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Jess Nervous > Headaches and Pain > Flashcards

Headaches and Pain Flashcards

1
Q

What examinations might you do as part of a headache presentation?

A

Fundoscopy, cranial nerves, BP, temperature (signs of sepsis), HR, skin and neck

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2
Q

Name three investigations you might do as part of a headache presentation

A

CT, MRI, inflammatory markers (esp if they have temperature)

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3
Q

What differentiates a primary from a secondary headache?

Name three types of primary headaches (and identify which are the more common) and six causes of secondary headaches

A

A primary headache is not caused by underlying disease or structural problems (benign), and are therefore not dangerous. Secondary headaches are caused by underlying disease, and can be harmless or dangerous.

Primary:

  1. Migraine - common
  2. Tension headache - common
  3. Cluster headaches and trigeminal neuralgia

Secondary:

  1. Head trauma
  2. Med overuse
  3. Cancer
  4. Infection (i.e meningitis)
  5. Vascular
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4
Q

Name six potential mechanisms of a headache

A

SIT RAT

  1. Skeletal muscle tension
  2. Arterial dilatation
  3. Traction on arteries
  4. Traction or dilation on venous sinuses
  5. Inflammation
  6. Referred pain
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5
Q

Name some potential causes for extracranial and intracranial

a) arterial dilation
b) inflammation

A

a) extracranial - migraine
intracranial - hypertension (benign intracranial hypertension), infection

b) extracranial - temporal arteritis
intracranial - meningitis

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6
Q

Which mechanism of a headache might occur post lumbar puncture?

A

Traction or dilation on venous sinuses

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7
Q

Name three things which may cause traction on arteries

A

Raised intracranial pressure (ICP), tumour, hemorrhage

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8
Q

How does the prevalence of migraines in M vs F change pre and post puberty? Name one other non-modifiable predisposing factor

A

Pre-puberty: M=F
Post-uberty: M 1:3 F

Genetics are a strong component

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9
Q

How commonly are auras experienced in migraines? Which types of auras are most commonly experienced?

A

20% have auras, usually visual (photophobia) or sensory (hyperacusis)

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10
Q

Name six possible precipitating factors for a migraine

A

Foods, alcohol, emotion, menses, bright light, OCP

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11
Q

Name the two hypothesized theories explaining the pathogenesis for migraines, which is more accepted and why?

A
  1. Vascular Theory: no longer accepted as studies have shown migraine head pain has some mild intracranial (not extracranial) vasodilation
  2. Central Neural circuitry: problem with the nerves in the brain
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12
Q

Describe the stages of a migraine

A

PAHR:

  1. Prodromal fatigue: vague change in mood/appetite
  2. Aura phase
  3. Headache phase
  4. Resolution
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13
Q

What kinds of acute and chronic management are provided for migraines?

A

Acute: analgesia (aspirin), triptans, antiemetic

Chronic: precipitant avoidance (headache diary), beta blockers/topiramate, acupuncture

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14
Q

Which type of headache is most common in primary care? What is the lifetime and chronic risk of having this headache?

A

Tension headache
Lifetime: 75%
Chronic: 2%

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15
Q

Describe a tension headache including the following features

a) Time it lasts
b) Sensation
c) intensity
e) frequency

A

a) 30 min-7 days
b) bilateral pressure, rarely systemic upset and no aura
c) worse during the day
d) ranges from infrequent attacks to daily pain

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16
Q

How are tension headaches managed?

A

Lifestyle: stress, alcohol, exercise, mood, med abuse, reassurance

Medication: OTC (paracetamol, ibuprofen), use low dose amitriptyline if experienced for >2days/week

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17
Q

Compare five differences between a migraine and tension headache

A

Where?
M - unilateral
T - bilateral

Feeling?
M - pulsatile
T - tight band pressure

Aura?
M - yes
T - no

Triggers
M - yes
T - stress

Responsiveness to migraine meds
M - responsive
T - limited response

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18
Q

How common are cluster headaches? Which age group and gender is more likely to experience one?

A

Uncommon: 1/1000
Age group: 30-40s
M 6:1 F

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19
Q

Describe the sensation and typical frequency of a cluster headache

A

Bouts of severe orbital pain lasting 15 min-3 hours that occurs frequently (daily for several weeks)

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20
Q

How might a cluster headache affect one’s routine differently from a migraine?

A

Cluster headaches often wake people during the night, making them restless

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21
Q

Name three symptoms that someone with a cluster headache is likely to experience and two symptoms/signs which are occasionally experienced

A

Likely: Conjunctival injection, lacrimation and nasal blockage

Occasionally: ptosis and horner’s syndrome

22
Q

How are cluster headaches managed?

A

Acute: O2 and triptan

Prophylaxis: specialist advice, avoidance of triggers (alcohol, nicotine), verapamil

23
Q

Name eight types of secondary headaches

A

TTTMMSSR

  1. temporal arteritis
  2. trigeminal neuralgia
  3. toothache
  4. Med overuse headache
  5. Meningitis
  6. Sinusitis
  7. Subarachnoid hemorrhage
  8. Raised ICP
24
Q

Name two things which may cause raised ICP

A

Tumour or idiopathic intracranial hypertension

25
Q

Name 7 red flags for a secondary headache

A

Keywords to remember in bold

  1. Worsening headache with FEVER
  2. Sudden onset headache reaching max intensity in 5 MIN
  3. PERSONALITY change
  4. Impaired level of CONSCIOUSNESS
  5. Recent (typically within 3 month) HEAD TRAUMA
  6. ORTHOSTATIC headache (changes with posture)
  7. NEW ONSET: cognitive dysfunction, neurological deficit
26
Q

Name four red flag triggers for a secondary headache (since they weren’t in the previous question!)

A

Exercise, cough, valsalva (trying to breath out with nose and mouth blocked) or sneeze

27
Q

Name two red flags of a secondary headache that relate the symptoms/signs to other diseases (also wasn’t in the previous question)

A

Giant cell arteritis and acute narrow-angle glaucoma (eye is indicative of changes in the CNS)

28
Q

Which headaches are most associated with neck pain?

A

Cluster/tension headaches

29
Q

How might plasticity influence one’s healing process?

A

Can lead to hyperalgesia and allodynia, which manifests into chronic pain

30
Q

Compare the two types of complex regional pain syndrome, which is more common?

A

Type 1: no identifiable lesion

Type 2: after a nerve injury

31
Q

Name one example of type 2 CRPS

A

Causalgia: severe burning pain in a limb following injury to a peripheral nerve

32
Q

Describe the presentation of CRPS and include the following aspects

a) location and pattern distribution
b) pain

A

Presentation is complex (varied and dynamic) and regional; doesn’t follow dermatomal distribution. Usually involves a single limb

Pain involves hyperalgesia and allodynia (out of proportion to precipitating events)

33
Q

Which age group, gender and other populations are predisposed to experiencing CRPS?

A

Age: ~41 years
F 4:1 M

Other:
85% have preceding traumatic injury
10% have a minor injury
5% unknown trigger (occurs spontaneously)

34
Q

What three ways might CRPS present?

A

With a triad of symptoms
1. Autonomic: i.e excess/reduced sweating, abnormal temperature sensations

  1. Sensory; pain may be spontaneous, hyperalgesia, allodynia
  2. Motor: weakness, tremor, dystonia, myoclonus (spasmodic jerky contractions)
35
Q

Name four signs associated with a CRPS presentation

A

Abnormal ANS: skin temp and color changes, altered sweating

Disuse: bone changes (periarticular osteoporosis, joint stiffness)

Distal edema

36
Q

What are the three general hypotheses explaining the mechanism behind CRPS?

A

Neurogenic inflammation, autonomic dysfunction, neuroplastic changes in the CNS

37
Q

How is CRPS managed?

A

Pharmacological: Steroids, analgesia, neuropathic meds, sympathetic nerve blocks

Non pharmacological: physio, occupational therapy, psychotherapy (CBT)

38
Q

Name four vessels, two general nerve and muscle locations and six other structures of the head and neck which contain pain receptors (and can thus sense pain)

A

Vessels: extracranial arteries, MMA, large veins, venous sinuses

Cranial and spinal nerves

Head and neck muscles

Meninges, falx cerebri, parts of brainstem, eyes, teeth and lining of mouth

39
Q

What is thought to be the cause behind tension headaches and cluster headaches?

A

Tension headaches: activation of peripheral nerves in the head and neck muscles

Cluster headaches: over activation of the trigeminal nerve and hypothalamus in the brain (but exact cause is unknown)

40
Q

What is the mechanism of action for triptan?

A

Blocks serotonin receptors and constricts blood vessels

*treats migraines

41
Q

Why give an antiemetic as part of acute management for migraines?

A

Anti-sickness (prevents vomiting) and for migraine-associated gastroparesis to stimulate gut motility for the analgesic

42
Q

What is one adverse effect of topiramate?

A

Its teratogenic

43
Q

Which inflammatory marker is raised in temporal arteritis and which type of headache does it commonly cause?

A

CRP, commonly associated with tension headaches

44
Q

Which symptom is characteristic of trigeminal neuralgia?

A

Shooting pain through the jaw

45
Q

Which symptom is characteristic of idiopathic intracranial hypertension?

A

Increased blind spot due to pressure on the optic nerve

46
Q

Name five things that can trigger CRPS

A

Minor trauma, bone fracture, stroke, MI, surgery

47
Q

Why might someone with CRPS present with numbness in her fingertips and cold extremities?

A

CRPS is relayed to the sympathetic nervous system

48
Q

Name five features that a visual aura might have

A

Zig-zag lines, bright lights, distorted objects, scotoma (dark patches), techopsia (flashes)

49
Q

Name three features you might expect to see in the clinical history of a patient presenting with a migraine

A
  1. Aura: visual, sensory or speech
  2. Headache: unilateral, throbbing, temporal region
  3. Associated symptoms: nausea, vomiting, photophobia
50
Q

Define the following field defects

a) scotoma
b) scintillations
c) hemianopic field defects

A

a) blind spots
b) flickering/flashes of light
c) loss of whole or part of field of vision

51
Q

Which clinical conditions are the following features of a headache suggestive of?

a) Headache worsens on leaning forward
b) Headache associated with eye pain
c) Reduced GCS (glasgow coma scale)
d) associated neurological deficits
e) associated with head trauma

A

a) space occupying lesion
b) temporal arteritis
c) Acute event (usually compromised vascular supply)
d) Space occupying lesion
e) compromised vascular supply

52
Q

Why should women who suffer from migraine be advised not to take the combined contraceptive pill? What is a safer alternative?

A

Combined pill has a small increase in ischemic stroke which increases in women who experience migraine with aura. Since the risk is from the estrogen component the POP is a safer option

Jess Nervous (16 decks)

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