Meningitis and Headaches... Flashcards
Give as many features you may wish to obtain in a history for meningitis.
- Exposure
- Petechial rash
- Recent infection
- Recent travel – endemic regions?
- History of IVDU
- History of recent or remote head trauma
- Otorrhea or rhinorrhea
- HIV infection or risk factors
- Immunocompromising conditions
Give 5 constitutional symptoms/signs of meningitis and 5 symptoms and signs more specific to meningitis.
- Stiff neck**
- Altered mental state (confusion, delirium, drowsiness, impaired consciousness)
- Non-blanching rash
- Bulging fontanelle (infants)
- Photophobia (Meningiococcal disease)
- Kernig’s Sign
- Brudzinski’s Sign
- Coma
- Paresis
- Focal neurological deficit
- Seizures
Constitutional: • Fever • Nausea • Vomiting • Lethargy • Irritable • Anorexia • Headache • Muscle ache • Joint pain • Cough
What is Kernig’s Sign? What feature may follow?
Thigh is flexed at the hip and knee at 90 degree angles, and subsequent extension in the knee is painful (leading to resistance)
What is Brudzinski’s Sign?
Forced flexion of the neck elicits a reflex flexion of the hips
Mr. X, A 67 year old builder, presents with headache and a fever. He says the lights are blinding him and he has been lethargic lately. He says his parents were proponents of anti-vaccination thus he has not had childhood immunisations.
O/E he has a temperature of 38.5ºC but all other observations are normal. You notice a purpuric rash on his back. Additionally, you identify neck stiffness and a focal neurological deficit.
When lying supine and flexed thigh at 90º, he finds it difficult to extend his leg. Additionally, when flexing his neck, he has involuntary flexion of his knees.
i) What risk factors for disease does this gentleman have?
ii) What type of rash might this be?
iii) What two signs are shown? Give them in order as they appear in the text.
Outline the investigations you wish to conduct and state any anticipated finds you might expect.
The CSF culture comes back as positive with protein present, hypoglycaemia and CRP raised.
iv) Give a DDx.
v) Outline the Management of the disease
i)
- Age > 65 years
- No immunisations
ii) Purpuric, non-blanching Meningiococcal rash
iii) Brudzinski’s Sign + Kernig’s Sign
Investigations:
• FBC: Leukocytosis, Anaemia, Thrombocytopenia
• Lumbar puncture to obtain CSF: Cell count and differential: Polymorphonuclear pleocytosis
• Blood culture: Positive
• CRP: Elevated
• Electrolytes: Acidosis; Hypomagnesemia; Hypocalcemia or Hyper/Hypoglycemia
• CSF Protein: Elevated protein
• CSF Glucose: Low < 2.5mmol/L
• CSF Gram stain: Positive
• CSF Culture: Positive
• Antigen detection in CSF: Neisseria meningitides capsular polysaccharide antigen
• Cranial CT: Raised ICP; Intracranial lesion
• Serum procalcitonin: Normal or elevated (99% sensitivity, 83% specificity bacterial vs viral)
DDx: Bacterial Meningitis
Management:
• ABCs: Airway, Breathing, Circulation
• Supportive: Electrolyte balance (ORT); Fluid balance
• ABX: Targeted
e.g. N. meningitidis: Cefotaxime 2g IV every 4 hours (adults)/ 200mg/kg/day IV in divided doses every 6 hours (neonates);
e.g. S. pneumoniae: Ampicillin: 2g IV every 4 hours (adults)/100-200mg/kg/day IV in divided doses every 6 hours (neonates)
What is Neonatal Meningitis?
inflammation of the lining of the brain (meninges) in newborns with bacterial colonization of maternal tract causing bacteremia in 1st week of life and meningitis at 2-3 weeks
Give the three aetiologies for neonatal meningitis. For each aetiological cause, give different pathogens which may be infective in each aetiology.
1) Transplacental • Rubella virus • Cytomegalovirus • HPV • Herpes Simplex Virus • HIV • Varicella Zoster Virus • Listeria monocytogenes • Treponema pallidum • Toxoplasma gondii
2) Intrapartum • CMV • HSV • HBV • HIV • Escherichia coli • Group B streptococcus • Chlamydia trachomatis • Neisseria gonorrhea • Listeria monocytogenes
3) Postpartum • CMV • HBV • VZV • HIV • HSV • Enteroviruses
Outline the pathophysiology of neonatal meningitis.
• Haematogenous spread (intrapartum) or direct extension from contiguous site (placenta/postpartum) -> bacteria spread -> Bacteria multiple in subarachnoid space -> induction of pro-inflammatory response -> inflammatory infiltrate: leukocytes, neutrophils… -> BB damaged via acute inflammation: PRISH ≈ permeability: proteins and cells enter CSF ± protein accumulation/fibrin deposition occludes aqueduct causing hydrocephalus ->
cerebral oedema and raised intracranial pressure ≈ neurological deficits ± damage
List the signs and symptoms of Neonatal Meningitis.
- Fever
- Headache
- Irritability (infants)
- Hypotonia (infants)
- Purpuric, non-blanching rash: Meningiococcal disease
- Bulging fontanelle (infants): raised ICP
- Opisthotonus (arching of back) (infants)
- Kernig’s Sign (supine and thigh flexed to 90º angle, difficult to extend or straighten leg – resistance)
- Brudzinski’s Sign: Flexion of neck causes involuntary flexion of knees and hips
- Focal neurological deficit: non-reactive pupil; ocular motility abnormalities; abnormal visual fields; gaze palsy; arm or leg drift
Master K, a 4 month old baby, presents with fever, headache and hypotonia.
O/E he has a temperature of 38.6ºC. You notice he has hypotonia and a purpuric, non-blanching rash. You notice bulging fontanelles, opisthotonos, positive Kernig’s and Brudzinski’s Sign.
i) Give the suspected DDx of the condition.
ii) What signs and Symptoms make you think this? List the others for this condition.
iii) List the investigations for the condition and any anticipated finds.
Your blood culture comes back and a bacterial pathogen of N. meningitidis is identified.
iv) Outline the management for this condition. Give the full prescription detail for any drugs given.
i) Neonatal meningitis
ii) Signs and Sx: • Fever • Headache • Irritability (infants) • Hypotonia (infants) • Purpuric, non-blanching rash: Meningiococcal disease
- Bulging fontanelle (infants): raised ICP
- Opisthotonus (arching of back) (infants)
- Kernig’s Sign (supine and thigh flexed to 90º angle, difficult to extend or straighten leg – resistance)
- Brudzinski’s Sign: Flexion of neck causes involuntary flexion of knees and hips
- Focal neurological deficit: non-reactive pupil; ocular motility abnormalities; abnormal visual fields; gaze palsy; arm or leg drift
iii) Investigations: Treat neonate < 3 months without delay if suspected bacterial meningitis
• FBC: Leukocytosis, Anaemia, Thrombocytopenia
• Lumbar puncture to obtain CSF: Cell count and differential: Polymorphonuclear pleocytosis
• Blood culture: Positive
• CRP: Elevated
• Electrolytes: Acidosis; Hypomagnesemia; Hypocalcemia or Hyper/Hypoglycemia
• CSF Protein: Elevated protein
• CSF Glucose: Low < 2.5mmol/L
• CSF Gram stain: Positive
• CSF Culture: Positive
• Antigen detection in CSF: Neisseria meningitides capsular polysaccharide antigen
• Cranial CT: Raised ICP; Intracranial lesion
• Serum procalcitonin: Normal or elevated (99% sensitivity, 83% specificity bacterial vs viral)
iv) Management: • ABCs: Airway, Breathing, Circulation • Supportive: Electrolyte balance (ORT); Fluid balance ABX: Targeted e.g. N. meningitidis: a) Suspected • Benzylpenicillin - < 1 year: 300mg IV - 1-6: 600mg - 6+: 1.2g
Known Meningitis
Cefotaxime: 200mg/kg/day IV in divided doses every 6 hours (neonates);
e.g. Group B streptococcus: Cefotaxime: 200mg/kg/day IV in divided doses every 6 houses for 14 days minimum
e.g. S. pneumoniae: Ampicillin: 100-200mg/kg/day IV in divided doses every 6 hours (neonates)
e.g. Gram-negative enteral bacilli: Cefotaxime: 200mg/kg/day IV in divided doses every 6 hours for 21 days minimum
List the 3 worst serogroups of Meningococcal meningitis.
A, B, C and W135
What pathogen causes meningococcal meningitis?
Neisseria Meningitidis
Outline the prophylaxis of meningococcal diseases.
List any patient groups you may wish to protect and how you do this.
- Ciprofloxacin PO 500mg single dose
- Pregnancy: Ceftriaxone IM 1g single dose
- Teenagers: ACW vaccine 0.5ml IM or deep SC
- Infants: Conjugate Meningococcus C vaccine
Should a child with suspected Meningococcal disease be allergic to Penicillin, what drug should be prescribed.
Chloramphenicol:
- child: 50-100mg/kg daily
- adult: 2-3g in 3 or 4 doses IV or orally
What are the risk factors for viral meningitis?
- Infants and young children
- Young adults
- Older people
- Seasonal: Summer and Autumn
- Exposure to mosquito or tick vector
- Unvaccinated for mumps
Outline 3 pathogens which may cause viral meningitis.
- Coxsackieviruses
- Echoviruses
- Enteroviruses
- Polioviruses
- Herpes virus-1 (HSV-1)
- VZV
- Mumps
- West Nile Virus
Outline the pathophysiology of viral meningitis.
• Transmission of pathogen into host -> replicate in tissues such as muscle, liver, respiratory or GI tract -> haematogenous spread -> viral penetration of BBB by infection of endothelial cells or migrating leukocytes -> virus spreads within subarachnoid space causing meningitis ± encephalitis or myelitis -> leukocytosis within CSF, pro-inflammatory cascade of IL-6 and TNF-a -> increased permeability of BBB allowing increased permeability of BBB
List the signs and symptoms of viral meningitis.
- Headache
- Nausea + Vomiting
- Photophobia
- Neck stiffness
- Fever
- Rash: Indicates infecting agent: Herpangina (Coxsackie Virus A); Maculopapular rash (Echovirus-9); Genital herpes (HSV-2)
- Kernig’s Sign
- Brudzinski’s Sign
What pathogen does a herpangina rash indicate in a patient with suspected viral meningitis?
Coxsackie Virus A
What pathogen does a maculopapular rash indicate in a patient with suspected viral meningitis?
Echovirus-9
What pathogen does a Genital herpes rash indicate in a patient with suspected viral meningitis?
Herpes Simplex Virus-2
Outline the investigations you would wish to conduct in a patient with suspected viral meningitis.
- FBC: WBC/CRP+ESR/Glucose
- U+E: Creatinine/eGFR/Urea
- CSF microscopy: Children = WBC > 5 cells/mm3 or Adults = > 20 cells/mm3
- CSF gram stain: Negative
- CSF bacterial culture: Negative
- CSF protein: Normal or elevated > 0.45g/L
- CSF glucose: may be low
- CSF viral culture: May be positive
• CT/MRI Head: Unremarkable in viral meningitis
Outline the management for Viral Meningitis for:
- HZV
- VZV
- CMV
- HZV/VZV: Aciclovir: 10mg/kg IV every 8 hours; higher doses for neonates (consult)
- CMV: Ganciclovir: 5mg/kg IV every 12 hours; consult for child doses
What is a brain abscess?
Focal, intracerebral infection evolving from area of cerebritis into collection of purulent material enveloped in a gliotic, vascularisaed capsule within the brain parenchyma
Outline the causes of a brain abscess.
- Direct spread from infection in paranasal sinuses, middle ear and teeth
- Indirect spread from infection in paranasal sinuses, middle ear and teeth
List 5 risk factors for a brain abscess.
- Male Sex
- Age < 30 years
- Sinusitis
- Otitis media
- Dental procedure/infection
- Meningitis
- Congenital heart disease
- Endocarditis
- Diabetes mellitus
- HIV
- Immunocompromised
- IVDU
- Granulomatous disease
- Hemodialysis
- Premature birth
Outline the pathophysiology of a brain abscess.
• Entry of pathogen into brain direct extension or haematogenous spread –> pathogen mediates inflammatory infiltrate ≈ increase permeability of BBB —> abscess located in grey-white junction
List the signs and symptoms of a brain abscess.
- Headache
- Meningismus (stiff neck + reaction to light + headache) w/o meningitis
- Fever
- Cranial nerve palsy: CN III, CN VI, anisocoria, papilloedema
- Positive Kernig’s sign
- Positive Brudzinski’s sign
- Neurological deficit: Motor or sensory findings; hemiparesis, focal seizures
- Hydrocephaly (increased head circumference)
- Bulging fontanelles
- Fever
Outline the investigations you would wish to conduct in a patient with a suspected brain abscess. Give the anticipated finds.
- FBC: Leukocytosis
- Serum erythrocyte sedimentation rate (ESR): Elevated
- Serum CRP: Elevated
- Serum PT and PTT: Normal
- Blood culture: May be positive
- Serum toxoplasma titre (suspect HIV/immunocompromised): May be positive
- CT-head/MRI with contrast: 1 ≤ ring-enhancing lesions
- US-head (infants): May show cavitary lesion
• LP + CSF analysis: WBC elevation, reduced glucose, toxoplasmosis, positive PCR
Outline the management for a patient with a brain abscess.
• Vancomycin: 15mg/kg IV every 12 hours \+ • Metronidazole: 500mg IV every 6 hours \+ • Ceftriaxone: 2g IV every 12 hours
Mnemonic: CMV
• Anticonvulsant: Phenytoin: 1000mg OD PO day 1, 300-600mg/day in 3 divided doses
What is viral encephalitis?
Inflammatory process of brain parenchyma
Give 5 risk factors for viral encephalitis.
- Age: <1 year or 65 < years
- Immunodeficiency
- Viral infections
- Body fluid exposure
- Organ transplantation
- Animal or insect bites
- Location
- Season
Give 5 putative pathogens that may cause viral encephalitis.
- HSV-1/HSV-2 (Most commonly diagnosed)
- VZV (Post-infective cerebellitis, acute infective encephalitis or vasculopathy)
- EBV (Immunocompromised)
- CMV (Immunocompromised; retinitis or radiculitis
- Poliovirus (Myelitis)
- Coxsackieviruses (aseptic meningitis)
- Echoviruses (aseptic meningitis)
- Arboviruses
- Mumps
- Measles
- Influenza virus
- Erythrovirus B19
Outline the pathophysiology of viral meningitis.
• Virus gains entry and replicates in local or regional tissues -> dissemination to CNS via haematogenous route (coxsackie viruses, enteroviruses, HSV, HIV, mumps…) or retrograde axonal transport (herpes virus) -> host immune response: Abs, Cytotoxic T cells, cytokines -> inflammation of brain parenchyma
A 67 year old gentleman, Mr. U, presents with a fever and a rash. His wife says he has been quite confused and has constantly switched the lights off. He has a PMHx of MI, HIV and a kidney transplant.
O/E you notice his marked fever of 38.6ºC. He scores a 6 on his 4AT assessment. You notice a rash which is in a truncal distribution on the left, anterior of his abdomen. The lesion is a Maculopapular rash. Mr. U clearly displays signs of meningismus.
i) What are Mr.U’s risk factors for illness?
ii) What are the questions a 4AT examination comprises of?
iii) What pathogen might be causing this illness based on the rash?
Give the Ddx’s you may suspect.
iv) Outline the investigations you wish to conduct. You suspect a viral encephalitis, give the anticipated finds of each investigation.
The MRI-brain comes back showing a diffuse hyper intense lesion.
v) Outline the management for Mr. U’s viral meningitis.
i) RF:
- Age (> 65)
- HIV
- Age: immunocompromised
- Organ transplant
ii)
1) Name and address (0, 0, 4)
2) DOB, Age, Place, Current Year (0, 1, 2)
3) Reverse months of the year test (0, 1, 2)
4) Acute fluctuation: Last 2 weeks still present in the last 24 hours?
iii) EBV
Viral Meningitis Viral Encephalitis** Brain Abscess Stroke Somatisation Seizure Sepsis
iv)
• FBC: Leukocytosis
• Electrolytes: Hyponatremia
• LFTs: Elevated
• Blood cultures: Detection of systemic bacterial infections
• Sputum culture: Detect mycoplasma tuberculosis (AFB stain)
• CT brain: may see prominent changes of hypodense lesions, haemorrhage, ring-enhancing lesions
• MRI brain: Hyperintense lesions, increased diffusion on DWI
• Electroencephalogram (EEG): Background slowing
• PCR
- CSF analysis: elevated WBC; elevated protein; low glucose; elevated RBCs
- CSF culture: Findings dependent on etiology
- CSF serology: Findings depend on etiology
v) Management:
• ABCD
• Aciclovir IV
List 3 common and 3 uncommon cause of headache.
- Tension headache
- Migraine
- Acute sinusitis
- Otitis media
- Menstrual headache
- Medication withdrawal
- Medication overuse
- Cervical paraspinal muscle tenderness
- Wisdom tooth impaction
- TMJ
- Acute hydrocephalus
ii) Uncommon • Idiopathic Intracranial Hypertension • Brain tumour • Hypertensive encephalopathy • Subarachnoid Hematoma • Meningitis • Other SOL • Temporal arteritis • Strokes
Outline what key features you would want to elucidate in a headache history.
• SOCRATES
- Site
- Onset: Frequency and When; Diurnal variation
- Character
- Radiation
- Associated symptoms
- Time
- Exacerbating
• Other neurological symptoms
- PMHx
- FHx
- DHx
What is a tension headache?
= episodic or chronic pain in the head in the absence of nausea, vomiting and lack of aggravation by routine physical activity
Give 3 risk factors for a tension headache.
- Mental tension
- Stress
- Missing meals
- Fatigue
Outline the aetiologies of tension headache and the subsequent pathophysiology.
Aetiology: • Muscle contraction • Stress • Disturbed sleep patterns • Insomnia
Pathophysiology:
• Pericranial muscle tension ≈ Release of inflammatory agents -> sensitization of peripheral trigeminal afferents ≈ central hypersensitivity
Give 3 signs and symptoms of a tension headache.
- Generalised head pain: bilateral, pressure-like, non-throbbing pain; constant or worst at evening; absence of nausea
- Frontal or occipital head pain
- Non-pulsatile head pain: Dull pain
- Constricting pain: Tight band around head
- Normal neurological examination
- Pericranial tenderness
- SCM muscle tenderness
- Trapezius muscle tenderness
A 37 year old housewife, Mrs. I, presents with a headache. She clarifies that the site is at her head only, the onset is constant but worst at evening. She says she does not feel sick. The pain does not radiate and is focused mainly at the front of her head. She says the type of pain is a dull pain, like a tight band around the head. Her PMHx is gravidity 2 and parity 1. She has experienced MHD following her miscarriage and has had disturbed sleep patterns, insomnia and stress. Due to this, she has lost appetite.
O/E she has no neurological deficits, in a normal neurological exam. You identify pericardial tenderness, SCM tenderness and trapezius muscle tenderness.
i) What are her risk factors for illness?
ii) Outline the key symptoms she is experiencing.
iii) What investigations might you order?
These come back as negative.
iv) What is your DDx?
v) Outline the management of Mrs. I’s condition.
i) RF: • Mental tension • Stress • Missing meals • Fatigue
Symptoms and Signs:
• Generalised head pain: bilateral, pressure-like, non-throbbing pain; constant or worst at evening; absence of nausea
• Frontal or occipital head pain
• Non-pulsatile head pain: Dull pain
• Constricting pain: Tight band around head
- Normal neurological examination
- Pericranial tenderness
- SCM muscle tenderness
- Trapezius muscle tenderness
iii) Investigations: • Clinical diagnosis • MRI Brain: Rule out pathology • Lumbar puncture: Rule out pathology
iv) Tension headache
v) Management:
• Supportive: Reassurance, explain muscles around head, relaxation exercises
• Analgesics: Paracetamol
• Amitriptyline (low-dose)
Give the pharmacological management of tension headache
Low-dose amitriptyline
Paracetamol
Give the non-pharmacological management of tension headache.
Reassurance
Relaxation exercises
Remove underlying cause: stress/anxiety/MHD
What is a Migraine?
chronic, genetically determined, episodic, neurological disorder presenting in early-to-midlife involving a prolonged unilateral headache which is pulsating and sharp involving nausea which decreases with activity.
Give 3 main differences between a migraine and a headache.
Migraine:
- Length: 4-72 hours
- Nausea + Vomiting
- Unilateral
- Pulsating and sharp pain
Headache:
- Temporary
- No nausea
- Global
- Dull headache
List the signs and symptoms of a migraine.
- Prolonged headache: 4-72 hours; unilateral (or bilateral), pulsating/sharp
- Nausea
- Decreased ability to function
- Headache worsens with activity
- Sensitivity to light (photophobia)
- Phonophobia
- Vomiting
- Unilateral
- Throbbing sensation
List 5 risk factors of a migraine.
- FHx migraine
- High caffeine intake
- Change in barometric pressure
- Female sex
- Menstruation
- Divorced/Widowed/Separated
- Obesity
- Habitual snoring
- Stressful life events
- Lack of sleep
Give two foods which may exacerbate migraines/cause migraines. What chemical group is present in these?
Red wine
Chocolate
Coffee
Group: Xanthine derivatives
Outline the pathophysiology of a migraine.
• Neurogenic inflammation of VI of trigeminal sensory neurons innervating large vessels and meninges of the brain –> release vasodilating agents + substances increasing permeability ≈ leakage of plasma proteins and platelet activation –> sensitises nerve fibres so previously ignored stimuli e.g. pulsations of meningeal vessels are interpreted as painful (peripheral sensitization) –> pain processed by brain ±
Aura: wave of neuronal excitation spreads anteriorly in cortex ≈ decreased neuronal activity and neuronal recovery ≈ cortical depression releases excitatory amino acids and other mediators of excitation ≈ activation of nocicpetors in adjacent dura and blood vessels
What is Aura?
wave of neuronal excitation spreads anteriorly in cortex ≈ decreased neuronal activity and neuronal recovery ≈ cortical depression releases excitatory amino acids and other mediators of excitation ≈ activation of nocicpetors in adjacent dura and blood vessels
List 3 signs and symptoms of migraine.
- Prolonged headache: 4-72 hours; unilateral (or bilateral), pulsating/sharp
- Nausea
- Decreased ability to function
- Headache worsens with activity
- Sensitivity to light (photophobia)
- Phonophobia
- Vomiting
- Unilateral
- Throbbing sensation
Outline any investigations you may wish to conduct in a patient with migraine symptoms.
Why do you do each?
- CT head: Normal; rule out intracranial haemorrhage
- CSF culture: Normal; rule out infection
- Lumbar Puncture: Normal in migraine; Rule out pathology
A 32 year old flight attendant, Mrs. Y, presents with a recent bout of ‘headache’. She clarifies, when asked, that the headache lasts for about 8 hours at a time. The onset is in the evening and worsens with activity. She describes feeling sick when experiencing these headaches. The pain is focused on the right side of her head and is described as sharp/pulsating. Her diet is balanced however admits to drinking a lot of coffee to conduct her shift work. She has no PMHx however she has had a history of MHD after her recent divorce. She is currently not on any oral contraception, and is asking to restart after she stopped about 3 months ago. Mrs. Y is a non-smoker but does enjoy 3 glasses of red wine with a bar of chocolate every evening.
i) What are Mrs. Y’s risk factors?
ii) Give the signs and symptoms Mrs. Y is feeling.
iii) Outline any investigations you may wish to carry out and why.
iv) Suggest your DDx.
v) Outline the management for Mrs. Y.
i) RF • Female sex • Menstruation • Divorced/Widowed/Separated • Stressful life events • Lack of sleep • Change in barometric pressure • High caffeine intake
ii) • Prolonged headache: 4-72 hours; unilateral (or bilateral), pulsating/sharp • Nausea • Decreased ability to function • Headache worsens with activity
iii)
• Clinical diagnosis
- FBC: Anaemia/ WBC/ CRP/ TSTs
- CT head: Normal; rule out intracranial haemorrhage
- CSF culture: Normal; rule out infection
- Lumbar Puncture: Normal in migraine; Rule out pathology
iv) Migraine
v) Management:
• Supportive: Hydration/Remove trigger/Relaxation therapy
1) Acute
• NSAID/Aspirin:
- Aspirin: 900-1000mg single dose then 300-900mg 4-6 hours - maximum 4g/day;
- Ibuprofen: 800mg single dose then 400-800mg every 4-6 hours – maximum 2.4g/day
(+ Adjunct)
• Anti-emetic: Metoclopramide: 5-10mg PO/IV/IM every 8 hours for maximum 5 days
• Triptan: Sumatriptan/Rizatriptan/Naratriptan ≈ 5HT-1b/5HT-1d (serotonin) receptor agonists
2) Prophylactic • ß-blockers • Low dose amitriptyline • Pizotifen • Sodium valproate • Candesartan • Lisinopril • Methysergide (retroperitoneal fibrosis)
Other
• Botulinum toxin injection: every 90 days
• Anti-CGRP mAb: Erenumab: > 4 migraines per motnh and try 3 other prophylactics
• Acupuncture
Outline the pharmacological management of a migraine.
• NSAID/Aspirin:
- Aspirin: 900-1000mg single dose then 300-900mg 4-6 hours - maximum 4g/day;
- Ibuprofen: 800mg single dose then 400-800mg every 4-6 hours – maximum 2.4g/day
(+ Adjunct)
• Anti-emetic: Metoclopramide: 5-10mg PO/IV/IM every 8 hours for maximum 5 days
• Triptan: Sumatriptan/Rizatriptan/Naratriptan ≈ 5HT-1b/5HT-1d (serotonin) receptor agonists
Outline the MOA of a Triptan. Name 2 examples
5-HT1b/5HT-1d receptor agonist
Sumatriptan
Naratriptan
Rizatriptan
Should a patient experience more than 4 migraines a month and have tried 3 other prophylactics, what mAb therapy can be used?
List 3 potential prophylactics that could have been trialled before the aforementioned mAb is trialled.
Erenumab (Anti-CGRP mAb)
Other Prophylactics: ß-blockers Low-dose amitriptyline Sodium valproate Candesartan Lisinopril
What is Trigeminal Autonomic Cephalgia?
group of primary headaches characterized by unilaterality of pain, short duration of symptoms and associated ipsilateral cranial autonomic symptoms – Horner syndrome, lacrimation and nasal congestion
What are the risk factors for Trigeminal Autonomic Cephalgia?
- FHx
- Male sex
- Head injury
- Heavy smoking
- Heavy drinking
List the symptoms and signs of Trigeminal Autonomic Cephalgia.
- Repeated attacks of unilateral pain: Unilateral orbital/retro-orbital/temporal pain/maxillary pain; lasts <3 hours; QDS
- Excruciating pain: Sharp/piercing/burning/pulsating; Trigeminal distribution
- Trigeminal distribution of pain
- Lacrimation
- Rhinorrhea
- Partial Horner’s Syndrome
- Photophobia
- Migrainous aura
Outline the management of Trigeminal Autonomic Cephalgia.
- Triptans: Sumatriptan/Rizatriptan/Naratriptan ≈ 5HT-1b/5HT-1d (serotonin) receptor agonists
- Oxygen
- High dose verapamil: up to 960mg/day
- Indomethacin (Paroxysmal Hemicrania)
What is a medication overuse headache?
Headache caused by reliance, strength and dose of medication.
- Duration: 15-31 days
- Worsened on analgesia
- Stimuli-dependent: Simple analgesia >15 days cf > 10 days for other acute – triptans
- Management: Abrupt cessation vs gradual stopping
What is a thunderclap headache?
- Onset: Instant/rapid <60 seconds
- Consider SAH but can be exertional (coital cephalgia)
- Urgent investigation: CT-head, LP after 12 hours, look for bilirubin and oxyhemoglobin
Give an exertional cause of thunderclap headache.
Coital cephalgia
A 59 year old builder, Mr. T, presents with a severe headache. He has tender temporal arteries and jaw claudication. He also describes very achy and fatigued muscles in numerous locations: biceps, triceps, trapezius, quadriceps… He also mentions how he suddenly lost vision in one eye, which is strange as he would have thought there would be pain if that happened.
O/E he has a normal neurological examination but displays
i) What signs and symptoms does he have?
ii) What investigations would you order?
iii) What is your DDx?
iv) How would you manage this?
i) Signs and Symptoms: • Features of polymyalgia • Jaw claudication • Tender temporal arteries • Amaurosis Fugax
ii) Investigations:
• Raised ESR
• Ultrasound + Doppler
• Temporal artery Biopsy
iii) DDx:
Temporal Arteritis***
Headache
iv) Management:
• Steroids
Give 3 risk factors for developing a cerebral venous sinus thrombosis.
Outline the features of this.
Outline the management of Cerebral Venous Sinus Thrombosis.
- Female
- OCP
- Age > 65
Signs and Sx:
• Headache
• Seizures
• Bilateral
Investigations:
• MRI/MRV
Management:
• Anticoagulants
