Themes 2 and 4: Headache and anatomy Flashcards
what are the challenges of communicating risk?
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
what are important skills for communicating risk to patients?
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
what are primary and secondary headaches?
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
what is a tension- type headache?
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
what is a migraine?
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
what is a cluster headache and how does it present?
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
what are the types of secondary headache?
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
what is a subarachnoid haemorrhage?
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
what is giant cell arteritis?
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
what are the causes and signs of raised intracranial pressure?
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
what is a space occupying lesion?
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)
what are the options for acute management of migraine?
- simple analgesia (paracetamol, NSAIDs)- must be taken at start of headache phase, some patients get gastric stasis in migraine which impairs drug absorption
- 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
- 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
what are the options for migraine prophylaxis?
first line- topiramate (anti-epileptic) or propranolol (beta-blocker)
other options- amitriptyline (anti-depressant)
what is the collection of nerves at the end of the spinal cord called?
the cauda equina
at what point does the spinal cord transition to cauda equina?
at approximately L1
how many vertebra are there in each region?
cervical- 7 thoracic- 12 lumbar- 5 sacral- 5 (fused) coccyx- 4 (fused)
what is the name of the termination of the spinal cord and where is it?
the conus medullaris
around L2
what are the meninges and their function ?
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
what is the dura mater?
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.
what is the extra dural space?
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.
how many dural layers surround the spinal cord and why?
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
what are the main dural reflections?
the layers of the dura separate and extent into the fissures of the brain forming the dural reflections:
- falx cerebri- extension within great longitudinal fissure
- tentorium cerebelli- extension within the transverse fissure
- falx cerebelli- extension between the cerebellar lobes
- diaphragm sellae- covers hypophyseal fossae
what is the arachnoid mater?
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.
what are the arachnoid granulations?
they are extensions from the arachnoid layer which help the CSF return to the venous system via the venous sinuses
