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!!!!! BRS YR2 !!!!! > Neuro - Headache > Flashcards

Neuro - Headache Flashcards

1
Q

What is a headache?

A

usually a symptom of life

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2
Q

What are the patterns of an acute single headache?

A 
→ Febrile illness
→ sinusitis
→ First attack of migraine
→ Following a head injury
→ Subarachnoid haemorrhage
→ Meningitis
→ tumour
→ drugs
→ toxins
→ stroke
→ Thunderclap (sudden onset)
→ low pressure
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3
Q

What are the patterns of an dull headache, increasing in severity?

A 
→ 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
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4
Q

What are the possible causes of a dull headache that’s unchanged over months?

A

→ chronic tension headache

→ depressive, atypical facial pain

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5
Q

What are the possible causes of a triggered headache that’s unchanged over months?

A

→ coughing, straining, exertion
→ coitus
→ food and drink

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6
Q

What are the possible causes of a recurrent headaches that’s unchanged over months?

A

→ migraine
→ cluster headaches
→ episodic tension headache
→ trigeminal or post-herpetic neuralgia

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7
Q

What are the red flags of headaches?

A

→ 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

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8
Q

What is 3rd nerve (oculomotor) palsy?

A

→ 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

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9
Q

What is Horner Syndrome?

A

→ 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

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10
Q

What are the signs of a subarachnoid haemorrhage?

A

→ sudden generalised headache “blow to the head” or “thunderclap” onset
→ meningism - stiff neck + photophobia

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11
Q

What proportion of SAHs are fatal?

A

around 50%

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12
Q

How are SAHs treated primarily?

A

→ Vasospasm may stop the leak.

→ Nimodipine and BP control due to high risk of further bleed

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13
Q

How were aneurysms treated once upon time?

A

aneurysms used to be clipped or wrapped

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14
Q

What causes SAHs?

A

→ most are caused by a ruptured aneurysm
→ few from arteriovenous malformations
→ some are unexplained

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15
Q

How are aneurysms treat now?

A

→ catheter inserted through the groin to access the cerebral arteries
→ the aneurysm is filled with platinum coils

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16
Q

What are the general categories of causes of headaches?

A

→ structure
→ pharmacological
→ psychological

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17
Q

How are SAHs assessed + diagnosed?

A 
→ early neurological assessment will confirm beed + establish the cause
→ Brain CT
→ lumbar puncture (RBC + xanthochromia)
→ MRA (MR angiogram)
→ angiogram
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18
Q

What is coning?

A

→ 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

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19
Q

What causes coning?

A

acute intracranial bleeding

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20
Q

What are other signs of raised ICP?

A

→ papilloedema = optic disc swelling

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21
Q

How can larger arteries in the neck cause headaches?

A

through artery dissections (abnormal, and usually abrupt, formation of a tear along the inside wall of an artery)

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22
Q

What is an artery dissection?

A

→ layers of blood vessels tissue can split, causing blood to seep between the layers
→ causes turbulent flow of blood

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23
Q

What are the secondary symptoms of arterial dissections?

A

→ strokes + clots (turbulent flow of blood with coagulant factors can cause this)
→ headaches + neck pain

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24
Q

What are the stats on strokes caused by arterial dissection?

A

→ causes 20% of ischaemic strokes under 45
→ carotid artery strokes > vertebral artery strokes
→ mean age of 40

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25
Q

What can cause arterial dissections?

A

→ traumatic

→ spontaneous

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26
Q

What tests can be used to diagnose artery dissection?

A

→ MRI / MRA
→ doppler
→ angiography

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27
Q

What is the treatment for artery dissection?

A

→ aspirin

→ anticoagulants

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28
Q

How do carotid artery dissection headaches present?

A

→ in a “phantom of the opera mask” distribution

→ in the frontal part of the face

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29
Q

How do vertebral artery dissection headaches present?

A

→ occipital headaches

→ in the back of the head + neck

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30
Q

What is temporal arteritis?

A

inflammation of the temporal artery

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31
Q

What is the demographic of people with temporal arteritis?

A

→ over the age of 55

→ 3 times commoner in females

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32
Q

What are the signs and symptoms of temporal arteritis?

A

→ constant unilateral headache
→ scalp tenderness
→ jaw claudation
→ 25% polymyalgia rheumatica-proximal muscle tenderness

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33
Q

What are the clinical features + diagnostic tests for temporal arteritis?

A

→ inflamed temporal artery is visible on ultrasound

→ biopsy should show inflammation + giant cells

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34
Q

How is temporal arteritis treated?

A

high dose steroids + aspirin

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35
Q

What is CVT?

A

→ cerebral venous thrombosis

→ thrombosis in dural venous sinus or cerebral vein

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36
Q

What are the signs and symptoms of CVT?

A

→ unusual no. of headaches due to raised ICP
→ non-territorial ischemia called “venous infarcts”
→ haemorrhage
→ thrombophilia
→ pregnancy
→ dehydration
→ behcets (inflammation of blood vessels + tissues)

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37
Q

What is meningitis?

A

inflammation of meninges

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38
Q

What are the different causes of meningitis?

A

→ viral (coxsackie, ECHO, Mumps, EBV)
→ bacterial (meningococci, pneumococci, haemophilus, tuberculous)
→ fungal (cryptococci)
→ granulomatous (sarcoid, lyme, brucella, behcets, syphilis)
→ carcinomatous

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39
Q

What are the presenting symptoms of meningitis?

A 
→ malaise
→ headache
→ fever
→ neck stiffness
→ photophobia
→ confusion
→ alteration of consciousness
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40
Q

What is the key principle of managing someone who’s suspected to have meningitis?

A

→ treat before diagnosis

→ meningitis is fatal

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41
Q

How is meningitis treated?

A

antibiotics if bacterial

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42
Q

How is meningitis diagnosed?

A

→ blood + urine culture
→ CT or MRI scan
→ then lumbar puncture

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43
Q

What is analysed in a lumbar puncture for meningitis?

A 
→ increased white cell count
→ decreased glucose
→ antigens
→ cytology
→ bacterial culture
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44
Q

Why should CT scans + MRIs be done before lumbar puncture in meningitis?

A

→ swollen meninges = raised ICP
→ needle from lumbar puncture could lead to rapid decompression
→ could lead to coning

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45
Q

How does bacterial meningitis present on a scan?

A

cerebral oedema with effacement of ventricles + sulci + inflamed meninges

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46
Q

What is sinusitis?

A

inflammation of sinuses

47
Q

What are the symptoms of sinusitis?

A 
→ 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
48
Q

How do sinuses appear on X-rays for people with sinusitis?

A

opacification of sinuses (whiter and denser sinuses)

49
Q

What kind of tumours can cause headaches?

A

→ literally any tumour in the brain

→ glioblastoma multiforme

50
Q

Why do tumours in the brain cause headaches?

A

they raise ICP

51
Q

What is idiopathic intracranial hypertension?

A

→ also called pseudotumour cerebri

→ high pressure around the brain + raised ICP

52
Q

What are the signs + symptoms of IIH?

A 
→ often young obese women
→ headache
→ visual obscurations
→ diplopia
→ tinnitus
→ papilloedema
→ visual field loss
53
Q

What drugs can cause IIH?

A

→ hormones
→ steroids
→ antibiotics
→ vitamin E

54
Q

How can IIH be treated?

A 
→ weight loss
→ diuretics
→ optic nerve sheath deocmpression
→ lumboperitoneal shunt
→ stenting of stenosed venous sinuses
55
Q

What does a CT scan for IIH look like?

A

→ cerebral oedema w effacement of ventricles + sulci

→ no mass lesion

56
Q

What is a low pressure headache?

A

headache due to low ICP

57
Q

What can cause a low pressure headache?

A

→ CSF leak due to tear in dura

→ traumatic post lumbar puncture or spontaneous

58
Q

What are the hallmarks of a low pressure headache?

A

→ 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

59
Q

What is the treatment for low pressure headaches?

A

→ rehydration
→ caffeine
→ blood patch

60
Q

What is a blood patch?

A

→ blood is injected into epidural space

→ tear is sealed due to coagulants in blood

61
Q

What is chiari malformation?

A

→ normal brain that sits very low within the skull

→ cerebellar tonsils descend through the foramen magnum

62
Q

What causes the headache in chiari malformation?

A

→ tonsils descend further when the patient coughs + tugs on the meninges
→ creates a cough headache

63
Q

How is chiari malformation treated?

A

→ treat whatever’s causing the cough

→ surgery can remodel bone of skull to take away some bone and create some space

64
Q

What is obstructive sleep apnoea?

A

→ 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

65
Q

What are the signs and symptoms of obstructive sleep apnoea?

A 
→ characteristic body habitus
→ history of loud snoring + apnoea spells
→ hypoxia + CO2 retention
→ non-refreshing sleep
→ depression
→ impotence
→ poor performance at work
66
Q

How does OSA cause headaches?

A

→ CO2 = vasodilator
→ so CO2 retention = increased vasodilation
→ leads to morning headaches

67
Q

How is OSA assessed + treated?

A

→ requires nocturnal NIV

→ surgery to remove and ease obstruction causing sleep apnoea

68
Q

What is trigeminal neuralgia? What are the signs + symtoms?

A

→ electric shock like pain in distribution of trigeminal sensory nerve in the face
→ can be a symptom of MS

69
Q

What are the causes of trigeminal neuralgia?

A

→ neurovascular conflict at the point of entry of the nerve into the pons
→ triggered by innocuous stimuli e.g. chewing gum, etc.

70
Q

How is trigeminal neuralgia treated?

A 
anticonvulsants :
→ carbamazepine
→ lamotrigine
→ gabapentin
surgery :
→ posterior fossa decompression
71
Q

What is atypical facial pain?

A

syndrome that encompasses a wide group of facial pain problems

72
Q

What demographic does atypical facial pain occur in?

A

→ most commonly in middle aged women

→ depressed + anxious

73
Q

What are the signs + symptoms of atypical facial pain?

A

→ 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

74
Q

How is atypical facial pain treated?

A

→ unresponsive to conventional analgesics, opiates + nerve blocks
→ mainstay of management tricyclics

75
Q

What proportion of people present with post-traumatic headaches?

A

→ 36% at discharge
→ 24% in the next 6 months
→ 16% at 12 months

76
Q

Who is predisposed to having post-traumatic headaches?

A

→ correlates with previous history of headaches

→ unrelated to duration of post-traumatic amnesia

77
Q

How does post-trauma headache depend on nature of head injury?

A

→ High in victims of car accidents
→ Low in perpetrators of car accidents
→ Low in sports injuries

78
Q

What pathologically causes post-traumatic headaches?

A

→ Neck injury
→ Scalp injury
→ Vasodilation due to autonomic damage
→ Depression - often delayed

79
Q

How do you manage + treat post-traumatic headaches?

A

→ Explanation
→ Prevent analgesic abuse
→ Non-steroidal anti-inflammatories - ibuprofen, naproxen
→ Tricyclic antidepressants - Amitriptyline

80
Q

What cervical spondylosis?

A

→ narrowing of joint space due to worn disc

→ commonest cause of new headache in older patients

81
Q

What are the symptoms of cervical spondylosis?

A 
→ Usually bilateral
→ Occipital pain can radiate forwards to the frontal region
→ Steady pain
→ No nausea or vomiting
→ Worsened by moving the neck
82
Q

How do you manage + treat cervical spondylosis?

A 
→ Rest
→ deep heat
→ massage.
→ Anti-inflammatory analgesics
→ Over-manipulation may be harmful
83
Q

What is a migraine?

A 
headaches, characterised by:
→ tendency to repeated attacks
→ triggers
→ easily hung-over
→ visual vertigo
→ motion sickness
84
Q

What forms do migraine attacks come in?

A

→ just pain
→ pain + focal symptoms
→ just focal symptoms

85
Q

What causes migraines?

A

spreading of electrical depression across the cerebral cortex

86
Q

What are the different phases of a migraine?

A 
→ prodrome
→ aura
→ headache
→ resolution
→ recovery
87
Q

What is a part of the prodrome phase of migraines?

A 
→ changes in mood
→ urination
→ fluid retention
→ food craving
→ yawning
88
Q

What is involved in the aura phase of migraines?

A 
→ visual
→ sensory (numbness / paraesthesia)
→ weakness
→ speech arrest
→ scintillations + blindspots
→ positive + negative
→ expanding Cs
→ elemental visual disturbances
89
Q

What is a part of the headache phase of migraines?

A 
→ hemicranial head pain 
→ body pain
→ nausea
→ photophobia
→ vomiting
→ phonophobia
90
Q

What is a part of the resolution phase of migraines?

A

period of time when the headache dies down
→ sweeter + more comforting type of pain
→ rest + sleep

91
Q

What is a part of the recovery phase of migraines?

A

→ mood disturbed
→ food intolerance
→ feeling hungover

92
Q

How long does a whole migraine cycle take?

A

48 hours or so

93
Q

How do you treat an acute migraine attack?

A

→ 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

94
Q

What are some of the lifestyle issues experienced by those with migraines?

A

→ 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.

95
Q

How can people with migraines change their lifestyles to help themselves?

A

→ 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

96
Q

What treatments can be used against chronic migraines?

A

→ 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

97
Q

What counts as a chronic migraine?

A

more than 14 migraines a month

98
Q

Why can oestrogen not be given to those who suffer from migraines?

A

oestrogen can trigger migraines

99
Q

How does Erenumab work?

A

→ 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.

100
Q

What is a tension type headache? What are the signs?

A

pain + tight muscles around head and neck bilaterally, as though head is in a vice

101
Q

How can a tension type headache be treated?

A

→ 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)

102
Q

What is a cluster headache?

A

→ Severe unilateral pain lasting 15-180 minutes untreated

→ Classified as a trigeminal autonomic cephalgia (headache)

103
Q

What are the symptoms of a cluster headache?

A

→ 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

104
Q

How are cluster headaches treated acutely?

A

→ Inhaled oxygen

→ S/C or Nasal Sumatriptan

105
Q

Why does inhaled oxygen help with cluster headaches?

A

Oxygen inhibits neuronal activation in the trigeminocervical complex

106
Q

What can prevent cluster headaches?

A 
→ Verapamil 
→ Prednisolone 
→ Lithium 
→ Valproate 
→ Gabapentin 
→ Topiramate 
→ Pizotifen
107
Q

What’s the difference in distribution between migraines + cluster headaches?

A

→ mig = 1:2, M:F

→ cluster = 9:1, M:F

108
Q

What’s the difference in duration between migraines + cluster headaches?

A

→ mig = 3-12 hours

→ cluster = 45 min - 3 hours

109
Q

What’s the difference in frequency between migraines + cluster headaches?

A

→ mig = 1 to 8 attacks monthly

→ cluster = 1 to 3 attacks daily (often at night)

110
Q

What’s the difference in remission between migraines + cluster headaches?

A

→ mig = unusual to have long remissions

→ cluster = long remissions are common

111
Q

What’s the difference in nausea between migraines + cluster headaches?

A

→ mig = nausea + vomiting frequent

→ cluster = nausea is rare

112
Q

What’s the difference in pain between migraines + cluster headaches?

A

→ mig = pulsating hemicranial pain

→ cluster = Steady, exceptionally severe, well localised pain, unilateral in each cluster

113
Q

What’s the difference in symptoms between migraines + cluster headaches?

A

→ mig = Visual or sensory auras seen

→ cluster = Eye waters, nose blocked, ptosis etc

114
Q

What’s the difference in activity between migraines + cluster headaches?

A

→ mig = Patients lie in the dark

→ cluster = Patients pace about

!!!!! BRS YR2 !!!!! (72 decks)

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