Neuro - Headaches, red flags, GCS and normal pressure hydrocephalus Flashcards

1
Q

Name the primary headaches

A
  • Migraine
  • Tension type headache
  • Trigeminal autonomic cephalgias
  • Analgesia induced headache
  • Cluster headache
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2
Q

Migraines: name the types of migraine and identity some triggers for migraines

A
  • Migraine without aura
  • Migraine with aura
  • Chronic migraine

Triggers: stress, relief from stress, too much/little sleep, missing meals, alcohol, dehydration, strong smells/perfumes
*The most effective way to reduce frequency of migraines is to address triggers

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3
Q

Migraine: what is the criteria for migraine without aura?

A

A. At least 5 attacks fulfilling criteria B-D
B. Attacks last 4-72h (untreated)
C. Attacks have 2+ of the following criteria: unilateral, pulsating, moderate or severe pain intensity, aggravated by or causing avoidance of physical activity (walking/climbing stairs)
D. During headache 1+ of following: N and or V, photophobia and photophobia
E. Not better accounted for by another diagnosis

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4
Q

Migraine: what is the criteria for migraine with aura?

A

A. At least 2 attacks fulfilling criteria B and C
B. >1 of following fully reversible aura sx: visual, sensory, speech/language, motor, brainstem, retinal
C. >2 of following criteria:
-1 aura sx spreads gradually over >5 mins and or >2 sx occur in succession
-Each individual aura sx lasts 5-60 mins
-1 aura sx are unilateral
-Aura accompanied or followed in <60 by headache
D. No better diagnosis found

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5
Q

Migraine: what is a chronic migraine?

A

-Headache occurring in 15 or more days/month for more than 3 months which on at least 8 days/month has the features of a migraine headache

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6
Q

What is the treatment for migraines?

A
  • Acute: simple analgesia (paracetamol, aspirin, ibuprofen) +/- triptan
  • Prophylaxis: topiramate (not in women of childbearing age) or propranolol (not in asthmatics)
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7
Q

Tension type headache: describe symptoms and treatment

A

Symptoms

  • Bilateral, pressing, tightening, non pulsating
  • Mild/mod but not disabling
  • No aggravation by/or avoidance of physical activity
  • No N/V, photophobia or photophobia
  • Attacks last hours/days

Treatment

  • Acute: simple analgesic (NSAIDs/paracetamol)
  • Prevention: amitriptyline
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8
Q

Trigeminal autonomic cephalgias: what headaches are included in this category?

A
  • Cluster Headache
  • Paroxysmal hemicrania
  • SUNCT/SUNA (short last unilateral neuralgiform headaches with conjunctival injection and tearing)
  • Both paroxysmal hemicrania and SUNCT are very rare
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9
Q

What is a cluster headache? Describe sx and treatment

A

Extremely disabling headaches affecting M>F

Symptoms

  • Unilateral (never bilat)
  • Very severe
  • Restlessness, no aggravation by physical activity
  • Ipsilateral to pain: lacrimation, nasal congestion, rhinorrhea, eyelid swelling/drooping
  • Attacks last 15 mins to 3h
  • Freq of attacks: 1-3 (up to 8)/day usually for 2-3 months at a time

Treatment

  • Acute stack: 15L 02 via NRB + subcut sumatriptan
  • Prevention: verapamil
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10
Q

Analgesia induced headache: features and management

A
  • Headache occurring on 15 or + days of the month in patient with pre-existing primary headache - develops due to regular overuse of acute or symptomatic headache medication
  • Management: withdraw medication carefully - patient may not start to feel better for several weeks and will need support.
  • If patient taking opioids, may use naproxen for 2 weeks as cover
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11
Q

Secondary headaches: describe some vascular and inflective/inflammatory causes

A

Vascular:

  • Heamorrhage: SAH, intracranial or intracerebral
  • Infarction: esp in posterior circulation
  • Venous: sinus/cortical thrombosis

Infection/inflammation:

  • Meningitis
  • Encephalitis
  • Abscess
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12
Q

Secondary headaches: describe some compressive/ICP and ophthalmic causes

A

Compression:

  • Obstructive hydrocephalus
  • Pituitary enlargement

ICP
-Spontaneous intracranial hypotension (worse on standing)

Ophthalmic
-Acute glaucoma

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13
Q

Secondary headaches: describe some systemic and traumatic causes

A

Systemic:

  • HTN
  • Infection: sinusitis, tonsillitis, atypical pneumonia

Trauma:
-Head trauma

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14
Q

Secondary headaches: describe some metabolic, drug induced and auto-immune causes

A

Metabolic:
-Hypoglycaemia

Other drugs

  • Caffeine
  • Vasodilators (CCB, nitrates)

Auto-immune
-Temporal arteritis

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15
Q

Headaches: red flags

A
  • Sudden/recent onset headache
  • Meningism
  • Non-blanching rash
  • Fever, nausea and vomiting
  • Confusion
  • Photophobia
  • Change in personality
  • Epilepsy
  • Changes in vision, diplopia, papilloaedema, hearing, smell
  • Cranial nerve palsy
  • Constitutional Sx: malaise, nigh sweats, jaw claudication , scalp tenderness
  • Changes in endocrine status: changes in appearance (GH), cold intolerance/low energy/wt gain (hypothyroidism), lactation (prolactin excess), oligo/amenorrhea (FSH/LH deficiency), weight gain/abdo straie (ACTH excess)
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16
Q

What investigations would you perform on a patient presenting with headache red flags?

A
  • Bloods: FBC, U+E, LFT, CRP/ESR + cultures (if pt systemically unwell)
  • Serology: enterovirus (most common cause of viral meningitis), HSV, HIV, syphilis
  • CSF: MC+S, protein count, glucose, xanthrochromia, opening pressure (high in SAH/meningitis, low in spontaneous intracranial hypotension)

Imaging:

  • Non contrast CT -SAH - within 24h
  • MRI: MRA (aneurism) or MRV (sinus thrombosis)
17
Q

What are the 3 components of the Glasgow Coma Scale?

A
  • Best motor response
  • Best verbal response
  • Best eye response
18
Q

Describe the grades of the best motor response

A
  1. No response to pain
  2. Extensor posturing to pain
  3. Abnormal flexor response to pain: pressure on nail bed causes abnormal flexion
  4. Withdraws from pain: pulls limb away from stimulus
  5. Localising response to pain: purposeful movements towards changing painful stimuli
  6. Obeying commands: patient does simple things you ask
19
Q

Describe the grades of the best verbal response

A
  1. None
  2. Incomprehensible speech -moaning but no words
  3. Inappropriate speech: random words
  4. Confused conversation: responds to questions in conversational manner but disorientated and confused
  5. Orientated: knows who/where they are + year and month
20
Q

Describe the grades of the best eye response

A
  1. No opening
  2. Opening in response to pain
  3. Opening in response to sound/voice
  4. Spontaneous eye opening
21
Q

What is normal pressure hydrocephalus?

A
  • Reversible cause of dementia seen in elderly patients
  • Thought to be caused by reduced CSF absorption at the arachnoid villi - these may lead to head injury, haemorrhage or meningitis
22
Q

What symptoms are seen in NPH?

A
  • Urinary incontinence
  • Dementia and bradyphrenia
  • Gait abnormality (similar to PD)
  • Approx 60% of patients will have all 3 features at the time of diagnosis, symptoms usually develop over a few months
23
Q

What investigations and management should you do for NPH?

A

CT will show hydrocephalus with enlarged 4th ventricle

Management

  • Ventriculoperitoneal shunting
  • Around 10% of have shunts experience significant complications (seizures, infection and intracerebral haemorrhages)