Neuro-ophthalmology: Management of Headaches Flashcards
what are headaches amongst the most common disorders of
the nervous system
how many % of years lost are due to migraine
1.3%
how many % of headaches are migraines
15%
how many % of headaches are cluster type
less than 1%
how many % of headaches are medication overuse
1-2%
how many % of headaches are chronic
4%
how many % of headaches are tension type
60%
how many % of headaches are other types
19%
which group of people are headaches more prevalent in and which group of people are headaches less prevalent in
- twice as more prevalent in women than men
- less prevalent in children than youth
list 3 roles that an optometrist should do for a patient who is complaining of headaches in practice
- Classify type of HA
- Identify and manage visual triggers
- Refer for further management (to those outside of scope of our expertise)
how many categories of headache types are there and out of this, how many subtypes are there
- 14 categories of headache types
- Over 90 subtypes of headache
out of the 90 subtypes of headache, what is 1 of those subtypes attributed to and list the 4 subforms that this 1 subtype is divided into and how can it be fixed if its down to one of these
- 1 subtype is attributed to disorders of the eyes
Subforms:
- acute glaucoma
- refractive error
- heterophoria or heterotropia
- ocular inflammatory disorder
can easily be fixed glasses or orthoptic exercises
which are the 3 main classifications of headaches, as stated by the international headache society
- primary headaches
- secondary headaches
- Painful cranial neuropathies, other facial pains and other headaches
list all 4 types of primary headaches
- Migraine
- Tension type headache
- Trigeminal autonomic cephalalgias (cluster headache)
- Other primary headache disorders
list all 5 types of secondary headaches
- Trauma
- Vascular
- Raised ICP
- Disorder of the eyes
- Other Secondary headaches
what is the prevalence of migraines amongst adults and how much of this accounts for males and for females
- 15% among >170,000 adults
- 8% males and 18% females
what is the prevalence of migraines amongst children and youths and how much of this accounts for boys and for girls
- 9% among >36,000 children and youths
- 5% boys and 9% girls
list the 5 phases of a migraine and state how many % of people the first 3 stages affect
- Premonitory symptoms - affects 60%
- Aura - affects 20%
- Headache - affects 80%
- Termination
- Postdrome - after affects
what is the premonitory symptoms of a migraine and list 3 things that these symptoms can be giving examples of each
An awareness that an attack is going to happen
- can be psychological symptoms
depression, euphoria, mental slowness, hyperactivity - can be neurologic phenomena
photophobia, phonophobia
nausea / vomiting (classic migraine symptom) - can be general
coldness, loss of appetite, food cravings
over what time period of a migraine does an aura develop and how long does it last for
- Develops over 5 - 20 minutes
- Normally lasts less than 60 minutes
‘Prolonged aura’ last up to a week
The effects of a ‘migranous infarction’ will last longer
what is the type of migraine aura symptoms called and name the 2 types including examples of what each one affects
- Focal neurological symptoms
- Sensory visual, auditory, numbness, tingling heightened sensitivity - Motor ophthalmoplegia, hemiplegia
list the 5 sensory focal neurological symptoms of a migraine aura
- visual
- auditory
- numbness
- tingling
- heightened sensitivity
list the 2 motor focal neurological symptoms of a migraine aura
- ophthalmoplegia
- hemiplegia
list the 4 types of symptoms that you get with a visual aura during a migraine
- Binocular and confined to one hemifield
Retinal migraine in which the symptoms are purely uniocular
- Teichopsia Fortification spectra (coloured fringues around objects)
- Hemianopia scintillating scotomata Water running down windscreen Heat haze Broken up / cracked mirror
- “Tunnel vision”
Very rarely total visual loss
when does the headache part of the migraine tend to start and how long does it tend to last
- 60 minutes after aura finishes
- lasting 4 – 72 hours
what 4 attributes describes the headache part of a migraine
- moderate to severe
- pulsating
- unilateral (localised to one side of the head)
- aggravated by movement
what 3 things can the headache part of a migraine be associated with
- photophobia or phonophobia
- poor concentration
- nausea, vomiting
what is a typical Aura with Non-migraine Headache and describe how it develops and it’s 4 features
Typical aura consisting of visual and/or sensory and/or speech symptoms
Gradual development
- No longer than one hour
- Mix of positive and negative features
- Complete reversibility
- Absence of typical headache associated with migraine
what ddx will you refer a px who is suffering from a typical Aura with Non-migraine Headache and for this reason what should you do
In older individuals refer to rule out transient ischaemic attack (as some patients can also complain about slurry speech)
list the 4 possible pathophysiology reasons for a migraine
- Thought to be vascular in origin
vessel constriction corresponds to aura
vessel dilation corresponds to headache
Pain from Intra-cranial, extra-cerebral vessels - Physiological trigger unknown
- Genetic influence
many have positive family history - Many have an external trigger
tiredness, certain foods or drinks, bright lights (strobe lights)
explain 2 reasons why the pathophysiology for a migraine is thought to be vascular
- vessel constriction corresponds to aura
- vessel dilation corresponds to headache
Pain from Intra-cranial, extra-cerebral vessels
list 3 visual triggers of a migraine
- Glare
Sun reflections, windows - Flicker
Flashlights, stroboscopes, TV or cinema - Patterns
Text
list 4 things you should do to manage/advise a patient to do who suffers from migraine
- If obvious diagnosis, letter of information to GP (good practise)
- Reassurance not life threatening not associated with serious illness exception can be young women on ‘the pill’ no known cure
- Ask px to write a ‘headache diary’
to identify and avoid triggers (self manage) - Medication by GP
pain relief during acute attack
preventative if > 5 attacks per month
what is the prevalence of tension type headaches in adults and in children
- 62% in >66,000 adults
- 16% in ~25,000 children
The largest type of headache
what are the 2 types of tension yep headaches and how long does each one last for
- Episodic lasts 30mins
or - Chronic last 7 days
does a tension type headache tend to be unilateral or bilateral
bilateral (px tends to hold there head)
which three locations can a tension headache pain be
Occipital, parietal or posterior neck
describe the symptoms of a tension type headache
- Tightness/pressing/band-like (but not pulsating)
- Mild to moderate – does not stop daily activities (so it history and symptoms, ask px if their headache stops them from doing things)
- Not made worse by routine physical activity
what 2 symptoms may a tension headache be associated with and what is it not associated with
- May be associated with photohobia and phonophobia
- No nausea/vomiting
what 3 factors (other than photophobia and phonophobia symptoms) may be associated a tension type headache
sleeplessness, stress or emotional conflict
what is the differential diagnosis of a tension type headache and how can you rule it out
- migraine
- ask px if theres visual aura or sickness following and any patterns to the headache
what 2 things can the pathophysiology of a tension type headache be down to
- Due to muscle contraction
- Commonly associated with psychological problems e.g. stress
what is the management of a tension type headache
Routine referral to GP
what and where is the symptoms of a Trigeminal autonomic cephalalgias (cluster headache)
- Pain on one side of the head in area of the trigeminal nerve
- symptoms in autonomic system on the same side
face pain, orbital, supraorbital and/or temporal (are secondary headaches due to the trigeminal nerve)
what is the pattern of a cluster headache attack and list the 6 things it can be associated with
- 1-8 attacks over a period of days or weeks
may be associated with:
- facial flushing
- conjunctival injection
- eyelid oedema
- rhinorrhea
- pupil constriction
- partial ptosis
what is the prevalence of cluster headaches in adults
0.3% in >10,000 adults
much rarer than other primary headache types
which category of people does cluster headaches affect more and by how much
Predominantly affects men
Affects 6x more males than females
what is the proper name for cluster headaches
Trigeminal autonomic cephalgias
list the 4 stages of the course of a cluster headache
- Starts around one eye or cheek
- Spreads across head
- Reaches a peak in a few minutes
- Lasts 30 minutes - a few hours
describe the symptom of a cluster headache and 2 things that a patient may say to describe the pain and when does it tend to affect the patient
- Intense pain
Sufferers bang head against wall
Burn head with hot compresses - Wakes patient in early hours
what does the pathophysiology show about a cluster headache
- Cause unknown,
no demonstrable pathology - fMRI
Hypothalamic activity
what is the management for a cluster headache
Refer to GP
Prophylactic medication, analgesics etc
list the 3 type of vascular causes that can be attributed towards a secondary headache
- Temporal arteritis
- Aneurysm
- Arteriovenous Malformation
which groups of people is temporal arteritis more prevalent in
- Normally only over age 60
- Female > male
describe 5 symptoms of a patient who has temporal arteritis
- Headache normally constant
- Gradual onset to a diffuse severe aching
- Superficial scalp tenderness – temporal
- Worse at night and in the cold
- Jaw claudication (when moving jaw e.g. chewing)
list 4 systemic associations of temporal arteritis
- fever
- anaemia
- weight loss
- polymyalgia rheumatica (aching pain all over)
name 3 ocular signs that can indicate temporal arteritis
- AION
- CRAO
- Amaurosis Fugax
what is the 2 signs of a AION, which is associated with temporal arteritis
- Partial or total infarction of optic nerve head
- Occlusion of short posterior ciliary arteries
what is a general sign to show a AION is arteritic
Usually inferior altitudinal hemianopia
which type of AION is related to giant cell arteritis
arteritic
what is the pathophysiology of a temporal arteritis, i.e. what it is due to and name a ddx
- Arteritis affecting external carotid and ophthalmic arteries
ddx:
- Elevated erythrocyte sedimentation rate (ESR) associated with non-arteritic AION (a ddx test done in hospital)
what is the management of a temporal arteritis and why
OPHTHALMIC EMERGENCY
- Risk of visual loss in other eye (70% within 10 days)
- Risk of cerebral vascular accident
- Treated with high doses of oral steroids
what 4 things is done in hospital to investigate a temporal arteritis
- Temporal artery biopsy
- MRI and Doppler study
- Erythrocyte sedimentation rate (ESR)
- C-reactive protein levels measured
what is the prognosis for vision with temporal arteritis
Visual acuity does not recover
Risk of visual loss in other eye (70% within 10 days)
how may an aneurysm cause a headache and how bad is the headache
Recurring headaches may precede a burst aneurysm
Often severe headache
list 5 symptoms of a ruptured aneurysm
- sudden, excruciating headache
- stiff neck
- vomiting
- altered behaviour
- may have focal lesions
IIIrd nerve palsy if posterior communicating artery affected
hemiparesis if middle cerebral artery affected
what can a ruptured aneurysm of a posterior communicating artery cause
IIIrd nerve palsy
what can a ruptured aneurysm of a middle cerebral artery cause
hemiparesis
what is the ddx of a headache caused by an aneurysm and therefore what action should you take
- migraine
- if the patient has a one off severe headache, refer them to A and E if its very bad or to the GP
what is a Arteriovenous Malformation
where arteries and veins are not connecting in the correct way and if it ruptures, it can give a sudden headache
what type of headache is caused by a Arteriovenous Malformation
Specific recurring headache - throughout life
list 3 signs/symptoms of a ruptured Arteriovenous Malformation or fistula
- sudden severe headache
- stiff neck
- homonymous field defect typical of occipital AVM
what is the pathophysiology of a Arteriovenous Malformation
- Focal damage near site of lesion
- Haemorrhage results in increased ICP
what is the pathophysiology of an aneurysm
- Focal damage near site of lesion
- Burst aneurysm of major vessel life threatening
what is the 2 management options of a aneurysm and a Arteriovenous Malformation
- Referral to GP same day
- Immediate referral to casualty if:
Suspect burst aneurysm or AVM
Aneurysm on major vessel
list all 7 headache characteristics from a raised ICP
- normally intermittent
- non specific, non localised
- dull, not throbbing
- worse after exercise
- may waken patient from sleep
- transient headache on coughing
- may be absent
list the 4 signs of a early papilloedema, caused by raised ICP
- Mild disc swelling and hyperaemia - nasal margins affected first
- Venous engorgement
- Blurring of disc margins and peripapillary RNFL
- Loss of spontaneous venous pulsation
what is the pathophysiology/reasons for a raised ICP
Traction on pain sensitive structures
intra-cranial, extra-cerebral, such as meninges
what is the management of a raised ICP
REFER TO CASUALTY
with recommendation for neurological investigation
list 4 causes of a secondary headache attributable to disorders of the eye
- acute glaucoma (closed angle)
- refractive error
- heterophoria or heterotropia
ocular motor nerve palsies - ocular inflammatory disorder
corneal lesions, anterior uveitis, optic neuritis
what are the general symptoms of a secondary headache attributable to disorders of the eye
- Asthenopia
- Uncorrected Rx /Incorrect Rx:
Not present on waking
Mild HA
Frontal, around eyes - Heterophoria or heterotropia (BV anomaly):
Recurrent
Mild HA
Intermittent blur/diplopia
May be relieved by closing one eye e.g. can be convergence insufficiency
HA resolves if visual problem is corrected
what is the management of a secondary headache attributable to disorders of the eye
- Treat refractive error or ocular motor imbalance in practice
- Refer ocular disease to the ophthalmologist with a degree of urgency depending on the condition
name a Secondary headache attributable to other secondary causes and give 2 example of this type
Painful cranial neuropathy and other facial pains:
- Trigeminal neuralgia
- Atypical facial pain
i.e. headaches = a secondary to facial pains that occurred in the first place
what does a Trigeminal neuralgia affect
Distribution of trigeminal nerve (Vth nerve):
- Mostly affects mandibular or maxillary region
- Can affect ophthalmic division, but not in isolation
what is the symptoms of a Trigeminal neuralgia (as a secondary cause of a headache) and when is the usual onset
- intense jabs of pain, repetitive
lasts only seconds, with an ache in between - Onset usually after age 50 years
what is the symptom of Atypical facial pain (as a secondary cause of a headache)
Diffuse ache - all over face
what is the pathophysiology of a Trigeminal neuralgia
- Compression of Vth nerve root leaving pons
usually an aneurysm or other vascular lesion
what is the 3 possible pathophysiology of a Atypical facial pain
- Dental pain / disease
- Nasopharyngeal neoplasm
- Psychological illness
what is the management of a Secondary headache attributable to other secondary causes such as Trigeminal neuralgia and Atypical facial pain
- Routine referral to GP
Treatment can be medical or surgical
list all 7 types of questions you will ask in a good history and symptoms for a patient who is suffering from headaches
- FLOADS
- Recent onset less than 6 months; sudden onset
- Change in pattern to HA
- Resistance to medication - more worrying
- Atypical symptoms
- GH: Systemic or neurological conditions
- +ive FH of migraine
which type of onset of headache is found out from asking FLOADS in your H and S is more worrying
sudden onset
new headaches is also more worrying than someone who has had headaches for years
if during H and S you find out that a 50 year old male is waking up at night by headaches, what 2 possible causes can it be and how will you differentiate from the 2
can be:
- Giant cell arteritis
- Cluster
To differentiate, will ask about scalp tenderness and when looking at the back of the eye will see signs of GCA, also vision will be reduced with GCA and not cluster
