Themes 2 and 4: Headache and anatomy

Question 1

what are the challenges of communicating risk?

Answer 1

finding the relevant data and portraying it in a way that is easy to understand
understanding the patients perception of risk
understanding terms
statistics can often be confusing and misleading
cognitive biases- anchoring, availability bias, optimism bias

Question 2

what are important skills for communicating risk to patients?

Answer 2

understanding what the patient already understands about the risk of a procedure/treatment
make use of signposting to discussing risk further
give information in small chunks and check understanding
give information with permission- not all patients want to know everything
avoid jargon
use visual aids
check understanding

Question 3

what are primary and secondary headaches?

Answer 3

primary headache- not caused by anything, headache is main problem, can be episodic and benign. include migraines, tension type headaches etc.
secondary headache- headaches caused by something, can be not- immediately life threatening or life threatening

Question 4

what is a tension- type headache?

Answer 4

primary headache
most common type of headache
can be associated with stress, depression
episodic <15 days per month, chronic >15 days
presentation:
mild/moderate bilateral pain- tight band around head, squeezing feeling
can get radiation to neck
varying duration- 30 minutes to 7 days
usually no other symptoms
normal neurological exam

Question 5

what is a migraine?

Answer 5

primary headache- more common in females
thought to be caused by a triggering event (lack of sleep, dehyration) causing activation of trigeminovascular pathways leading to pain.
4 phases- prodrome (symptoms before headache), aura (transient focal neurological symptoms), headache, postdrome (symptoms after headache)
3 main types of migraine- migraine without aura, migraine with aura, migraine aura without headache

Question 6

what is a cluster headache and how does it present?

Answer 6

rare type of primary headache- more common in males, smokers
tend to occur in bouts then remit over months/years
presentation:
severe unilateral pain around eye
associated with ipsilateral autonomic symptoms- eye watering, nasal congestion, rhinorrhea, facial sweating, eyelid swelling
excruciating sharp pain behind eye
lasts 15 minutes to 3 hours
often occurs at night and wakes patient
not associated with auras or nausea/ vomiting

Question 7

what are the types of secondary headache?

Answer 7

not immediately life threatening- substances/withdrawal headache, head/neck/ENT, homeostatic dysfunction, psychiatric
dangerous- vascular (subarachnoid haemorrhage, giant cell arteritis), raised intracranial pressure, intracranial infection, space occupying lesion

Question 8

what is a subarachnoid haemorrhage?

Answer 8

bleeding into subarachnoid space (between Pia and arachnoid mater) causing increase in intracranial pressure
commonest cause of non-traumatic SAH is a ruptured berry aneurysm
presentation:
presents as an explosive ‘thunderclap headache’- occipital
may have signs of meningism- neck stiffness, photophobia
nausea and vomiting
if severe can lead to reduced consciousness
can have multiple less severe headaches before the thunderclap headache caused by sentinel bleeds before aneurysm ruptures
high morbidity/ mortality

Question 9

what is giant cell arteritis?

Answer 9

medium and large vessel vasculitis primarily affecting the carotid artery and its branches
medical emergency- can lead to blindness
presentation:
headache- usually occipital or temporal (over arteries affected)
scalp tenderness
jaw claudication- tenderness on chewing
amaurosis fugax- temporary visual loss- like curtain coming down over vision
generally unwell, tired, stiff joints
associated with polymyalgia rheumatica- rheumatalogical condition asscociated with shoulder and/ or pelvic girdle pain/stiffness

Question 10

what are the causes and signs of raised intracranial pressure?

Answer 10

causes- space occupying leision, intracranial infection (meningitis, encephalitis), disruption to CSF flow, bleeds/head trauma, idiopathic
presentation:
triad of headache, vomiting, papilloedema
headache- gradual onset, worse in morning/on coughing, wakes from sleep
visual disturbance
changes in mental state
late signs- raised BP, wide pulse pressure, bradycardia

Question 11

what is a space occupying lesion?

Answer 11

something occupying the space in the brain- causing raised intracranial pressure
most likely a tumour, can also be an abscess, haematoma
they produce symptoms by pressing on other structures, raising intracranial pressure, provoking seizures (lesion makes brain more unstable)

Question 12

what are the options for acute management of migraine?

Answer 12

1. simple analgesia (paracetamol, NSAIDs)- must be taken at start of headache phase, some patients get gastric stasis in migraine which impairs drug absorption
2. anti-emetics (cyclizine, metoclopramide)- prevent nausea/vomiting, useful in conjunction with analgesia as they can be pro-kinetic and increase gastric emptying- preventing gastric stasis
3. 5HT1 receptor agonist (triptans- sumatriptan, zolmitriptan)- cause vasoconstriction and have direct action on neurones- modulate neurotransmitter release. given orally, subcutaneously, nasally. should be taken during headache phase
   first line- combination therapy oral triptan+ analgesia

Question 13

what are the options for migraine prophylaxis?

Answer 13

first line- topiramate (anti-epileptic) or propranolol (beta-blocker)
other options- amitriptyline (anti-depressant)

Question 14

what is the collection of nerves at the end of the spinal cord called?

Answer 14

the cauda equina

Question 15

at what point does the spinal cord transition to cauda equina?

Answer 15

at approximately L1

Question 16

how many vertebra are there in each region?

Answer 16

cervical- 7 
thoracic- 12
lumbar- 5
sacral- 5 (fused)
coccyx- 4 (fused)

Question 17

what is the name of the termination of the spinal cord and where is it?

Answer 17

the conus medullaris

around L2

Question 18

what are the meninges and their function ?

Answer 18

the membranous coverings of the brain. they have a supportive role by providing a framework for the cerebral and cranial vasculature and a provide protection to the CNS from mechanical damage along with CSF
they consist of 3 layers: dura mater, arachnoid mater and Pia mater

Question 19

what is the dura mater?

Answer 19

the outermost layer of the meninges. tough, fibrous, double membrane that surrounds the brain and spinal cord like a loose fitting bag. the outer layer is the periosteal layer and the inner layer is the meningeal layer.. these layers are mostly adherent to each other but separate in certain areas to form dural reflections and venous sinuses.

Question 20

what is the extra dural space?

Answer 20

the space between the bone and the dura mater. although it is more of a potential space as the dura is mainly adherent to the bone.

Question 21

how many dural layers surround the spinal cord and why?

Answer 21

only the meningeal layer surrounds the spinal cord. the periosteal layer is continuous with the outer surface of the skull. so the spinal cord has only one dural layer and a continuous extra dural space

Question 22

what are the main dural reflections?

Answer 22

the layers of the dura separate and extent into the fissures of the brain forming the dural reflections:

1. falx cerebri- extension within great longitudinal fissure
2. tentorium cerebelli- extension within the transverse fissure
3. falx cerebelli- extension between the cerebellar lobes
4. diaphragm sellae- covers hypophyseal fossae

Question 23

what is the arachnoid mater?

Answer 23

the middle layer of the meninges. it is a thin avascular loose fitting layer that lines the dura. the arachnoid mater and dura mater are not tightly adhered and are easily separated by low pressure to form the subdural space.

Question 24

what are the arachnoid granulations?

Answer 24

they are extensions from the arachnoid layer which help the CSF return to the venous system via the venous sinuses

Question 25

what is the Pia mater?

Answer 25

the inner layer of the meninges. it is thin, translucent and tightly adherent to the surface of the brain (follows the gyri and sulci).

Question 26

what is the subarachnoid space?

Answer 26

a true space between the arachnoid and Pia mater which is filled with CSF and blood vessels. there are large regions in the subarachnoid space called cisterns. the subarachnoid space is divided by trabeculae that join the arachnoid mater to the Pia mater.

Question 27

what is the blood supply of the meninges?

Answer 27

from 3 main arteries:
1. anterior meningeal artery 
2. middle meningeal artery- main supply to dura, branch of external carotid
3. posterior meningeal artery 
also accessory meningeal artery

Question 28

which meningeal artery is most at risk of rupture from trauma?

Answer 28

middle meningeal artery as it runs beneath the pterion- an area where the skull is thin.. rupture of a meningeal artery leads to a epidural haematoma

Question 29

what is the innervation of the meninges?

Answer 29

the main innervation of the dura is from the opthalmic division of the Trigeminal nerve (CN V1), the maxillary (CN V2) and mandibular (CN V3) also play a role

Question 30

what are the dural venous sinuses?

Answer 30

they are formed between the two layers of the dural mater. they receive blood from within the brain and allow drainage via the internal jugular vein. they have no valves so blood can travel in both directions

Question 31

how does blood flow through the venous sinuses?

Answer 31

from the inferior sagittal sinus blood can move through the straight sinus to meet the confluence of sinuses. here it is joined by contributions from the superior sagittal sinus and occipital sinuses. it can then flow down the paired transverse sinuses into the sigmoid sinuses and into the internal jugular vein

Question 32

what are the cavernous sinuses?

Answer 32

they are paired plexus of veins connected by intercavernous sinuses that drain the ophthalmic veins. they drain into the sigmoid sinuses via the superior petrosal sinus or the internal jugular vein via the inferior petrosal sinus.

Question 33

what is the connection between the inferior petrosal sinuses called?

Answer 33

the basilar sinus

Question 34

what structures pass through the cavernous sinus?

Answer 34

O TOM CAT
Occulomotor (CN III)
Trochlear (CN IV)
Opthalmic division of the trigeminal (CN V1)
Maxillary division of the trigeminal (CN V2)
Carotid artery (internal)
Abducent (CN VI)
T represents the level of the level of C and A trochlear nerve

Question 35

what are the ventricles of the brain?

Answer 35

they are cavities within the brain responsible for the production, transport and removal of CSF. there are 2 lateral ventricles, the third ventricle and the fourth ventricle

Question 36

what are the connections between the ventricles of the brain?

Answer 36

interventricular foramen (of munro)- between the lateral ventricles and the third ventricle
cerebral aqueduct- connection between third and fourth ventricle
median aperture- between the fourth ventricle and the cisterna magna
lateral apertures- between fourth ventricle and cisterna magna

Question 37

what is the obex?

Answer 37

the point at which the fourth ventricle narrows to become the central canal of the spinal cord (bathes spinal cord)

Question 38

what is hydrocephalus?

Answer 38

an abnormal buildup of fluid in the ventricles which puts pressure on brain tissues. can be congenital, acquired or normal pressure hydrocephalus

Question 39

what are the 2 classifications of hydrocephalus?

Answer 39

communicating- flow of CSF is blocked after it exits the ventricles
non-communicating- flow of CSF is blocked alone one or more of the narrow passages connecting the ventricles.