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Neurology > Week 4- headache > Flashcards

Week 4- headache Flashcards

1
Q

Key things to ask in a headache history

A

Onset/peak- whether it was acute, subacute or gradual
Relieving factors- posture?
Exacerbating factors- posture, vasvalva (sneezing, coughing, straining etc), diurnal variation.
Associated features- autonomic features, positive visual symptoms, ptosis, miosis, nasal stuffiness
Consider demographics e.g. migraine is common in young females.

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2
Q

What are redflags in headache histories?

A 
New onset headache >55 
Known/previous malignancy
Immuno-supressed 
Early morning headache
Exacerbation by valsalva
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3
Q

What is the valsalva manoeuvre? What does it do to cardiac output?

A

When you ask a patient to forcibly exhale against a closed mouth and nose. Reduces cardiac output momentarily because of the increased pressure in the chest.

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4
Q

Who is likely to get a migraine?

A

Young women.

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5
Q

What is an aura that is associated with a migraine?

A

Sensory symptoms- e.g. vision or hearing changes. Could be dizziness, ringing in the ears, photophobia, tingling, speech changes etc.

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6
Q

What is the criteria for diagnosing someone with migraine without aura?

A

5 separate attacks lasting 4-72 hours.
Must have:
2 of- unilateral, throbbing pain, moderate/severe, worse on movement
1 of- autonomic features, photophobia, phonophobia.

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7
Q

Pathophysiology of migraine

A

Stress can trigger changes in the brain, which causes serotonin to be released. This causes blood vessels to constrict and dilate. Chemicals, including substance P, irritate nerves and blood vessels causing pain.
Migraine centre activated

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8
Q

What part of the pathophysiology causes the aura?

A

The vasoconstriction.

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9
Q

How long does an aura associated with migraine usually last?

A

20-60 mins.

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10
Q

How long after the aura develops does the headache occur?

A

<1 hour.

However sometimes they come on simultaneously.

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11
Q

What commonly occurs to the vision in an aura?

A

It goes monochromatic.

You can also get a central scotoma (blurring), central fortification (image in the centre is blurry) or hemianopic loss.

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12
Q

What are common triggers of migraine?

A

Sleep, dietary (cheese, red wine and caffeine common) stress, hormonal, physical exertion

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13
Q

How can you identify triggers clinically?

A

Headache diary with what they were eating/doing the day they get them.

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14
Q

How would you treat migraine non pharmacologically?

A

Stress management/relaxation techniques
Avoidance of triggers
Realistic goal setting.

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15
Q

How would you treat migraine acutely pharmacologically?

A

NSAIDs- take as soon as symptoms start. If gastroparesis occurs- add an antiemetic.
- Aspirin 900mg or naproxen 250mg or ibuprofen 400mg
Triptans- take as soon as symptoms start. More specific migraine agents. Equally good as NSAIDs. Rizatriptan.

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16
Q

How can triptans be administered?

A

Orally, sublingually and subcutaneously.

Consider method of administration when the patient has nausea and vomiting.

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17
Q

When would you consider prophylaxis treatment in migraine?

A

More than 3 attacks per month or very severe attacks.

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18
Q

What is the aim of prophylaxis treatment in migraine?

A

To titrate the drug up to allow efficacy at the lowest possible dose.

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19
Q

Which drugs are used for prophylaxis in migraine?

A

Propanalol- beta blocker. Reduces migraine frequency in 60-80% of people
Topiramate- carbonic anhydrase inhibitor. Poor side effects.

(others include amitryptilline, gabapentin, sodium valproate etc)

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20
Q

When should you not use propranolol for prophylaxis in migraine?

A

Person with asthma or heart failure

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21
Q

What adverse effects can topiramate cause?

A

Weight loss, paraesthesia, impaired concentration, enzyme inducer.

22
Q

How long should you trial each prophylaxis treatment before trying another?

A

4 months minimum.

23
Q

Are any investigations required in migraine?

A

Nope

Unless new onset over 55.

24
Q

What is a tension headache?

A

A mild bilateral headache. Presents with like a tingling/pressing quality.
Its not associated with nausea, vomiting or photophobia.

25
Q

How would you treat a tension headache?

A

Simple pain killers

26
Q

What preventative treatments can be used for tension headaches?

A

Tricyclic antidepressants.

27
Q

What mechanical issue can tension headaches be related too?

A

Temperomandibular jaw dysfunction. Causes spasm in the fronts-temporal muscle. Often patients grind their teeth at night.

28
Q

What is trigeminal autonomic cephalgia (TAC)?

A

Pain in the distribution of the trigeminal nerve unilaterally with ipsilateral cranial autonomic features.

29
Q

What are cranial autonomic features?

A

Ptosis, miosis, nasal stuffiness, nausea/vomiting, tearing, eye lid oedema.

30
Q

What are the 4 main types of TAC?

A

Cluster headache
Paroxysmal hemicrania
Hemicrania continua
SUNCT

31
Q

Who gets a cluster headache?

A

Men are more likely than women

30’s-40’s

32
Q

When do cluster headaches occur?

A

Night time

Seasonal

33
Q

Symptoms of a cluster headache?

A

Severe unilateral pain
They can either come in long clusters (last weeks to months) or several smaller clusters throughout the day.
Person won’t be able to sit still.

34
Q

How should you treat cluster headaches?

A

At the beginning of a bout, give them 40mg prednisolone for 2 weeks.

35
Q

In the acute setting, how might you treat cluster headaches?

A

Give them high flow oxygen

Sub cutaneous sumatriptan

36
Q

Which drug might you use for prophylaxis of cluster headaches?

A

Verapamil.

37
Q

Who gets paroxysmal hemicrania?

A

Elderly (generally 50’s-60’s)

Women more often than men.

38
Q

Symptoms of paroxysmal hemicrania?

A

Severe, unilateral headache. Along with unilateral autonomic features. They last about 10-30 minutes.
Get them 1-40 times a day.

39
Q

How would you treat paroxysmal hemicrania?

A

Indomethacin

40
Q

Differences between cluster headache and paroxysmal hemicrania?

A

Paroxysmal hemicrania has a shorter duration and is more frequent than cluster headaches.

41
Q

What does SUNCT stand for?

A 
S- short lived
U- unilateral
N- nebralgiaform headache
C- conjunctival injections
T- tearing
42
Q

What is the treatment of SUNCT?

A

Lamotrigine

Gabapentin

43
Q

When should you image patients with suspected TAC?

A

The ones with new onset, unilateral cranial autonomic features require imaging. Need an MRI brain and MR angiogram.

44
Q

What is idiopathic intracranial hypertension and who does it affect?

A

Generally affects very fat people. It will stop if they lose weight.
Symptoms are morning nausea/vomiting, visual loss and a headache with diurnal variation (fluctuates throughout the day)

45
Q

What investigations would you do into idiopathic, intracranial hypertension?

A

Fundoscopy- look for absence of venous pulsations (everyones venous BV’s have a slight pulse, except for these patients). They’ll also have papilloedema.
MRV (magnetic resonance venography)
Lumbar puncture- only group of patients with papilloedema that you can do lumbar puncture on. Will show elevated pressure, normal constituents.

46
Q

Management of idiopathic intracranial hypertension?

A

Lose weight- first line of management.

Acetazolamide- lowers CSF pressure. Can cause tingling and often not well tolerated in patients.

47
Q

What is trigeminal neuralgia?

A

Severe unilateral stabbing pain triggered by touch in V2/V3 region. Lasts from 1 second to a minute and a half.
Patients can have from 10-100 recurrences a day.

48
Q

Who gets trigeminal neuralgia?

A

Elderly

Women more common than men.

49
Q

How would you treat trigeminal neuralgia?

A

Carbamazepine, gabapentin, phenytoin or baclofen.

Or surgical management of ablation or decompression.

50
Q

What investigations are done into patients with suspected trigeminal neuralgia?

A

MRI of the brain if any signs on examination e.g. no response to medical treatment, atypical features etc.

Neurology (19 decks)

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