eventually fail causing swelling, ischaemia due to decreased CPP, internal shift / herniation as strictures displaced

87
Q

What is subfalcine herniation

A

Cingulate gyrus moves under falx cerebri

88
Q

What is uncul tentorial herniation

A

Uncus of temporal lobe herniates under tentorium cerebelli

Brain stem compressed

89
Q

What happens if brain stem compressed

A

3rd CN palsy - ipsilateral fixed dilated pupil

Spinal tracts affected = contralateral paralysis

90
Q

What is tonsilar herniation / Coning

A

Tonsils move down crushing brain stem through foramen magnum
Death due to cardiorespiratory centre involvement
Neurosurgical emergency

91
Q

What causes Cushing’s reflex

A 
Arterioles compressed
Autonomic sympathetic activated
Causes hypertension and tachy
Irregular breathing 
Hypertension picked up so vagus = bradycardia
92
Q

What makes up CPP

93
Q

What is CBF regulated by

A 
CPP
Conc of CO2 and O2
Neurohormonal
Cerebral metabolism
Autoregulation - ability to maintain CPP over a wide range of pressures
94
Q

What happens if CPP low

A

Arterioles dilate so more blood

Will constrict if high

95
Q

What happens if CPP falls too low

A

Arterioles can’t dilate anymore so no flow

96
Q

What happens if CPP becomes too high

A

Cannot compensate anymore

97
Q

If this auto regulation fails what happens and when does it happen

A

Raised ICP and decreased CPP
Vasogenic and cytotoxic oedema
Usually first few days after brain injury

98
Q

What causes cerebral / brain abscess

A

Head injury
Spread from dentist / sinus / ear infection
Bacteraemia
Neurosurgical

99
Q

Common organism

A

Strep

Fungal in immunocompromised

100
Q

What are symptoms

A 
Fever 
Headache
Focal signs 
Raised ICP 
Menigism if empyema
101
Q

How do you Dx

A 
CT - 1st line 
Hard to distinguish between abcess and tumour 
MRI
Bloods
Biopsy to drain
102
Q

How do you treat

A

Surgical drainage

IV Ax

103
Q

What is differential

A

Tumour

Subdural haematoma

104
Q

What is GCA

A

Inflammation of large arteries in brain

105
Q

How does patient present

A 
>50
New headache
Jaw claudication / pain
Visual disturbance 2 to ischaemic neuropathy - unilateral blidness / amuorisis fujax (pale optic disc on fundoscopy) 
Systemically unwell
Prominent beaded temporal arteries / tender 
PULSELESS as occluded 
Nausea
Anoreixa
Features of PMR
106
Q

What is associated

A

Polymyalgia rheumatica

107
Q

How do you Dx

A

Raised ESR / CRP / platelet / WCC as autoimmune
Temporal artery doppler replaced biopsy as biopsy could miss skip lesions
Fluorescein angiography may confirm
CK / EMG normal

108
Q

How do you Rx

A

Opthamalogy
High dose prednisolone - 1mg/kg
If amaurosis fujax = give IV as risk of vision
Drugs to lower intraocular pressure

Also give calcium / biphosphonates/ PPI for bone protection if on steroid

109
Q

What causes cerebral venous sinus thrombosis (occlusion of venous channels)

A

Infections in mastoids or orbit = common cause of cavernous sinus thrombosis
Other infection - TB / sepsis / endocarditis
Trauma
Head injury
Hypercoagulable state - preg / OCP / steroid / post-partum
Intracranial hypertension
Post LP dural puncture
Severe dehydration

110
Q

What are signs

A 
Consider in all patient with subacute headache presenting with a seizure 
Headache
- usually diffuse and progressive but can have thunderclap 
N+V
Focal neuro 
Reduced GCS 
Papilloedema 
Dilopia 
Seizure 
Stroke 
CN palsy

Cavernous sinus

  • Reduced acuity
  • Proptosis
  • Opthamolplegia
  • Absent corneal reflex
111
Q

Who is at risk

A 
OCP
Dehydration
Malignancy 
Sepsis
Pregnancy
Post-partum 
Vasculitis
IBD 
SLE
112
Q

How do you Dx and Rx

A 
Exclude SAH
Thrombophilia screen 
MR venogram = 1st line 
- Empty delta scan 
MRI > CT if suspect 
- Hyperdense vein

Phenytoin if siezure
Anti-coagulation with heparin = Rx of choice

If deteriorating consciousness = radiologically guided catheter to delivery thrombolytic therapy due to risk of haemorrhage as blockage leads to cerebral oedema with haemorrhage risk

Shunt if raised ICP

After acute episode = DOAC

113
Q

What causes spontaneous intracranial hypotension

A

CSF leak post LP or epidural

Very rare

114
Q

What are the symptoms

A

Headache

Worse sitting up

115
Q

How do you Dx

116
Q

How do you treat

A 
Conservative
Best red
IV fluid
Analgesia 
Caffiene 
Epidural blood patch if fails
117
Q

Who is at risk

A

Connective tissue

Marfans

118
Q

What causes disruption to BBB and what does it lead too

A

Increased ECF causing vasogenic oedema

Tumour / abscess / trauma

119
Q

What causes membrane failure

A

Cell damage

Causes influx of Ca and swelling = cytotoxic oedema

120
Q

How do you Rx BBB failure

A

Mannitol + steroids

121
Q

How do you Rx membrane failure

122
Q

What are rare variants of migraine

A

Basilar
Hemiplegic
Opthamoplegic

123
Q

What is basillar

A 
Bilateral visual disturbance
Dysarthria
Ataxia 
Vertigo
Nystagmus
Diplopia
124
Q

What is hemiplegic

A

Aura of hemiplegia / ataxia
Can persist after headache gone
Can present like stroke

125
Q

What is opthalmolpegic

A

Extra-ocular nerve palsy

Acute CN III palsy, pain, and dilated pupil

126
Q

What are symptoms of idiopathic intracranial hypertension

A 
Daily headache
- Bifrontal temporal
- Worse straining
Blurred vision
Papilloedema
Enlarged blind spot
6th nerve palsy = most commonly focal sign 
May cause cerebral thrombosis
Present like mass with none found
127
Q

Who is at risk

A 
Young
Female
Obesity
Pregnancy
OCP
Anabolic Steroid
Tetracycline
Lithium
Retinoid / vit A
128
Q

How do you investigate

A

CT shows no focal
LP shows raised ICP with normal composition
Fundoscopy

129
Q

How do you Rx

A 
Weight loss
Prednisolone 
Repeat LP to drain CSF 
Surgery
VP sunt 
If evidence of visual damage
Urgent opthamology
Diuretic 
Carbonic anhydride to reduce CSF 
Optic nerve decompression as can lead to permanent blindness
130
Q

When do you suspect acute glaucoma

A

Eye pain and reduced vision

131
Q

When do you suspect GCA

A

> 50 with headache thats lasted a few weeks

132
Q

What headache features should get urgent CT

A 
Vomiting >1
New neuro
Reduced conscious (GCS) 
Valsalva or positional 
Progressive with fever
133
Q

What do exertional headache require if new onset / 1st presentation

A

CT to exclude structural brain abnormality

134
Q

How does carotid artery / vertebral artery dissection present

A

Abrupt onset unilateral headache
Can be precipitated by trauma
HTN / aneurysm - but consider if stroke and no CVS RF
Neck or face pain
Horner syndrome may be seen
Brain stem and cerebellar signs if vertebral

135
Q

What are known association

A

Hypertension

Marfan’s

136
Q

When do you consider and how do you Dx

A

Any young patient presenting with Sx of a stroke

Dx = CTA or MRA

137
Q

What should anyone with headache in ED be asked

A

Any exposure to CO

138
Q

Important to remember

A

Headaches can present with a combination so can be confusing
What is most likely

Neuro (19 decks)

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