Neuro - Headache Flashcards
What is a headache?
usually a symptom of life
What are the patterns of an acute single headache?
→ Febrile illness → sinusitis → First attack of migraine → Following a head injury → Subarachnoid haemorrhage → Meningitis → tumour → drugs → toxins → stroke → Thunderclap (sudden onset) → low pressure
What are the patterns of an dull headache, increasing in severity?
→ Usually benign → Overuse of medication (e.g. codeine) → Contraceptive pill, hormone replacement therapy → Neck disease → Temporal arteritis → Benign intracranial hypertension → Cerebral tumour → Cerebral venous sinus thrombosis
What are the possible causes of a dull headache that’s unchanged over months?
→ chronic tension headache
→ depressive, atypical facial pain
What are the possible causes of a triggered headache that’s unchanged over months?
→ coughing, straining, exertion
→ coitus
→ food and drink
What are the possible causes of a recurrent headaches that’s unchanged over months?
→ migraine
→ cluster headaches
→ episodic tension headache
→ trigeminal or post-herpetic neuralgia
What are the red flags of headaches?
→ onset (thunderclap, acute, subacute)
→ meningism (photophobia, phonophobia, stiff neck, vomiting)
→ systemic symptoms (fever, rash, weight loss)
→ neurological symptoms or focal signs (visual loss, confusion, seizures, hemiparesis, double vision, 3rd nerve palsy, Horner syndrome, papilloedema)
→ orthostatic-better lying down
→ strictly unilateral
What is 3rd nerve (oculomotor) palsy?
→ weakness of the oculomotor nerves
→ completely closed eyelid and deviation of the eye outward and downward
→ eye cannot move inward or up
→ pupil is typically enlarged and does not react normally to light
What is Horner Syndrome?
→ combination of signs + symptoms due to disruption of nerve pathway from brain to face + eye, usually on one side
→ decreased pupil size, drooping eyelid, decreased sweating on affected side of face
What are the signs of a subarachnoid haemorrhage?
→ sudden generalised headache “blow to the head” or “thunderclap” onset
→ meningism - stiff neck + photophobia
What proportion of SAHs are fatal?
around 50%
How are SAHs treated primarily?
→ Vasospasm may stop the leak.
→ Nimodipine and BP control due to high risk of further bleed
How were aneurysms treated once upon time?
aneurysms used to be clipped or wrapped
What causes SAHs?
→ most are caused by a ruptured aneurysm
→ few from arteriovenous malformations
→ some are unexplained
How are aneurysms treat now?
→ catheter inserted through the groin to access the cerebral arteries
→ the aneurysm is filled with platinum coils
What are the general categories of causes of headaches?
→ structure
→ pharmacological
→ psychological
How are SAHs assessed + diagnosed?
→ early neurological assessment will confirm beed + establish the cause → Brain CT → lumbar puncture (RBC + xanthochromia) → MRA (MR angiogram) → angiogram
What is coning?
→ brain has a capacity for volume + pressure
→ when volume in brain increases, intracranial pressure (ICP) increases
→ when ICP crosses a threshold, brain can no longer be contained and herniates through weak points
→ hernias = coning
What causes coning?
acute intracranial bleeding
What are other signs of raised ICP?
→ papilloedema = optic disc swelling
How can larger arteries in the neck cause headaches?
through artery dissections (abnormal, and usually abrupt, formation of a tear along the inside wall of an artery)
What is an artery dissection?
→ layers of blood vessels tissue can split, causing blood to seep between the layers
→ causes turbulent flow of blood
What are the secondary symptoms of arterial dissections?
→ strokes + clots (turbulent flow of blood with coagulant factors can cause this)
→ headaches + neck pain
What are the stats on strokes caused by arterial dissection?
→ causes 20% of ischaemic strokes under 45
→ carotid artery strokes > vertebral artery strokes
→ mean age of 40
What can cause arterial dissections?
→ traumatic
→ spontaneous
What tests can be used to diagnose artery dissection?
→ MRI / MRA
→ doppler
→ angiography
What is the treatment for artery dissection?
→ aspirin
→ anticoagulants
How do carotid artery dissection headaches present?
→ in a “phantom of the opera mask” distribution
→ in the frontal part of the face
How do vertebral artery dissection headaches present?
→ occipital headaches
→ in the back of the head + neck
What is temporal arteritis?
inflammation of the temporal artery
What is the demographic of people with temporal arteritis?
→ over the age of 55
→ 3 times commoner in females
What are the signs and symptoms of temporal arteritis?
→ constant unilateral headache
→ scalp tenderness
→ jaw claudation
→ 25% polymyalgia rheumatica-proximal muscle tenderness
What are the clinical features + diagnostic tests for temporal arteritis?
→ inflamed temporal artery is visible on ultrasound
→ biopsy should show inflammation + giant cells
How is temporal arteritis treated?
high dose steroids + aspirin
What is CVT?
→ cerebral venous thrombosis
→ thrombosis in dural venous sinus or cerebral vein
What are the signs and symptoms of CVT?
→ unusual no. of headaches due to raised ICP
→ non-territorial ischemia called “venous infarcts”
→ haemorrhage
→ thrombophilia
→ pregnancy
→ dehydration
→ behcets (inflammation of blood vessels + tissues)
What is meningitis?
inflammation of meninges
What are the different causes of meningitis?
→ viral (coxsackie, ECHO, Mumps, EBV)
→ bacterial (meningococci, pneumococci, haemophilus, tuberculous)
→ fungal (cryptococci)
→ granulomatous (sarcoid, lyme, brucella, behcets, syphilis)
→ carcinomatous
What are the presenting symptoms of meningitis?
→ malaise → headache → fever → neck stiffness → photophobia → confusion → alteration of consciousness
What is the key principle of managing someone who’s suspected to have meningitis?
→ treat before diagnosis
→ meningitis is fatal
How is meningitis treated?
antibiotics if bacterial
How is meningitis diagnosed?
→ blood + urine culture
→ CT or MRI scan
→ then lumbar puncture
What is analysed in a lumbar puncture for meningitis?
→ increased white cell count → decreased glucose → antigens → cytology → bacterial culture
Why should CT scans + MRIs be done before lumbar puncture in meningitis?
→ swollen meninges = raised ICP
→ needle from lumbar puncture could lead to rapid decompression
→ could lead to coning
How does bacterial meningitis present on a scan?
cerebral oedema with effacement of ventricles + sulci + inflamed meninges
What is sinusitis?
inflammation of sinuses
What are the symptoms of sinusitis?
→ malaise → headache → fever → blocked nasal passages → loss of vocal resonance → anosmia → nasal or post-nasal catarrh (build-up of mucus) → frontal pain characteristically stats 1-2 hours after rising + clears in the afternoon
How do sinuses appear on X-rays for people with sinusitis?
opacification of sinuses (whiter and denser sinuses)
What kind of tumours can cause headaches?
→ literally any tumour in the brain
→ glioblastoma multiforme
Why do tumours in the brain cause headaches?
they raise ICP
What is idiopathic intracranial hypertension?
→ also called pseudotumour cerebri
→ high pressure around the brain + raised ICP
What are the signs + symptoms of IIH?
→ often young obese women → headache → visual obscurations → diplopia → tinnitus → papilloedema → visual field loss
What drugs can cause IIH?
→ hormones
→ steroids
→ antibiotics
→ vitamin E
How can IIH be treated?
→ weight loss → diuretics → optic nerve sheath deocmpression → lumboperitoneal shunt → stenting of stenosed venous sinuses
What does a CT scan for IIH look like?
→ cerebral oedema w effacement of ventricles + sulci
→ no mass lesion
What is a low pressure headache?
headache due to low ICP
What can cause a low pressure headache?
→ CSF leak due to tear in dura
→ traumatic post lumbar puncture or spontaneous
What are the hallmarks of a low pressure headache?
→ headache starts when they get up due to low volume of CSF in head
→ headache stops when they lie down due to higher volume of CSF in head
→ X-rays show meningeal enhancement
What is the treatment for low pressure headaches?
→ rehydration
→ caffeine
→ blood patch
What is a blood patch?
→ blood is injected into epidural space
→ tear is sealed due to coagulants in blood
What is chiari malformation?
→ normal brain that sits very low within the skull
→ cerebellar tonsils descend through the foramen magnum
What causes the headache in chiari malformation?
→ tonsils descend further when the patient coughs + tugs on the meninges
→ creates a cough headache
How is chiari malformation treated?
→ treat whatever’s causing the cough
→ surgery can remodel bone of skull to take away some bone and create some space
What is obstructive sleep apnoea?
→ muscles that support the soft tissues in your throat, such as your tongue and soft palate, temporarily relax
→ when these muscles relax, your airway is narrowed or closed, and breathing is momentarily cut off
What are the signs and symptoms of obstructive sleep apnoea?
→ characteristic body habitus → history of loud snoring + apnoea spells → hypoxia + CO2 retention → non-refreshing sleep → depression → impotence → poor performance at work
How does OSA cause headaches?
→ CO2 = vasodilator
→ so CO2 retention = increased vasodilation
→ leads to morning headaches
How is OSA assessed + treated?
→ requires nocturnal NIV
→ surgery to remove and ease obstruction causing sleep apnoea
What is trigeminal neuralgia? What are the signs + symtoms?
→ electric shock like pain in distribution of trigeminal sensory nerve in the face
→ can be a symptom of MS
What are the causes of trigeminal neuralgia?
→ neurovascular conflict at the point of entry of the nerve into the pons
→ triggered by innocuous stimuli e.g. chewing gum, etc.
How is trigeminal neuralgia treated?
anticonvulsants : → carbamazepine → lamotrigine → gabapentin surgery : → posterior fossa decompression
What is atypical facial pain?
syndrome that encompasses a wide group of facial pain problems
What demographic does atypical facial pain occur in?
→ most commonly in middle aged women
→ depressed + anxious
What are the signs + symptoms of atypical facial pain?
→ daily, constant, poorly localised deep aching or burning
→ facial or jaw bones, may extend to the neck, ear or throat
→ not lancinating
→ not conforming to to the strict anatomical distribution of any nerve
→ no sensory loss
→ pathology in teeth, temporomandibular joints, eye, nasopharynx + sinuses must be excluded
How is atypical facial pain treated?
→ unresponsive to conventional analgesics, opiates + nerve blocks
→ mainstay of management tricyclics
What proportion of people present with post-traumatic headaches?
→ 36% at discharge
→ 24% in the next 6 months
→ 16% at 12 months
Who is predisposed to having post-traumatic headaches?
→ correlates with previous history of headaches
→ unrelated to duration of post-traumatic amnesia
How does post-trauma headache depend on nature of head injury?
→ High in victims of car accidents
→ Low in perpetrators of car accidents
→ Low in sports injuries
What pathologically causes post-traumatic headaches?
→ Neck injury
→ Scalp injury
→ Vasodilation due to autonomic damage
→ Depression - often delayed
How do you manage + treat post-traumatic headaches?
→ Explanation
→ Prevent analgesic abuse
→ Non-steroidal anti-inflammatories - ibuprofen, naproxen
→ Tricyclic antidepressants - Amitriptyline
What cervical spondylosis?
→ narrowing of joint space due to worn disc
→ commonest cause of new headache in older patients
What are the symptoms of cervical spondylosis?
→ Usually bilateral → Occipital pain can radiate forwards to the frontal region → Steady pain → No nausea or vomiting → Worsened by moving the neck
How do you manage + treat cervical spondylosis?
→ Rest → deep heat → massage. → Anti-inflammatory analgesics → Over-manipulation may be harmful
What is a migraine?
headaches, characterised by: → tendency to repeated attacks → triggers → easily hung-over → visual vertigo → motion sickness
What forms do migraine attacks come in?
→ just pain
→ pain + focal symptoms
→ just focal symptoms
What causes migraines?
spreading of electrical depression across the cerebral cortex
What are the different phases of a migraine?
→ prodrome → aura → headache → resolution → recovery
What is a part of the prodrome phase of migraines?
→ changes in mood → urination → fluid retention → food craving → yawning
What is involved in the aura phase of migraines?
→ visual → sensory (numbness / paraesthesia) → weakness → speech arrest → scintillations + blindspots → positive + negative → expanding Cs → elemental visual disturbances
What is a part of the headache phase of migraines?
→ hemicranial head pain → body pain → nausea → photophobia → vomiting → phonophobia
What is a part of the resolution phase of migraines?
period of time when the headache dies down
→ sweeter + more comforting type of pain
→ rest + sleep
What is a part of the recovery phase of migraines?
→ mood disturbed
→ food intolerance
→ feeling hungover
How long does a whole migraine cycle take?
48 hours or so
How do you treat an acute migraine attack?
→ Aspirin/ibuprofen (Non-steroidals) and paracetamol and metoclopramide (anti-emetic)
→ Soluble preparations to aid absorption
→ Triptans-tablets, melts, nasal sprays, s/c injections (vasoconstrictions) + synergise with NSAIDS
→ Hit the headache hard and fast
→ Opiates-caution! Analgesic abuse potential
→ A short nap
→ TMS (transcranial magnetic stimulation) interrupts complex networks that trigger and perpetuate migraine
What are some of the lifestyle issues experienced by those with migraines?
→ Migraineurs have sensitive heads even in between attacks.
→ Over-react to any sort of stimulation.
→ Can’t ignore the world around them, it overstimulates their brains.
How can people with migraines change their lifestyles to help themselves?
→ avoid trigger e.g. dietary, environmental, hormonal, weather, dehydration, stress
→ Drink 2 litres water/day
→ Avoid caffeinated drinks
→ Don’t skip meals
→ Fresh food - Avoid ready meals & take-aways due to preservatives + additives
→ Don’t oversleep or have late nights + keep electronics downstairs
→ Analgesic abuse
What treatments can be used against chronic migraines?
→ Over-the-counter preparations: feverfew, coenzyme Q10, riboflavin, magnesium, EPO, nicotinamide
→ Tricyclicantidepressants (TCAs) : amitriptyline 7pm (makes you drowsy tho)
→ Beta-blockers : Propranolol, Atenolol (drops BP and pulse)
→ Serotonin antagonists: pizotifen, methysergide
→ Calcium channel blockers : flunarazine, verapamil
→ Anticonvulsants: valproate, topiramate, gabapentin
→ Greater occipital nerve blocks (injectable into the nerves to numb pain)
→ Botox in a crown of thorns distribution (injectable)
→ Suppress ovulation for those triggered by it (progesterone only pill or implant/injection)
→ Erenumab
What counts as a chronic migraine?
more than 14 migraines a month
Why can oestrogen not be given to those who suffer from migraines?
oestrogen can trigger migraines
How does Erenumab work?
→ Injectable drug erenumab (Aimovig)
→ cut number of days people had migraines from an average of 8 a month to between 4 and 5 a month.
→ Monoclonal antibody
→ disables calcitonin gene-related peptide or its receptor (CGRP mAbs)
→ Episodic migraine, chronic migraine, or cluster headache.
What is a tension type headache? What are the signs?
pain + tight muscles around head and neck bilaterally, as though head is in a vice
How can a tension type headache be treated?
→ NSAID’s preferred: Ibuprofen, Naproxen, Diclofenac
→ Paracetamol
→ Tricyclic antidepressants : Amitriptyline 50-75mg daily (30-60% derive some symptomatic relief)
→ SSRIs (probably less effective)
→ Biofeedback and relaxation (unproven)
What is a cluster headache?
→ Severe unilateral pain lasting 15-180 minutes untreated
→ Classified as a trigeminal autonomic cephalgia (headache)
What are the symptoms of a cluster headache?
→ Forehead and facial sweating
→ Miosis and/or ptosis
→ A sense of restlessness or agitation
→ Frequency between one on alternate days to 8 per day
→ Not associated with a brain lesion on MRI
At least one of the following, ipsilaterally:
→ Conjunctival redness and/or lacrimation (flow of tears)
→ Nasal congestion and/or rhinorrhoea (free discharge of thin nasal fluid)
→ Eyelid oedema
How are cluster headaches treated acutely?
→ Inhaled oxygen
→ S/C or Nasal Sumatriptan
Why does inhaled oxygen help with cluster headaches?
Oxygen inhibits neuronal activation in the trigeminocervical complex
What can prevent cluster headaches?
→ Verapamil → Prednisolone → Lithium → Valproate → Gabapentin → Topiramate → Pizotifen
What’s the difference in distribution between migraines + cluster headaches?
→ mig = 1:2, M:F
→ cluster = 9:1, M:F
What’s the difference in duration between migraines + cluster headaches?
→ mig = 3-12 hours
→ cluster = 45 min - 3 hours
What’s the difference in frequency between migraines + cluster headaches?
→ mig = 1 to 8 attacks monthly
→ cluster = 1 to 3 attacks daily (often at night)
What’s the difference in remission between migraines + cluster headaches?
→ mig = unusual to have long remissions
→ cluster = long remissions are common
What’s the difference in nausea between migraines + cluster headaches?
→ mig = nausea + vomiting frequent
→ cluster = nausea is rare
What’s the difference in pain between migraines + cluster headaches?
→ mig = pulsating hemicranial pain
→ cluster = Steady, exceptionally severe, well localised pain, unilateral in each cluster
What’s the difference in symptoms between migraines + cluster headaches?
→ mig = Visual or sensory auras seen
→ cluster = Eye waters, nose blocked, ptosis etc
What’s the difference in activity between migraines + cluster headaches?
→ mig = Patients lie in the dark
→ cluster = Patients pace about
