It's all in the mind Flashcards
What is a migraine?
Migraines are a complex neurological condition that cause headache and other associated symptoms. They occur in “attacks” that often follow a typical pattern.
A recurrent headache associated with both visual and gastrointestinal disturbance.
What are the symptoms of a migraine?
Unilateral intense headache Moderate or severe throbbing sensation Aggravated by daily activities Discomfort with lights (photophobia) Discomfort with loud noises (phonophobia) With or without aura Nausea and vomiting Lasts between 4 hours and 3 days
How common are migraines?
10% prevalence
Sometimes a strong family history
Before age 30 years
What causes migraines?
Unknown
Due to vasodilatation or oedema of blood vessels, with stimulation of the nerve ending near affected extracranial meningeal arteries. This vasodilatation is thought to be caused by nitric oxide, 5-hydroxytryptamine and neuropeptide C-related peptide.
What are aura symptoms?
Sparks in vision Blurring vision Lines across vision Loss of different visual fields Aura symptoms typically develop over the course of about 5 minutes and last for up to an hour.
What are the different types of migraine?
Migraine without aura
Migraine with aura
Silent migraine (migraine with aura but without a headache)
Hemiplegic migraine
What are Hemiplegic migraines?
Hemiplegic migraines can mimic stroke. It is essential to act fast and exclude a stroke in patients presenting with symptoms of hemiplegic migraine.
Symptoms: Typical migraine symptoms, sudden or gradual onset, hemiplegia (unilateral weakness of the limbs), ataxia, changes in consciousness
What are some common triggers of migraines?
CHeese and chocolate Oral contraceptive pill Caffeine AlcohOL Anxiety Travel Exercise
What are the 5 stages of migraines?
Premonitory or prodromal stage (can begin 3 days before the headache) - subtle symptoms
Aura (lasting up to 60 minutes)
Headache stage (lasts 4-72 hours)
Resolution stage (the headache can fade away or be relieved completely by vomiting or sleeping)
Postdromal or recovery phase
What is the acute treatment for migraines?
Avoid trigger factors
Paracetamol
Triptans (e.g. sumatriptan 50mg as the migraine starts)
NSAIDs (e.g ibuprofen or naproxen)
Antiemetics if vomiting occurs (e.g. metoclopramide)
What is the prophylaxis for migraines?
Headache diary
Propranolol (beta blocker)
Topiramate (this is teratogenic and can cause a cleft lip/palate so patients should not get pregnant)
Amitriptyline at night is sometimes useful
Acupuncture is an option recommended by NICE for the treatment of migraines. It is reported to be as effective as prophylactic medications.
Supplementation with vitamin B2 (riboflavin) may reduce frequency and severity.
NSAIDS (e.g. mefanamic acid) or triptans (frovatriptan or zolmitriptan)
What is domestic abuse?
Domestic violence, also called domestic abuse, includes physical, emotional and sexual abuse in couple relationships or between family members.
What are the different types of abuse?
Emotional abuse
Physical abuse
Sexual abuse
Threats and intimidation
How would you support someone experiencing domestic abuse?
Listen
Acknowledge their difficult situation
Refer if they have experienced physical abuse
Help them to report it to the police if they choose to
Be ready to provide information about organisations that offer help
What is a space occupying lesion?
A space-occupying lesion of the brain is usually due to malignancy but it can be caused by other pathology such as an abscess or a haematoma.
How would a space occupying lesion present?
A new headache with features suggestive of raised intracranial pressure, including papilloedema, vomiting, posture-related headache, or headache waking the patient from sleep.
A new headache with focal neurological symptoms, or non-focal neurological symptoms such as blackout, and change in personality or memory.
An unexplained headache that becomes progressively severe.
An unexplained headache in anyone previously diagnosed with cancer or HIV.
A new onset of epileptic seizures.
What symptoms could indicate a space occupying lesion?
Tension-type presentation or migraine Vomiting Nausea Change in mental status or a behavioural change Weakness, ataxia or disturbance of gait Deficits of speech or vision Generalised convulsions
What are the red flags for headaches?
Sudden onset New headache over the age of 50 Abnormal neurological signs Headache changing with posture (Indicating raised ICP) Headache made worse by coughing, sneezing, bending, straining (May indicate raised ICP) Fever History of HIV History of cancer
What would you include in a history for a headache?
Onset, duration, frequency and temporal pattern
Pain characteristics including severity, site and spread of pain
Associated symptoms: aura, nausea, photophobia, phonophobia, autonomic symptoms, systemic and neurological features
Precipitating and relieving factors
Comorbidities and PMH
Drugs history
What would you include in an examination for a headache?
Vital signs
General appearance and mental state
Extracranial structures - carotid arteries, temporal arteries, sinuses and temporomandibular joints
Look for signs of meningeal irritation, tenderness of cervical paraspinal muscles, limitation in range of movement and crepitation in the neck.
Fundoscopy (looking for papilledema, pupillary asymmetry and reactivity).
Cranial nerve examinations
How would you test CNI?
Olfactory
Test each nostril separately by asking the patient to close one nostril and smell different odours from small bottles.
How would you test CNII?
Optic
Test visual acuity using a Snellen’s charts.
Test coloured vision using pseudo – isochromatic plates.
Test visual fields with either confrontation test or using perimeter. The Red Pin test can also be used to outline the central field.
Ophthalmoscopy is essential to visualise the optic disc.
How would you test CNIII, IV and VI?
Oculomotor, Trochlear, Trigeminal
Tested together as they control the external ocular muscles responsible for ocular movements.
Ask the patient to look at and follow your finger (Each eye separetly and both simultaneously) and make a H shaped movement.
How would you test CNV?
Trigeminal
Sensory: Test all sensory modalities at the three main branches.
Motor: Test the temporal and masseter muscles by asking patient to clench their teeth.
How would you test CNVII?
Facial
Ask patient to shut their eyes as tight as possible, then raise their eyebrows, then smile and whistle at you. Also taste sensation on the anterior 2/3 of the tongue.
How would you test CNVIII?
Vestibulocochlear
Simply whisper in each ear and ask patient to repeat. Use a vibrating tuning fork to perform Rinne and Weber tests.
How would you test CNIX?
Glossopharyngeal
Tickle the back of the pharynx for the sensory branch of the IX and not if reflex contraction occurs.
How would you test CNX?
Vagus
Tickle the back of the pharynx for motor branch (Palatal or ‘gag’ reflex)
How would you test CNXI?
Accessory
Test the function of the Trapezius muscle by asking patient to shrug their shoulders against resistance and of the Sternocleidomastoid muscle by asking patient to turn head on each side against resistance.
How would you test CNXII?
Ask patient to put out the tongue as far as possible is it straight or deviated to one side.
What investigations would you do to diagnose a headache?
Investigations are generally not required to diagnose primary headache.
Arrange review and ask the person to keep a diary over a few weeks to record frequency, duration and severity of headaches; associated symptoms; all prescribed and over the counter medications taken to relieve headaches and possible triggers.
What features indicate a serious cause of headache?
New severe or unexpected headache:
Sudden onset - intracranial haemorrhage, venous sinus thrombosis, hypertensive encephalopathy and vertebral artery dissection
New onset in over 50s - giant cell arteritis or space occupying lesion
Progressive or persistent headache or headache that has changed dramatically
Associated symptoms
What does a thunderclap headache suggest?
Subarachnoid haemorrhage, venous sinus thrombosis, bacterial meningitis, spontaneous cerebral spinal fluid leak, carotid dissection and hypertensive encephalopathy.
If there is a patient with a headache with a change in neurological function?
Urgent direct access for MRI scan of the brain within 2 weeks
Very urgent referral (within 48 hours) should be considered to assess for suspected brain or CNS cancer in young people
What is a progressive headache?
A headache that worsens with time can be due to a progressive intracranial lesion such as tumour, subdural hematoma or hydrocephalus.
