Neurology Flashcards
Differentials for headache
- Tension headaches
- Migraines
- Cluster headaches
- Secondary headaches
- Sinusitis
- Giant cell arteritis
- Glaucoma
- Intracranial haemorrhage
- Subarachnoid haemorrhage
- Analgesic headache
- Hormonal headache
- Cervical spondylosis
- Trigeminal neuralgia
- Raised intracranial pressure (brain tumours)
- Meningitis
- Encephalitis
Red Flags for headaches
- Fever, photophobia or neck stiffness MENINGITIS OR ENCEPHALITIS
- New neurological symptoms HAEMORRHAGE, MALIGNANCY, STROKE
- Dizziness STROKE
- Visual disturbance TEMPORAL ARTERITIS OR GLAUCOMA
- Sudden onset occipital headache SUBARACHNOID HAEMORRHAGE
- Worse on coughing or straining RAISED INTRACRANIAL PRESSURE
- Postural, worse on standing, lying or bending over RAISED INTRACRANIAL PRESSURE
- Severe enough to wake from sleep
- Vomiting RAISED INTRACRANIAL PRESSURE OR CO POISONING
- History of trauma INTRACRANIAL HAEMORRAGE
- Pregnancy PRE-ECLAMPSIA
- Previous headache history + progression or change in character
Types of migraine
- Migraine without aura
- Migraine with aura
- Silent migraine (aura but no headache)
- Hemiplegic migraine (mimic stroke)
Triggers of migraine
- Chocolate
- Hangovers, dehydration
- Orgasms
- Cheese
- Oral contraceptives
- Lie-ins (abnormal sleep patterns)
- Alcohol
- Tumult = loud noise, strong smells, bright lights
- Exercise
- Stress
- Menstruation
- Trauma
Stages of migraine
- Premonitory/prodromal stage = 3 days before
- Aura = up to 60 mins
- Headache = 4-72 hours
- Resolution
- Post-dromal or recovery
Presentation of migraine
- Prodrome = yawning, cravings, mood/sleep changes
- Headache lasting 4-72 hours
o Moderate to severe intensity
o Pounding or throbbing in nature
o Usually unilateral but can be bilateral - Nausea and vomiting
- Photophobia/phonophobia (sound sensitive)
- Motion sensitivity
- Visual or other aura lasting 15-30 mins
o Sparks, lines, blurring in vision
o Loss of different visual fields
o Paraesthesiae spreading from fingers to face - Hemiplegic migraine
o Typical migraine symptoms
o Hemiplegia (unilateral weakness of limbs)
o Ataxia
o Speech = dysphasia or paraphasiae
o Changes in consciousness - Papilloedema
Management of migraine
- Dark quiet room and sleep
1. Paracetamol or NSAIDs + oral triptan
o S/E = Tingling, heat, tightness, heaviness, pressure
o CI = Hx of IHD or cerebrovascular disease - Antiemetics – if vomiting (metoclopramide)
Prevention of migraines
- Keep headache diary to identify triggers and avoid triggers
- Propranolol (not in asthma)
- Topiramate (not in pregnancy or women of child bearing age)
- Amitriptyline
- Botox
- 10 sessions of Acupuncture over 5-10 wks
- Supplementation with B2 (riboflavin)
- NSAIDS/triptans (if associated with menstruation)
Risk factors for tension headache
- Stress
- Sleep deprivation
- Bad posture
- Hunger (skipping meals)
- Eyestrain
- Anxiety/Depression
- Noise
- Alcohol
- Dehydration
Presentation of tension headache
- Can be episodic (<15 days/month) or chronic (>15 days/month for at least 3 months)
- Bilateral pressing/tight non-pulsatile headache
o Mild/moderate intensity
o Headaches can last from 30 mins to 7 days
o Comes on and resolves gradually - Scalp muscle tenderness
- Pressure behind eyes
- No visual changes
Management of tension headache
- Lifestyle
o Reassurance and lifestyle advice
o Stress relief and relaxation techniques
o Hot towels to local area - Medication
o Basic analgesia paracetamol, ibuprofen, aspirin
o TCA amitriptyline
Risk factors for cluster headache
Smoking
Triggers of cluster headache
- Alcohol
- Strong smells
- Exercise
Presentation of cluster headaches
- Episodic = clusters last 4-12 wks and followed by pain-free periods of months-yrs
- Chronic = attacks for more than 1 yr without remission
- Sudden excruciating stabbing unilateral pain around one eye, temple or forehead
o Rises in crescendo over mins and last 15 mins to 3 hrs
o Once or twice a day (usually same time)
o Often nocturnal/early morning = wakes patient from sleep - Vomiting
- Restlessness or agitation
- Red swollen, watering eye with lid swelling
- Facial flushing/sweating
- Rhinorrhoea (nasal discharge)
- Miosis (excessive pupil constriction)
- Ptosis (eyelid dropping)
Management of cluster headaches
- SC sumatriptan
- High flow O2 for 15 mins via non-breathable mask
Prophylaxis of cluster headaches
- 1st line = CCB (verapamil)
- Avoid alcohol
- Prednisolone (short course for 2-3 wks)
- Lithium
What is giant cell arteritis
Chronic vasculitis characterised by granulomatous inflammation in walls of medium and large arteries
Presentation of GCA
- New-rapid onset headache (temporal) <1m
- Temporal artery abnormality
o Tenderness on palpation of temporal artery
o Thickening
o Nodularity
o Red overlying skin
o Pulsation (reduced or absent) - Visual disturbances
o Loss of vision
o Diplopia
o Changes to colour vision
o Fundoscopy pallor and oedema of optic disc, cotton wool patches, small haemorrhages in retina - Scalp tenderness (brushing hair)
- Scalp necrosis
- Intermittent jaw claudication
- Systemic features Low grade fever, Fatigue, Anorexia, Weight loss, Depression, Night sweats
- Features of PMR proximal muscle pain, morning stiffness, tenderness, aching
Investigations for GCA
- Raised inflammatory markers ESR >50
- Temporal artery biopsy skip lesions
- Creatine kinase and EMG normal
- Vision testing
o Anterior ischaemic optic neuropathy
o Temporary visual loss
o Diplopia
o Swollen pale disc and blurred margins
Management of GCA
- MEDICAL EMERGENCY
- Urgent high-dose Glucocorticoids = 40-60mg oral prednisolone per day for 1-2 yrs
o Given before temporal artery biopsy
o No visual loss prednisolone
o If visual loss give IV methylprednisolone
o Should be dramatic response - Urgent ophthalmology review = Visual damage often irreversible
- Bone protections with bisphosphonates
- Low dose aspirin
Complications of GCA
- Loss of vision
- Aortic aneurysm
- Aortic dissection
- Large artery stenosis
- Aortic regurgitation
- CVD = MI, HF, stroke, peripheral arterial disease
- Scalp necrosis, peripheral neuropathy, depression, confusion, encephalopathy, deafness
Management of analgesia overuse headache
- Withdrawal of analgesia
o Immediately for paracetamol, NSAIDs or triptans
o Gradually for opiates
Presentation of trigeminal neuralgia
- 90% unilateral, 10% bilateral
- Intense electricity-like shooting facial pain, comes on spontaneously
- Lasts between few secs to hrs
- Attacks worsen over time
Management of trigeminal neuralgia
- Carbamazepine
- Surgery to decompress or intentionally damage nerve