Neurology 1 Flashcards
How do migraines typically present?
Recurrent, severe headache which is usually unilateral and throbbing in nature
May be be associated with aura, nausea and photosensitivity
Aggravated by, or causes avoidance of, routine activities of daily living. Patients often describe ‘going to bed’.
In women may be associated with menstruation
How do tension headaches typically present?
Recurrent, non-disabling, bilateral headache, often described as a ‘tight-band’
Not aggravated by routine activities of daily living
How do cluster headaches typically present?
Pain occurs once or twice a day, each episode lasting 15 mins - 2 hours with clusters typically lasting 4-12 weeks
Intense pain around one eye (recurrent attacks ‘always’ affect same side)
Patient is restless during an attack
Accompanied by redness, lacrimation, lid swelling
More common in men and smokers
How does temporal arteritis typically present?
Typically patient > 60 years old
Usually rapid onset (e.g. < 1 month) of unilateral headache
Jaw claudication (65%)
Tender, palpable temporal artery
Raised ESR
How does a medication overuse headache typically present?
Present for 15 days or more per month
Developed or worsened whilst taking regular symptomatic medication
Patients using opioids and triptans are at most risk
May be psychiatric co-morbidity
Give some causes of an acute onset single episode of headache
meningitis / encephalitis
subarachnoid haemorrhage
head injury
sinusitis
glaucoma (acute closed-angle)
Give some causes of chronic headache
chronically raised ICP
Paget’s disease
psychological causes
Give some red flags for a headache
Fever, photophobia or neck stiffness (meningitis)
History of head trauma (haemorrhage)
History of cancer (brain mets)
Postural , triggered by coughing / straining (raised ICP)
Visual disturbance (GCA, glaucoma, tumours)
New-onset neurological deficit
Change in personality
Impaired level of consciousness
What may tension headache be associated with?
Stress
Depression
Alcohol
Skipping meals
Dehydration
How can tension headaches be managed?
Reassurance
Simple analgesia (e.g., ibuprofen or paracetamol)
Low dose amitriptyline is generally first-line for chronic or frequent tension headaches
What is a common trigger for cluster headaches?
drinking alcohol
How should cluster headaches be investigated?
most patients will have neuroimaging - underlying brain lesions are sometimes found even if the clinical symptoms are typical for cluster headache
MRI with gadolinium contrast is the investigation of choice
How should cluster headaches be managed?
NICE recommend seeking specialist advice from a neurologist
acute:
100% oxygen (80% response rate within 15 minutes)
subcutaneous triptan (75% response rate within 15 minutes)
prophylaxis: verapamil
Which patients are most at risk of developing medication overuse headaches?
patients using opioids and triptans are at most risk
How should medication overuse headaches be managed? What is the risk with this?
simple analgesics and triptans should be withdrawn abruptly (may initially worsen headaches)
opioid analgesics should be gradually withdrawn
Withdrawal symptoms such as vomiting, hypotension, tachycardia, restlessness, sleep disturbances and anxiety may occur
Headache following lumbar puncture (LP) occurs in approximately one-third of patients.
What features does it present with?
usually develops within 24-48 hours following LP but may occur up to one week later
may last several days
worsens with upright position
improves with recumbent position
How can headache following LP be managed?
supportive initially (analgesia, rest)
if pain continues for more than 72 hours then specific treatment is indicated, to prevent subdural haematoma
treatment options include: blood patch, epidural saline and IV caffeine
Migraine is a complex neurological condition causing episodes of headache and associated symptoms. It tends to affect women more than men and is most common in young adults.
What are the 4 main types?
Migraine without aura
Migraine with aura
Silent migraine (migraine with aura but without a headache)
Hemiplegic migraine
What are the 5 stages of migraine?
Premonitory or prodromal stage (can begin several days before the headache)
Aura (lasting up to 60 minutes)
Headache stage (lasts 4 to 72 hours)
Resolution stage (the headache may fade away or be relieved abruptly by vomiting or sleeping)
Postdromal or recovery phase
Give some typical features of migraine
Usually unilateral but can be bilateral
Pounding or throbbing in nature
Photophobia (discomfort with lights)
Phonophobia (discomfort with loud noises)
Osmophobia (discomfort with strong smells)
Aura (visual changes)
Nausea and vomiting
What is aura?
sensory disturbance commonly associated with migraines
Visual symptoms are the most common.
These may be:
Sparks in the vision
Blurred vision
Lines across the vision
Loss of visual fields (e.g., scotoma)
What are hemiplegic migraines?
migraines associated with hemiplegia (unilateral limb weakness). Other symptoms may include ataxia and impaired consciousness
may be familial
can mimic a stroke or TIA so should be investigated urgently
Give some common migraine triggers
Stress
Bright lights
Strong smells
Certain foods (e.g., chocolate, cheese and caffeine)
Dehydration
Menstruation
Disrupted sleep
Trauma
What are the medical options for managing an acute migraine attack?
NSAIDs (e.g., ibuprofen or naproxen)
Paracetamol
Triptans (e.g., sumatriptan)
Antiemetics if vomiting occurs (e.g., metoclopramide or prochlorperazine)