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Med Year 3 > headaches > Flashcards

headaches Flashcards

1
Q

what are primary headaches

A

disorders where there is no known secondary underlying pathology eg migraine

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2
Q

what are secondary headaches

A

underlying disease that is causing the headaches

  • SOL
  • Intracranial hypertension
  • Vasculitis
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3
Q

what would you not want to miss on an examination?

A
  • swollen optic discs
  • papilloedema = raised ICL requiring emergency brain imaging
  • visual field test: peripheral field loss and enlarged blind sports combined with headaches
  • test eye movements, failure to abduct/adduct eye = nerve palsy
  • abnormal plantar test
  • ataxia and headache = lesion in posterior fossa of the brain
  • white plaque on tongue = oral hairy leukoplakia
  • purpuric rash, non-blancing = meningococcal septeicaemia (medical emergency, requires emergency AB)
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4
Q

what does a blanching rash all over suggest

A

livedo reticularis = antiphospholid AB syndrome or lupus

  • at risk of venous clot in sinuses in brain
  • also seen in vasculitis
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5
Q

what investigations could you do for headaches if neurological exam requires it?

A

CT scan, MRI, CSF monometer (measure ICP when performing LP), spinal fluid, neutrophils in CSF, biopsy (uncommon in headaches)

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6
Q

what do the colours of CSF mean?

A

clear = normal

yellow fluid = xanthochromic fluid = breakdown of blood in fluid = subarachnoid haemorrhage

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7
Q

what could biopsies indicate

A

high ESR, and inflammatory infiltrates in histology; common in GCA

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8
Q

what are the emergency symptoms of a headache

A 
thunderclap onset
acute onset with papilloedema 
acute onset with neurological signs
head trauma / injury
photophobia and nuchal rigidty 
reduced consciousness 
acute red eye / acute angle closure glaucoma 
new onset headache in 3rd trimester pregnancy
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9
Q

what is giant cell arteritis

A

inflammation of the lining of your arteries, most often in your head

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10
Q

what are the symptoms of GCA

A

jaw claudication, visual disturbance, temporal arterty is prominent and tender, diminished pulse, other cranial nerve palsies, limb claudication

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11
Q

what is the 2 week suspected cancer referral

A

-headache with features of raised ICP: wakes from sleep, valsalva manoeuvres, papilloedema, headache present upon waking and easing once up, tinnitus, transient visual loss when changing posture, vomiting, seizures

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12
Q

red flags for secondary headaches

A
  • undifferentiated headache of recent origin and present for >8 weeks
  • recurrent headaches triggered by exertion
  • orthostatic headache (occurs in upright position, suggesting low CSF pressure)
  • new onset headache in those >50, immunosuppressed/HIV
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13
Q

what is the type of pain in a migraine

A

throbbing pain lasting 4 hours -3 days, mostly unilateral, aggravated by physical activity

can be chronic or episodic

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14
Q

what are the associated symptoms with a migraine?

A

sensitivity to light, nausea, aura

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15
Q

what is aura

A

neurological feature preceding headache, may affect one eye only, sensory symptoms: unilateral parasthesia and numbness affecting hand and up the arm, spreading to face, lips and tongue.

visual symptoms = flickering lights, spots etc

20-30% suffer with it

lasts 5-60 minutes

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16
Q

what is a cluster headache

A
  • more common in men
  • most severe pain ever
  • unilateral - sharp, boring, burning, throbbing or tightening side locked
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17
Q

what are the associated symptoms of cluster headaches

A
  • on the same side as the headache:
  • red or water eye
  • nasal congestion or runny nose
  • swollen eyelid
  • forehead and facial sweating
  • constricted pupil/drooping eyelid
  • restlessness
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18
Q

how do you manage cluster headaches

A

12-15L O2, using non re-breathe mask
subcutaneous or nasal triptans acutely

prophylactic: verapamil, lithiuum, prednisolone (steroids but max 2 weeks)

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19
Q

how long does a cluster headache last and how often does it occur

A

15-180 minutes

episodic: 1 every other day to 8 per day, with remission >1 month
chronic: continous remission <1 month in a 12 month period

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20
Q

what is a tension-type headache

A

band-like ache, mostly featureless, can have mild photo or photobia but no nausea

not aggravated by ADL

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21
Q

how long do tension headaches last

A

30 mins - continous, >15 days per month for more than 3 months = chronic

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22
Q

what is a menstrual headache

A

migraine occuring between 2 days before and 3 days after first day of their period, for 2/3 consecutive cycles

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23
Q

what is a medication overuse headache

A

headaches have developed or worsened while they were taking triptans or opiods >10 days a month

or

paracetamol or NSAIDs >15 days a month

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24
Q

treatment of a tension headache?

A
  • aspirin, paracetamol etc, no opioids

prophylactic: 10 sessions of acupuncture over 5-8 weeks

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25
Q

acute treatment of a migraine?

A

oral triptan, NSAID, 900mg aspirin (one of them, if not responding, combine NSAID and triptan for 1 dose)

anti-emetic in addition (bc migarines can cause gastric stasis leading to nausea) eg domperidone

if ineffective: non-oral metoclopramide, non-oral NSAID or triptan

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26
Q

prophylactic treatment of a migraine?

A

topiramate or propanolol

amitryptilline (blocks action of seretonin which is a vasoconstrictor)

riboflavin, 400mg OD, may be effective

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27
Q

what meds are contraindicated in migraine with aura?

A

the oral CP

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28
Q

if all other treatment is ineffective, what do you give for menstrual related migraine?

A

frovatriptan, 2.5mg BD or zolmitriptan on days migraine is expected

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29
Q

migraine in pregnancy treatment?

A

paracetamol, triptan or NSAID

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30
Q

how do you manage a medication overuse headache

A

stop taking all overused meds abruptly for 4-8 weeks , prophylactic treatment for underlying disorder

31
Q

what is the pathology of migraines

A

vascular changes (aura - intracerebral vasoconstrictoin and hence headache due to reactive vasodilation)

arterial vasoconstriction induced by ergotamine = relieves migraine headaches

32
Q

what triggers migraine attacks

A 
relaxing after stress
menstruation bc oestrogen decline
jet lag 
oral cp (oestrogen in pills makes blood easier to clot)
cheese - contains tyramine 
flickering lights
33
Q

how do triptans work

A

strong agonist actions at seretonin 5-HT receptor, in arterial smooth muscle causing vasoconstriction

acts on 5-HT receptors in CNS

34
Q

what is the second line treatment for migraines

A

ACE-I and ARBs or CCB bc calcium causes vasoconstriction

35
Q

what is meningitis and what is the main triad of symptoms

A

medical emergency; inflammation of the meninges (dura, arachnoid and pia mater)

headache, neck stiffness and photophobia

36
Q

causes of meningitis

A

irritation due to infection, blood or trauma

viral infection more common but bacterial - higher mortality

37
Q

RF for meningitis

A

extremes of age - babies and young adults more commonly get bacterial meningitis

living in close proximity

immunosuppression eg asplenia

absence of vaccination history

impaired blood brain barrier

38
Q

pathophys of bacterial meningitis

A

transmitted via droplet spread but requires frequent close contact
can spread from otitis media or URT in susceptible people
entry of bacteria into the CSF

meningococcal disease = neisseria mengitides

39
Q

differential diagnoses for meningitis?

A

encephalitis (HSV causes this) - but causes confusion which meningitis doesn’t

subarachnoid haemorrhage

brain malignancy

sepsis from any source

40
Q

associated symptoms of meningitis?

A

fever, non-blanching rash, kernig’s sign - stiffness of hamstring (cannot straighten leg when hip is flexed), brudzinki’s sign (neck stiffness causes patient hips and knees to flex when knee is flexed)

41
Q

how do you examine for meningitis?

A 
look for signs and symptoms
fundoscopy for papillodema
glass test
neuro exam 
cognitive assessment
42
Q

if a patient comes in to PRIMARY care with a non-blanching rash what do you do

A

give benzylpenicillin 1.2g IV before admitting

43
Q

what investigations do you do for meningitis?

A 
CSF sample
blood cultures for organism 
serology for viruses
throat swab for bacteria and virus 
urine pneumococcal antigen 
CT or MRI of brain to rule out signs of intracranial pathology
44
Q

what organisms cause meningitis

A

meningococcus, pneumococcus, haemophilus influenzae, listeria monocytogenes

also HSV etc

45
Q

how do you analyse CSF for meningitis?

A

high protein and low glc: in bacterial (protein leaks out of damaged BBB and bacteria eat glc)

WCC high, no RBC should be present

will be turbid

46
Q

how do you first manage bacterial meningitis (that is non septic)

A

if raised ICP = call ICU

LP prior to antibiotics if possible

antibiotics: ceftriazone: 2g/12h, and add amoxicillin 2g/4h if >60 or immunocompromised

give dexamethasone 10mg/6h IV if meningism features

47
Q

what is the prophylactic treatment for bacteria meningitis

A

give people in close contant ciprofloxacin 500mg 1 dose

48
Q

how do you treat viral meningitis

A

supportive management only

if viral encephalitis suspected, give IV acoclovir

49
Q

what are the types of intracranial SOLs

A

tumours; benign or malignant, primary or secondary

infection: presenting with brain abscess, subdural empyema, granuloma, parasitic
vascular: extradural, subdural, arachnoid and parenchymal haemorrhages

hydrocephalus

50
Q

what causes hydrocephalus

A

non-communicating or obstructive eg tumours, cycts, intraventricular haemorrhage

communicating: meningitis or SAH
overproduction: choroid plexus papilloma

51
Q

what are the symptoms of a primary brain tumour

A

raised ICP leads to:

  • headache worse in morning
  • vomiting
  • blurring of vision
  • deterioration of conscious level
  • hypertension
  • bradycardia

also: symptoms of neurological defecits and hormonal effects, and fatigue

52
Q

what are the symtpoms associated with the frontal lobe

A

weakness, dysphagia, personality changes and dementia

53
Q

what are the symptoms associated with the parietal lobe

A

sensory symptoms, dressing apraxia, visual field defects

54
Q

what are the symptoms associated with the temporal and occipital lobes

A

dysphasia, visual field defects

55
Q

how does ICP affect the posterior fossa

A

dysmetria, in-coordination, gait ataxia, cranial nerve palsies, tremors

56
Q

how do you diagnose a brain tumour

A

CT, MRI, bloods, neuro exam and CSF

57
Q

what is a glioma

A

commonest primary tumour, grade 1-4

rapidly life-threatening if grade 4

management is surgery, steroids, radio and chemo, symptomatic treatment

58
Q

what is a meningioma

A

benign tumour of arachnoid cap cells

treatment is surgical excision

cause: trauma, radiation, oncogenic virus and hormones but rest still unclear

59
Q

what is a vestibular schwannoma

A

benign tumour arising from nerve sheath of vestibular nerves

very slow growing

presents with ipsilateral hearing problems and tinnitius

affects 5,7th and lower CN

treatment - surgical excision if feasible otherwise radiosurgery

60
Q

what is a subdural haematoma

A

bleeding from veins so haematoma in between dura and arachnoid = only gradually raises the ICP so delay between injury and presentation = even upto 9 months

61
Q

signs and symptoms of SDH

A

fluctuating levels of consciousness, slow, sleepiness, headache, personality change and unsteadiness

seziures, localising neuro symptoms eg unequal pupils

62
Q

what are the differentials

A

stroke, dementia, CNS masses

63
Q

imaging of a SDH

A

crescent-shaped but inside the skull on MRI or CT

64
Q

management of a SDH

A

reverse clotting abnormalities, larger ones>10mm or midline shift need craniotomy or burr hole washout

65
Q

what is an extradural haemotoma

A

collection of blood in potential space between skull and dura mater

66
Q

what are the causes of an extradural haematoma

A

traumatic skull fracture

laceration of the middle menigneal artery

67
Q

how does an EDH present

A

lucid interval (detiororating consciousness after any head injury that intially presented no LOC)

severe headahce, vomiting, confusion and seizures follow

brisk reflexes

if bleeding continues, ipsilateral pupil dilates, coma etc

68
Q

what are the tests for an EDH

A

CT (lens-shaped), broken skull may show up on x-ray

69
Q

managing EDH

A

clot evacuation and ligation of BV

70
Q

how to measure ICP

A

external ventricular drain with strain-gauge pressure transducer

fibre-optic intra-parenchymal transducer
airpouch balloon

71
Q

general routine measures to control ICP

A

-head up tilt, 30-45 degrees

keep neck straight and avoid tight ETT taps

avoid hypotension = use cerebral vaspressors

maintain adequate sedation

maintain euvolaemia (proper amount of blood in body) to reduce cerebral oedema

maintain normal CO2

72
Q

how do you manage an acute rise in ICP

A 
heavy sedation
CSF drainage 
osmotic therapy 
hyperventilation 
barbiturate therapy 
decompressice craniectomy
73
Q

what is osmotic therapy

A 
mannitol - osmotic diuretic 
reduces ICP by reducing brain volume; draws free water out of tissue into circulation so dehydrates brain parenchyma 
usual bolus dose 100ml
effects are: 2-60 mins; last 4-24 hours 
may be rebound increase in ICP
74
Q

what are barbiturates

A

phenobarbitone, thiopentone

reduce brain metabolism and cerebral blood flow - lowers ICP

Med Year 3 (25 decks)

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