MedEd headache Flashcards
how often should heachache patients be allowed to take analgesia?
2 days a week
what might happen if headache patients take too much simple analgesia and what is ‘too much’?
they might get a medication overuse headache
too much= more than 2 days a week
how do you manage a medication overuse headache?
stop all analgesic medication
warn the patient that the headache will get worse at first but then it will get better
what triad of symptoms occurs in cluster headaches?
lacrimation
rhinorrhea
partial horners (ptosis, miosis, anyhdrosis)
describe the characteristics of a migraine
unilateral headache excruciating pain 2-4 hrs photophobia aura (visual or smells) n+ v has identifiable triggers
describe the characteristics of a cluster headache
lacrimation rhinorrhea partial horners episodic excruciating unilateral pain behind an eye drinking hx previous head injury
what type of headaches are unilateral?
migraine
cluster headache
describe the characteristics of acute angle closure glaucoma?
severe headache unilateral pain behind an eye redness of eye visual disturbance- eg blurring of vision, halos around lights n+ v
what ix might you do in cluster headache and why?
no specific ix at all
MRI to exclude anything more sinister
ESR to exclude giant cell arteritis
pituitary function tests to check for pituitary adenoma
how is cluster headache managed acutely?
sub cut sumatriptan
high dose high flow o2
what prophylaxis can be given for cluster headache?
verapamil (CCB)
what is jaw claudication a sign of and why?
temporal arteritis- when the jaw moves it contracts the temporalis muscle and irritates the inflammed artery
what is kernig’s sign used for, how do you carry it out and what is a positive result?
it is used to diagnose meningitis
lie the patient on their back, flex hip with extended knee
if pain is ellicited this is positive for meningitis
what ix is contraindicated in someone with raised ICP and why?
lumbar puncture because it can cause herniation
what makes symptoms worse when someone has raised ICP?
lying down
what makes symptoms better when someone has raised ICP?
standing up/NOT lying down
what is a sign of raised ICP? explain why
bilateral visual loss- if caused by hydrocephalus it can compress the optic nerve
what side of the head is a migraine on?
unilateral
what is the onset of a migraine like?
comes on gradually
what is the character of pain in a migaine?
pulsating and throbbing
how long do migraines last?
4-72 hrs
what is a characteristic feature of a migraine you should remember and need to ask about?
it interferes with the current activities someone is doing
what are rf for migraine?
family hx
stressful life event
female sex
sleep disorder
how is conservative management of migraines carried out?
headache diary
avoid triggers
relaxation techniques eg CBT and mindfulness
what drug must you not give to a migraine patient to help them manage their migraines?
opiods
how is acute management of a migraine carried out?
simple analgesia eg paracetamol/ibuprofen
triptans- these are analgesia specific to migraines but should only be used if really needed
what medication is an analgesia specific to migraines?
triptans
what preventative medications can be given for migraines?
first line propanolol or topimarate
second line amitriptyline
what are associated symptoms for migraine?
aura: flashing lights and tingling photophobia phonophobia nausea and vomitting visual changes numbness
what is trigeminal neuralgia?
facial pain syndrome in one or more distribution of the trigeminal nerve
how does pain theoretically arise in trigeminal neuralgia?
compression of branches of the trigeminal nerve by veins or arteries
what are the 3 big risk factors for trigeminal neuralgia?
old age
woman
multiple sclerosis
why does multiple sclerosis increase risk of trigeminal neuralgia?
because there is inflammation of the myelin sheath which makes it more likely a vein or artery will compress it and cause pain
where is the pain located in tirgeminal nerve neuralgia?
unilateral
describe the character of pain in trigeminal neuralgia
short episodes of unilateral stabbing/ shock like pain associated with numbness
what ix are done for trigeminal neuralgia?
none, usually diagnosis is clinical
how is trigeminal neuralgia managed?
first line= anti convulsants
long term= microvascular decompression or ablation
what surgery might be done for trigeminal neuralgia and when is this needed?
microvascular decompression or ablation surgery
usually needed for patients in hospital with severe disease because anticonvulsants are not enough to manage it
what is papilloedema?
optic disc swelling due to raised ICP
what causes papilloedema?
raised ICP
how can you identify papilloedema on fundoscopy?
there will be a blurred edge of the optic disc (the circle in the center) instead of a well demarcated edge
what symptoms do you get with a raised ICP?
bilateral headache worse in the morning cushing's triad (irregular breathing, bradycardia, raised systolic BP) associated with vomitting papilloedema
what do papilloedema, cushings triad, bilateral headache worse in the morning associated with vomitting point towards?
raised ICP
why might a headache be worse in the morning?
if someone has raised ICP because they have been lying down
what does a headache that is worse in the morning mean?
there is likely raised ICP
what makes a headache due to raised ICP worse?
lying down
what ix do you do immediately if there is raised ICP?
CT head
what ix should you never do if there is raised ICP?
lumbar puncture
between what 2 layers is the subarachnoid space?
under the arachnoid mater
above the pia mater
what does the subarachnoid space contain?
CSF
in what space is the CSF found?
subarachnoid
in meningitis what space is the virus in?
subarachnoid
what are the 2 ways you can acquire meningitis? explain what these mean (ie where the virus comes from and where it ends up)
direct spread- pathogen enters directly through an opening eg skull fracture, nose, deformity like spina bifida into subarachnoid space
haematogenosu spread- pathogen enters brain through bloodstream and leaves endothelial cells to enter subarachnoid space
what are the 3 ways you can get meningitis?
virus
bacteria
TB
what is the most common type of pathogen that causes meningitis?
virus
if a neonate has bacterial meningitis, what organism is likely to have caused it?
e coli
if a child has bacterial meningitis, what organism is likely to have caused it?
h influenzae, strep pneumoniae
if a teenager/young adult has bacterial meningitis, what organism is likely to have caused it?
neisseria meningitidis
if an elderly person has bacterial meningitis, what organism is likely to have caused it?
strep pneumoniae, listeria monocytogenes
if a uni student has meningitis what organism is likely to have caused this? why is this concerning?
neisseria meningitidis
this is concerning as it can cause meningococcal disease
what pathogen can cause meningococcal disease and is therefore dangerous? in who is this more likely
neisseria meningitidis
this is most likely in teens/young adults/ uni students
what are rf for meningitis?
below 5 y/o
over 65 y/o
crowded spaces eg uni accomodation
what are symptoms of meningitis?
meningism- neck stiffness, photophobia and headache
fever
nausea and vomiting
in later stages:
seizures
altered mental status
malaise
what is the triad of meningism?
neck stiffness
photophobia
headache
what 3 signs can be found in someone with meningitis?
kernig’s sign
brudzinski’s sign
petechial rash (non blanching)
what ix are done for meningitis? what is GS
obs, VBG CT head before LP if there is neurological deficit or reduced consciousness lumbar puncture (GS), 2 sets of blood cultures ideally one before treatment but do not delay treatment for it
what is gold standard ix for meningitis? what must you do before it and why
lumbar puncture
must do a CT head before it to rule out raised ICP
how are blood cultures done in meningitis and how many are needed?
you need 2 blood cultures, the first should ideally be before treatment is started but dont delay treatment for the blood culture
when might you do an LP before CT head in a patient with meningitis and why?
if they don’t have neurological deficits or reduced consciousness do the LP first because there are no signs of raised ICP and LP is the most important ix in meningitis
describe appearance, cells, glucose and protein level of CSF in bacterial meningitis and explain why this is so
appearance= cloudy/turbid cells= high neutrophils (polymorphs) glucose= low because bacteria metabolise the glucose protein= high because of inflammation of meninges
describe appearance, cells, glucose and protein level of CSF in viral meningitis and explain why this is so
appearance= clear cells= high lymphocytes (mononuclear) glucose= normal or high as viruses dont use the glucose protein= high due to meningeal inflammation
describe appearance, cells, glucose and protein level of CSF in TB meningitis and explain why this is so
appearance= fibrin web cells= high lymphocytes (mononuclear) glucose= low as bacteria metabolises glucose protein= high due to inflammation of meninges
if CSF if cloudy, low in glucose, high in protein and neutrophils what is the likely cause of meningitis?
bacterial
if CSF is clear, normal/high glucose, high protein and lymphocytes what is the likely organism of meningitis?
viral
if CSF has a fibrin web, is low in glucose, high in protein and lymphocytes what is the likely cause of meningitis?
TB
what causes of meningitis cause a low CSF glucose? why?
bacteria (inc TB)- they metabolise the glucose to multiply
what causes of meningitis cause a normal/high CSF glucose? why?
viral- the virus doesnt need to metabolise glucose to replicate
how is meningitis managed at GP?
immediate IM benzylpenicillin and urgently refer to hospital
how is meningitis managed in A&E?
broad spec abx (ceftriaxone IV, benzylpenicillin IM)
acyclovir if viral
targeted abx treatment depending on sensitivity
IV dexamethasone due reduce cerebral inflammation
what are complications of meningitis?
hearing loss
sepsis
impaired mental status
what are some complications of meningitis?
hearing loss
sepsis
impaired mental status
what broad spec medications are given for meningitis in hospital?
IV ceftriaxone
IM benzylpenicillin
acyclovir
IV dexamthasone
what is giant cell arteritis?
inflammation of the temporal arteries
what is the character of pain in giant cell arteritis?
dull ache
what triggers pain in giant cell arteritis? what does not trigger pain in giant cell arteritis and can be used to help narrow your differential
movement of the jaw eg eating
touching of the jaw does not trigger the pain
how can you differentiate giant cell arteritis from trigeminal neuralgia?
giant cell= a dull aching pain, triggered by jaw movements
trigeminal= electric shock like pain on one side of the face, triggered by touching the jaw
what is the difference in pathophysiology between giant cell arteritis and trigeminal neuralgia?
giant cell arteritis= inflammation of the arteries causing pain
trigeminal neuralgia= compression of the facial nerve causing pain
