Neuro-Ophthalmology: Management of Headaches Flashcards
how frequent are migraines in disorders of nervous system?
35%- other stats in lecture
are headaches more common in males or females?
females
what group of people are headaches less prevalent in?
young people (with the exception of Aliya) and children
what are the 4 ocular causes of secondary headaches with underlying associations to the eyes?
-acute glaucoma
-uncorrected ref error
-heterotropia/phoria
-ocular inflammation
4 types of primary headache?
- Migraine
- Tension typeheadache
- Trigeminal autonomic cephalalgias (cluster headache)
- Other primary headache disorders
as well as primary and seconary headaches, what is the 3rd classification of headaches a px can experience?
Painful cranial neuropathies, other facial pains and other headaches
main causes of secondary headaches?
- Trauma
- Vascular
- Raised ICP
- Disorder of the eyes (covered in another card)
- Other Secondary headaches
5 phases of migraine symptoms?
Premonitory symptoms
Aura
Headache
Termination
Postdrome
what are premonitory symptoms in a migraine?
being aware of an oncoming migraine
list the typical premonitory symptoms
- psychological symptoms
- neurological phenomena
- general symptoms
what are some psychological symptoms of the premonitory symptom phase?
- depression
- euphoria
- mental slowness
- hyperactivity
what are some neurological symptoms of the premonitory symptom phase?
- photophobia
- phonophobia (sound)
- nausea
- vomiting
This phase can occur hours- days before the HA
what is phonophobia (think of phones ringing)
sensitivity to noise
what are some general symptoms of the premonitory symptom phase?
coldness, loss of appetite, food cravings
how long does it take for visual aura to develop
5-20 minutes
how long does visual aura typically last?
upto 60 mins
how long can take prolonged aura take to dissapear?
upto 1 week
do migranous infarctions last longer than a typical aura?
yes
list some focal neurological symptoms found in the visual aura phase of a migraine?
Sensory : visual, auditory, numbness, tingling, Heightened sensitivity
Motor: ophthalmoplegia (muscle paralysis), hemiplegia(one side of the body/ face paralysed)
how do we differentially diagnose between visual aura and ret detachment?
ret detachment- 1 eye only
visual aura- BIN and confined to one hemifield
what are other associations that can be seen in a visual aura?
teichopsia (scintillating scotoma, google this for a pic)
hemianopia
tunnel vision
what happens in teichopsia?
- 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
what happens in hemianopia?
scintillating scotomata
Water running down windscreen
Heat haze
Broken up / cracked mirror
is complete visual loss with tunnel vision in visual aura common?
no it is very rare
what comes after a visual aura?
the actual headache- 60 mins after aura finishes
how long does a migraine headache tend to last?
4 to 72 hours (i can confirm 3 days is correct)
what is the type of pain associated with migraine?
moderate to severe- can have unilateral pulsing
what can aggravate a migraine further?
movement
what does the patient experience during the headache phase of the migraine?
- photophobia
- phonophobia
- poor concentration
- nausea
- vomiting
what is the typical presentation of aura in non-migraine headaches
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
should we refer older patients presenting with these symptoms? Why?
yes to rule out TIA
Main pathophysiological origin of migraines
thought to be vascular-
vessel constrcition= aura
vessel dilation=headache
in which vessels does pain orginate from?
Intra-cranial, extra-cerebral vessels
what is the physiological trigger for migraines
it is unknown
what is another underlying cause of migraines
genetics- fh plays key role
what are external triggers for migraines?
-certain foods (?)
-bright lights
-tiredness
-not in notes but poss stress?
name some visual triggers of migraines
- glare: sun reflections/windows
- flicker: flashlights, stroboscopes, tvs or cinemas
- patterns= text
how do we manage migraines?
if obviously migraine- routine letter to GP
-also px reassurance
why would women on the pill need extra monitoring?
to rule out associated high BP
What can we advise px to do to keep track of their migraines
keep a ‘migraine diary’ and to take meds (esp if more than 5 attacks per month)
how long do tension headaches last?
30 mins to 7 days- can be episodic or chronic
are tension headaches BIL or unilateral
bilateral
what part of the head and or neck can the px experence pain?
- occipital
- parietal
- posterior neck
how are the symptoms of tension headaches different to migraines?
- Tightness/pressing/band-like (but not pulsating)
- Mild to moderate pain that doesn’t stop daily activites
- doesn’t get worse by moving around
what are other associated symptoms of tension headaches?
- photohobia
- phonophobia
- No nausea/vomiting
- Associated with sleeplessness, stress or emotional conflict
is it easy to differentiate between tension headaches and migraines?
no
pathophysiology of tension headaches
thought to occur with muscle contraction- psychological problems associated also
management of tension headaches
referral to GP
what are *Trigeminal autonomic cephalalgias (cluster headache)
pain on one side of head in trigeminal nerve area- symptoms in autonomic systemon same side
what parts of head face and or neck do cluster headaches affect
face pain, orbital, supraorbital
and/or temporal
what is another name for cluster headaches?
migrainous neuralgia
how long can cluster HA’s last?
1-8 attacks over a period of weeks/days
signs px is having a cluster HA attack
- facial flushing
- conj injection
- eyelid oedema
- rhinorrhea
- pupil constriction
- partial ptosis
what gender do cluster HA’s affect the most
men
are cluster HA’s common?
one of the raest form of HA’s- 0.3% in >10,000 adults
typical presentation of cluster HA
- Starts around one eye or cheek
- Spreads across head
- Reaches a peak in a few minutes
- Lasts 30 minutes - a few hours
what is the pain like in a cluster headache?
INTENSE pain-px would want to bag head against wall or burn? head with warm compresses- can wake px in early hours of morning
pathophysiology of Trigeminal autonomic cephalgias (Cluster headaches)
unknown, fMRI’s have shown Hypothalamic activity
management of cluster headaches
refer to gp
what can the gp prescribe for cluster headaches?
can give given prophylactic meds or analgesics
vascular conditions associated with headaches:
temporal arteritis :)
which gender is more likely to have temporal arteritis
females
is he headache constant or not in temporal arteritis
constant
pain threshold in temporal arteritis
Gradual onset to a diffuse severe
aching
where is the pain in temporal arteritis?
Superficial scalp tenderness –
temporal
symptom/systemic associations of temporal arteritis
Worse at night and in the cold
* Jaw claudication
* Systemic associations: fever,
anaemia, weight loss, polymyalgia rheumatica
pathophysiology of temporal arteritis
arteries affecting external carotid and ophthalmic arteries
* Elevated erythrocyte sedimentation rate (ESR)
ocular isgns of temporal artertis?
AION,
CRAO,
Amaurosis fugax
management for temporal arteritis? and why?
OPTHALMIC EMERGENCY! Same day HES
* Risk of visual loss in other eye (70% within 10 days)
* Risk of cerebral vascular accident
management for temporal arteritis done by HES?
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
does VA recover in temporal arteritis?
nope
other vascular causes of headache?
aneurysms or Arteriovenous malformation
what occurs in an aneurysm?
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
how do we manage an aneurysm?
emergency referral
what happens Arteriovenous malformation
Specific recurring headache
* Ruptured AVM or fistula
* sudden severe headache
* stiff neck
* homonymous field defect typical
of occipital AVM
what is management of Arteriovenous malformation?
emergency referral
characteristics of headache associated with raised ICP?
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
what eye condition is raised ICP linked to and what is the management?
papilloedmea- same day emergency referral - casualty with neuroloigcal investigation
what are the 4 disorders of the eyes associated with secondary ha’s?
1.)acute glaucoma
2. ref error
3. heterophoria or heterotropia
4. ocular inflammatory disorder
how do heterophoia or tropias relate to headaches?
-ocular motor nerve palsies+ conv insuffiency!
what ocular inflam disroders relate to ha’s
-corneal lesions, anterior uveitis, optic neuritis
what type if incorrected rx is associated with ha’s
hyperope uncorrected on screens and reading
general symptoms of disorders of the eyes + ha’s?
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
how do we treat ha’s relating disorders of eyes
Treat ref error or ocular motor imbalance
* HA resolves if visual problem is corrected
* Refer ocular disease
what can be associated with Painful cranial neuropathy and other facial pains
-trigeminal neuralgia
-atypical facial pains
symptoms in trigeminal neuralgia (cluster headaches)?
- intense+ repetitivejabs of pain
- lasts only seconds, with an ache in between
what nerve is affceted in trigeminal neuralgia
trigeminal (5th nerve)- you clearly have given up on the cards if this wasnt obvious x
what facial areas are affected in trigeminal neuralgia
- Mostly affects mandibular or maxillary region
can affect ophthlamic division but not in isolation
age of onset of trigeminal neuralgia?
after 5 years
management for trigeminal neuralgia?
-routine referral to GP
* Treatment can be medical or surgical
what is our role as an optom when manageing ha’s?
good h+S
wHEN MANAGEING HA’S, WHAT DOES A GOOD H+S INCLUDE?
- 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
wht changes in pattern of ha are concerning?
-recent onset
-change in pattern of long term ha’s- eg if they’ve become more frequent- is concerning
3 managment options for headaches?
-Emergency medical referral
* routine referral
* Optometrically managed
