Neuro - Headaches, red flags, GCS and normal pressure hydrocephalus Flashcards
Name the primary headaches
- Migraine
- Tension type headache
- Trigeminal autonomic cephalgias
- Analgesia induced headache
- Cluster headache
Migraines: name the types of migraine and identity some triggers for migraines
- 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
Migraine: what is the criteria for migraine without aura?
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
Migraine: what is the criteria for migraine with aura?
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
Migraine: what is a chronic migraine?
-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
What is the treatment for migraines?
- Acute: simple analgesia (paracetamol, aspirin, ibuprofen) +/- triptan
- Prophylaxis: topiramate (not in women of childbearing age) or propranolol (not in asthmatics)
Tension type headache: describe symptoms and treatment
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
Trigeminal autonomic cephalgias: what headaches are included in this category?
- Cluster Headache
- Paroxysmal hemicrania
- SUNCT/SUNA (short last unilateral neuralgiform headaches with conjunctival injection and tearing)
- Both paroxysmal hemicrania and SUNCT are very rare
What is a cluster headache? Describe sx and treatment
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
Analgesia induced headache: features and management
- 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
Secondary headaches: describe some vascular and inflective/inflammatory causes
Vascular:
- Heamorrhage: SAH, intracranial or intracerebral
- Infarction: esp in posterior circulation
- Venous: sinus/cortical thrombosis
Infection/inflammation:
- Meningitis
- Encephalitis
- Abscess
Secondary headaches: describe some compressive/ICP and ophthalmic causes
Compression:
- Obstructive hydrocephalus
- Pituitary enlargement
ICP
-Spontaneous intracranial hypotension (worse on standing)
Ophthalmic
-Acute glaucoma
Secondary headaches: describe some systemic and traumatic causes
Systemic:
- HTN
- Infection: sinusitis, tonsillitis, atypical pneumonia
Trauma:
-Head trauma
Secondary headaches: describe some metabolic, drug induced and auto-immune causes
Metabolic:
-Hypoglycaemia
Other drugs
- Caffeine
- Vasodilators (CCB, nitrates)
Auto-immune
-Temporal arteritis
Headaches: red flags
- 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)
What investigations would you perform on a patient presenting with headache red flags?
- 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)
What are the 3 components of the Glasgow Coma Scale?
- Best motor response
- Best verbal response
- Best eye response
Describe the grades of the best motor response
- No response to pain
- Extensor posturing to pain
- Abnormal flexor response to pain: pressure on nail bed causes abnormal flexion
- Withdraws from pain: pulls limb away from stimulus
- Localising response to pain: purposeful movements towards changing painful stimuli
- Obeying commands: patient does simple things you ask
Describe the grades of the best verbal response
- None
- Incomprehensible speech -moaning but no words
- Inappropriate speech: random words
- Confused conversation: responds to questions in conversational manner but disorientated and confused
- Orientated: knows who/where they are + year and month
Describe the grades of the best eye response
- No opening
- Opening in response to pain
- Opening in response to sound/voice
- Spontaneous eye opening
What is normal pressure hydrocephalus?
- 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
What symptoms are seen in NPH?
- 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
What investigations and management should you do for NPH?
CT will show hydrocephalus with enlarged 4th ventricle
Management
- Ventriculoperitoneal shunting
- Around 10% of have shunts experience significant complications (seizures, infection and intracerebral haemorrhages)
