Neurology Flashcards
Definition of Migraine & Types
A primary headache disorder, form of sensory processing disturbance with manifestations within & outside CNS function
A recurrent, moderate to severe headache commonly a/w nausea, photophobia & phonophobia.
The headache is typically unilateral and pulsating in nature lasting 4-72 hours.
There are two major types of migraine:
- Migraine without aura: characteristic migraine headache with associated symptoms.
Migraine with aura: a migraine headache that is preceded (and sometimes accompanied) by focal neurological symptoms.
Possible triggers/risk factors for Migraine
Stress Caffeine intake Menstruation Exercise Lack of Sleep OCP Certain foods e.g. chocolate Family history
Clinical features of Migraine
Unilateral or bilateral throbbing/pulsating headache Can be preceded by an aura Visual changes Moderate to severe pain a/w nausea, photophobia, phonaphobia wanting to sleep/sit in dark quiet room
Management of Migraine
Preventative measures - avoid triggers, keep diary, lifestyle advice
Acute - NSAID e.g. aspirin at aura, triptan at headache (sumatriptan), antiemetic e.g. metoclompromide
Preventative (if >2/month) - beta blockers, amitriptyline, topiramate, candasartan
Definition of Cluster Headaches
A severe primary headache disorder characterised by recurrent unilateral headaches centred on the eye or temporal region.
Clinical Features of Cluster Headaches
Unilateral severe headache
Autonomic sx – eye streaming, runny nose, conjunctival congestion, swelling of face/eyelids
Some patients can have night time attacks which will wake pt from sleep usually 2-6am
Severe agitation & restlessness
Periodicity
Investigations & Diagnosis of Cluster Headaches
Investigations:
Patients presenting with their first bout of a cluster-like headache should be referred to neurology for further review.
• Due to TACs being v common, patients should be referred to neurology as dx should be confirmed by specialist
Investigations typically consist of imaging to exclude sinister causes:
• MRI Brain
• CT Head
Diagnosis - clinical, dx by specialist
Management of Cluster Headaches
Aim to terminate acute attacks & prevent further ones
• Sumatriptan is often used first-line to terminate acute attacks (S/C or intranasally)
• Short burst oxygen therapy: 100% oxygen (12-15L/min) can be administered via a non-rebreather face mask for 15-20 minutes
• Avoid triggers e.g. alcohol, smoking
Traditional analgesic medications like paracetamol, opiates and NSAIDs are not recommended.
Preventative (long term) - verapamil (high dose, ECG monitoring), topiramate
Definition of Trigeminal Neuralgia & Clinical Features
Sudden, severe facial pain, often described as a sharp shooting pain or like having an electric shock in the jaw, teeth or gums (within the distribution of the trigeminal nerve).
Short-lived episodes of electric shock pain in the distribution of the trigeminal nerve
Usually unilateral (>97%)
Recurrent attacks - triggers inc cold air, eating
Aetiology of trigeminal neuralgia
Primary trigeminal neuralgia
• Refers to disease caused by vascular compression - thought to account for 80-95% of cases
• This normally occurs near the root of the nerve at the ‘nerve root entry zone’
• The compression is thought to lead to demyelination and abnormal electrical activity in response to stimuli
Secondary trigeminal neuralgia
• Refers to disease occurring secondary to another condition
• Compression may be caused by other lesions (e.g. vestibular schwannoma, meningioma, cysts)
• Multiple Sclerosis
Idiopathic trigeminal neuralgia
Management of Trigeminal Neuralgia
Consider urgent ref for MRI if sinister cause suspected
1st line - carbamazepine 100mg BD & titrate upwards until remission
2nd line - gabapentin or lamotrigine
Surgical options - microvascular decompression or gamma knife radiosurgery
Definition & Risk factors for Idiopathic intracranial hypertension
A disorder caused by chronically elevated intracranial pressure (ICP), which leads to the characteristic clinical features of headache, papilloedema (swollen optic discs) and visual loss.
Weight (obesity), age (reproductive age) & sex (female)
Clinical features of IIH
Headache - worse on lying down, bending forwards & in the morning
Visual changes - transient vision loss, flashes of light, diplopia
Tinnitus
Neck/back pain
pain behind eyes
papilloedema
6th nerve palsy
Investigations for IIH
Obs (BP) Urinalysis - pregnancy & renal disease Bloods Opthalmoscopy MRI (R/O other causes) LP - measure pressures
Differentials for IIH
SOL, venous sinus thrombosis, obstructive hydrocephalus, decreased CSF reabsorption or increased CSF production
Management of IIH
Weight loss
• Low sodium weight loss plan
Serial LPs
Occasionally may be offered to remove excess CSF
Pharmacotherapy
• carbonic anhydrase inhibitor (e.g. acetazolamide) is the treatment of choice for IIH
• Thought to work by reducing amount of CSF production
Surgical
• Optic nerve sheath fenestration
Shunting
Clinical Features of Tension Type Headache
Classically they produce a mild ache across the forehead and in a band-like pattern around the head.
This may be due to muscle ache in the frontalis, temporalis and occipitalis muscles. Tension headaches comes on and resolve gradually and don’t produce visual changes.
Risk factors/associations for tension type headaches
Stress Depression Dehydration Alcohol Skipping meals
Red Flags in Headaches
Headache Characteristics - severe sudden onset, progression or acute changes, worse on standing/lying down
Precipitating factors - recent trauma (subdural), triggered by Valsalva manoeuvre
Associated features -
fever/photophobia/neck stiffness (meningitis), papilloedema (IIH, SOL, CVS), vomiting (SOL, CO poisoning), dizziness/vertigo (stroke), visual changes (GCA, glaucoma)
Patient factors - age >50 or <10, immunodeficiency, active or previous cancer, pregnancy
Management of Tension Headaches
Analgesia: Simple painkillers such as paracetamol of NSAIDs (if no contra-indications), to be taken when headache occurs.
Lifestyle: Evaluate and offer help with possible precipitants. Consider sources of stress, depression/anxiety, sleep disorder and chronic illnesses. Some patients find regular exercise helps.
Medication-Overuse Headaches; definition & management
Medication ‘overuse’ itself has been shown to result in chronic headaches.
As the name suggests this occurs when regular analgesia taken for symptomatic relief of headache causes or perpetuates the condition.
It gives similar non-specific features to a tension headache.
Stop/reduce medications within a month - may get worse before better
Definition & Aetiology of Subarachnoid Haemorrhage
Arterial haemorrhage/bleeding into subarachnoid space (bet arachnoid & pia mater)
Traumatic - HI
Spontaneous - aneurysm rupture, AVM, rarer (CA dissection)
Risk factors for SAH
Hypertension
Smoking
Alcohol
Substance/drug abuse e.g. cocaine, amphetamines
Sex - higher risk in females
Race: higher incidence in Japanese/Finnish populations
Family history of aneurysms
Genetic predisposition
○ autosomal dominant polycystic kidney disease (increased tendency to form berry aneurysms) or type IV Ehlers-Danlos syndrome
Clinical features of SAH
Sudden severe thunderclap headache Photophobia & neck stiffness N&V Visual changes - ptosis, 3rd nerve palsy, diplopia Reduced GCS
Investigations & Management of SAH
Observations & Examination, Bloods inc G&S, clotting, Imaging (CT head)
If CT head normal - LP in 12hrs (detect bilirubin)
Initial management - A to E survey, ?airway management if needed
Medical - analgesia, anti-emetics, IV fluids & monitoring, regular neurological observations, nimodipine
Surgical/aneursym management - coiling/clipping
Definition & Aetiology of Subdural Haemorrhage
Rupture of bridging veins, bleeding between dura & surface of brain
acute - within 72hrs, subacute 3-20days, chronic after 3 weeks
Usually caused by trauma (fall, HI) but can be caused by aneurysm rupture, AVM etc
RFs: elderly, alcoholics, anticoagulated, HTN, presence/hx of aneurysms
Clinical features of Subdural Haemorrhage
History of trauma & HI with decreased level of consciousness (ACUTE)
Worsening headaches for 7-14days after injury, altered mental state (SUBACUTE)
Headache, fluctuating confusion, cognitive impairment, focal weakness, seizures (CHRONIC)
Seizures Weakness Vomiting Reduced consciousness Sudden neurological sx
Investigations for subdural haemorrhage
Urgent CT head - confirm diagnosis, crescent shaped
• History/examination/observations - inc neuro examination, pupils & A-E survey
• Bloods - FBC (Hb, plt), U&Es, LFTs (alcohol), clotting, G&S, bone profile
• Imaging - CT head
○ Crescent shaped
○ Acute subdural bleeds = hyperdensity = paler
Chronic subdural bleeds = hypodense = darker
Management of Subdural Haemorrhage
Management:
Initial
A to E survey; C spine, D inc pupil check & GCS, signs of raised ICP
Conservative
If small & minimal midline shift
Closely monitor with neuro obs, manage & prevent ICP
Ensure normal sats, normal temp, normal CO2, adequate sedation and paralysis, ICP monitoring
Seizure management
Surgical
Stopping bleeding/evacuation of chronic subdurals
Burr Holes
