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Eye Disease > Neuro-Ophthalmology: Management of Headaches > Flashcards

Neuro-Ophthalmology: Management of Headaches Flashcards

1
Q

how frequent are migraines in disorders of nervous system?

A

35%- other stats in lecture

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2
Q

are headaches more common in males or females?

A

females

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3
Q

what group of people are headaches less prevalent in?

A

young people (with the exception of Aliya) and children

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4
Q

what are the 4 ocular causes of secondary headaches with underlying associations to the eyes?

A

-acute glaucoma
-uncorrected ref error
-heterotropia/phoria
-ocular inflammation

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5
Q

4 types of primary headache?

A
  1. Migraine
  2. Tension typeheadache
  3. Trigeminal autonomic cephalalgias (cluster headache)
  4. Other primary headache disorders
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6
Q

as well as primary and seconary headaches, what is the 3rd classification of headaches a px can experience?

A

Painful cranial neuropathies, other facial pains and other headaches

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7
Q

main causes of secondary headaches?

A
  • Trauma
  • Vascular
  • Raised ICP
  • Disorder of the eyes (covered in another card)
  • Other Secondary headaches
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8
Q

5 phases of migraine symptoms?

A

Premonitory symptoms
Aura
Headache
Termination
Postdrome

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9
Q

what are premonitory symptoms in a migraine?

A

being aware of an oncoming migraine

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10
Q

list the typical premonitory symptoms

A
  • psychological symptoms
  • neurological phenomena
  • general symptoms
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11
Q

what are some psychological symptoms of the premonitory symptom phase?

A
  • depression
  • euphoria
  • mental slowness
  • hyperactivity
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12
Q

what are some neurological symptoms of the premonitory symptom phase?

A
  • photophobia
  • phonophobia (sound)
  • nausea
  • vomiting

This phase can occur hours- days before the HA

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13
Q

what is phonophobia (think of phones ringing)

A

sensitivity to noise

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14
Q

what are some general symptoms of the premonitory symptom phase?

A

coldness, loss of appetite, food cravings

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15
Q

how long does it take for visual aura to develop

A

5-20 minutes

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16
Q

how long does visual aura typically last?

A

upto 60 mins

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17
Q

how long can take prolonged aura take to dissapear?

A

upto 1 week

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18
Q

do migranous infarctions last longer than a typical aura?

A

yes

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19
Q

list some focal neurological symptoms found in the visual aura phase of a migraine?

A

Sensory : visual, auditory, numbness, tingling, Heightened sensitivity
Motor: ophthalmoplegia (muscle paralysis), hemiplegia(one side of the body/ face paralysed)

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20
Q

how do we differentially diagnose between visual aura and ret detachment?

A

ret detachment- 1 eye only
visual aura- BIN and confined to one hemifield

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21
Q

what are other associations that can be seen in a visual aura?

A

teichopsia (scintillating scotoma, google this for a pic)
hemianopia
tunnel vision

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22
Q

what happens in teichopsia?

A
  • fortification spectra (flash of lights in a zig-zag pattern looks like the above of a ‘fort’ hence the name)
  • coloured fringes at edge of vision
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23
Q

what happens in hemianopia?

A

scintillating scotomata
Water running down windscreen
Heat haze
Broken up / cracked mirror

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24
Q

is complete visual loss with tunnel vision in visual aura common?

A

no it is very rare

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25
Q

what comes after a visual aura?

A

the actual headache- 60 mins after aura finishes

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26
Q

how long does a migraine headache tend to last?

A

4 to 72 hours (i can confirm 3 days is correct)

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27
Q

what is the type of pain associated with migraine?

A

moderate to severe- can have unilateral pulsing

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28
Q

what can aggravate a migraine further?

A

movement

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29
Q

what does the patient experience during the headache phase of the migraine?

A
  • photophobia
  • phonophobia
  • poor concentration
  • nausea
  • vomiting
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30
Q

what is the typical presentation of aura in non-migraine headaches

A

similar to migraines:
-visual and/or sensory and/or speech symptoms
-Gradual development
-won’t last longer than 1 hour
-positive to hypersensitivty to light
-Complete reversibility
-Absence of typical headache associated with migraine

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31
Q

should we refer older patients presenting with these symptoms? Why?

A

yes to rule out TIA

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32
Q

Main pathophysiological origin of migraines

A

thought to be vascular-
vessel constrcition= aura
vessel dilation=headache

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33
Q

in which vessels does pain orginate from?

A

Intra-cranial, extra-cerebral vessels

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34
Q

what is the physiological trigger for migraines

A

it is unknown

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35
Q

what is another underlying cause of migraines

A

genetics- fh plays key role

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36
Q

what are external triggers for migraines?

A

-certain foods (?)
-bright lights
-tiredness
-not in notes but poss stress?

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37
Q

name some visual triggers of migraines

A
  • glare: sun reflections/windows
  • flicker: flashlights, stroboscopes, tvs or cinemas
  • patterns= text
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38
Q

how do we manage migraines?

A

if obviously migraine- routine letter to GP
-also px reassurance

39
Q

why would women on the pill need extra monitoring?

A

to rule out associated high BP

40
Q

What can we advise px to do to keep track of their migraines

A

keep a ‘migraine diary’ and to take meds (esp if more than 5 attacks per month)

41
Q

how long do tension headaches last?

A

30 mins to 7 days- can be episodic or chronic

42
Q

are tension headaches BIL or unilateral

A

bilateral

43
Q

what part of the head and or neck can the px experence pain?

A
  • occipital
  • parietal
  • posterior neck
44
Q

how are the symptoms of tension headaches different to migraines?

A
  • Tightness/pressing/band-like (but not pulsating)
  • Mild to moderate pain that doesn’t stop daily activites
  • doesn’t get worse by moving around
45
Q

what are other associated symptoms of tension headaches?

A
  • photohobia
  • phonophobia
  • No nausea/vomiting
  • Associated with sleeplessness, stress or emotional conflict
46
Q

is it easy to differentiate between tension headaches and migraines?

A

no

47
Q

pathophysiology of tension headaches

A

thought to occur with muscle contraction- psychological problems associated also

48
Q

management of tension headaches

A

referral to GP

49
Q

what are *Trigeminal autonomic cephalalgias (cluster headache)

A

pain on one side of head in trigeminal nerve area- symptoms in autonomic systemon same side

50
Q

what parts of head face and or neck do cluster headaches affect

A

face pain, orbital, supraorbital
and/or temporal

51
Q

what is another name for cluster headaches?

A

migrainous neuralgia

52
Q

how long can cluster HA’s last?

A

1-8 attacks over a period of weeks/days

53
Q

signs px is having a cluster HA attack

A
  • facial flushing
  • conj injection
  • eyelid oedema
  • rhinorrhea
  • pupil constriction
  • partial ptosis
54
Q

what gender do cluster HA’s affect the most

A

men

55
Q

are cluster HA’s common?

A

one of the raest form of HA’s- 0.3% in >10,000 adults

56
Q

typical presentation of cluster HA

A
  • Starts around one eye or cheek
  • Spreads across head
  • Reaches a peak in a few minutes
  • Lasts 30 minutes - a few hours
57
Q

what is the pain like in a cluster headache?

A

INTENSE pain-px would want to bag head against wall or burn? head with warm compresses- can wake px in early hours of morning

58
Q

pathophysiology of Trigeminal autonomic cephalgias (Cluster headaches)

A

unknown, fMRI’s have shown Hypothalamic activity

59
Q

management of cluster headaches

A

refer to gp

60
Q

what can the gp prescribe for cluster headaches?

A

can give given prophylactic meds or analgesics

61
Q

vascular conditions associated with headaches:

A

temporal arteritis :)

62
Q

which gender is more likely to have temporal arteritis

A

females

63
Q

is he headache constant or not in temporal arteritis

A

constant

64
Q

pain threshold in temporal arteritis

A

Gradual onset to a diffuse severe
aching

65
Q

where is the pain in temporal arteritis?

A

Superficial scalp tenderness –
temporal

66
Q

symptom/systemic associations of temporal arteritis

A

Worse at night and in the cold
* Jaw claudication
* Systemic associations: fever,
anaemia, weight loss, polymyalgia rheumatica

67
Q

pathophysiology of temporal arteritis

A

arteries affecting external carotid and ophthalmic arteries
* Elevated erythrocyte sedimentation rate (ESR)

68
Q

ocular isgns of temporal artertis?

A

AION,
CRAO,
Amaurosis fugax

69
Q

management for temporal arteritis? and why?

A

OPTHALMIC EMERGENCY! Same day HES
* Risk of visual loss in other eye (70% within 10 days)
* Risk of cerebral vascular accident

70
Q

management for temporal arteritis done by HES?

A

Temporal artery biopsy
* MRI and Doppler study
* Erythrocyte Sedimentation rate (ESR) - side note for aliya: blood test that that can show if you have inflammation in your body.
* C-reactive protein levels
* Treated with high doses of oral steroids

71
Q

does VA recover in temporal arteritis?

A

nope

72
Q

other vascular causes of headache?

A

aneurysms or Arteriovenous malformation

73
Q

what occurs in an aneurysm?

A

sudden, painful af headache
* stiff neck
* vomiting
* altered behaviour
* may have focal lesions
* IIIrd nerve palsy if posterior
communicating artery affected
* hemiparesis if middle cerebral
artery affected

74
Q

how do we manage an aneurysm?

A

emergency referral

75
Q

what happens Arteriovenous malformation

A

Specific recurring headache
* Ruptured AVM or fistula
* sudden severe headache
* stiff neck
* homonymous field defect typical
of occipital AVM

76
Q

what is management of Arteriovenous malformation?

A

emergency referral

77
Q

characteristics of headache associated with raised ICP?

A

normally INTERMITTEN
* non specific, non localised
* dull, not throbbing
* worse AFTER exercise (like migraine)
* may waken patient from sleep (like cluster)
* transient headache on coughing
* may be absent

78
Q

what eye condition is raised ICP linked to and what is the management?

A

papilloedmea- same day emergency referral - casualty with neuroloigcal investigation

79
Q

what are the 4 disorders of the eyes associated with secondary ha’s?

A

1.)acute glaucoma
2. ref error
3. heterophoria or heterotropia
4. ocular inflammatory disorder

80
Q

how do heterophoia or tropias relate to headaches?

A

-ocular motor nerve palsies+ conv insuffiency!

81
Q

what ocular inflam disroders relate to ha’s

A

-corneal lesions, anterior uveitis, optic neuritis

82
Q

what type if incorrected rx is associated with ha’s

A

hyperope uncorrected on screens and reading

83
Q

general symptoms of disorders of the eyes + ha’s?

A

General symptoms
* Asthenopia:
in Uncorrected Rx /Incorrect Rx
* Not present on waking
* Mild HA
* Frontal, around eyes
in Heterophoria or heterotropia
* Recurrent
* Mild HA
* Intermiaent blur/diplopia
* May be relieved by closing one eye

84
Q

how do we treat ha’s relating disorders of eyes

A

Treat ref error or ocular motor imbalance
* HA resolves if visual problem is corrected
* Refer ocular disease

85
Q

what can be associated with Painful cranial neuropathy and other facial pains

A

-trigeminal neuralgia
-atypical facial pains

86
Q

symptoms in trigeminal neuralgia (cluster headaches)?

A
  • intense+ repetitivejabs of pain
  • lasts only seconds, with an ache in between
87
Q

what nerve is affceted in trigeminal neuralgia

A

trigeminal (5th nerve)- you clearly have given up on the cards if this wasnt obvious x

88
Q

what facial areas are affected in trigeminal neuralgia

A
  • Mostly affects mandibular or maxillary region
    can affect ophthlamic division but not in isolation
89
Q

age of onset of trigeminal neuralgia?

A

after 5 years

90
Q

management for trigeminal neuralgia?

A

-routine referral to GP
* Treatment can be medical or surgical

91
Q

what is our role as an optom when manageing ha’s?

A

good h+S

92
Q

wHEN MANAGEING HA’S, WHAT DOES A GOOD H+S INCLUDE?

A
  • FLOADS
  • Recent onset < 6 months; sudden onset
  • Change in pattern to HA
  • Resistance to meds
  • Atypical symptoms
  • GH: Systemic or neurological conditions
  • +ive FH of migraine
93
Q

wht changes in pattern of ha are concerning?

A

-recent onset
-change in pattern of long term ha’s- eg if they’ve become more frequent- is concerning

94
Q

3 managment options for headaches?

A

-Emergency medical referral
* routine referral
* Optometrically managed

Eye Disease (48 decks)

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