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TCD > Case 4: Headache > Flashcards

Case 4: Headache Flashcards

1
Q

what is a primary headache? Give an example

A

Disorder where there is no secondary underlying pathology

E.g. migraine, cluster headache

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2
Q

What is a secondary headache? Give an example

A

Often potentially serious underlying mechanism

E.g. space occupying lesion, intracranial hypertension, vasculitis, arteritis

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3
Q

Signs of raised intracranial pressure

A

Papilloedema on fundoscopy
(blurred, swollen looking optic discs. haemorrhagic changes round the optic disc)

Peripheral visual field loss / enlarged blind spots

Pain on eye movements (nerve stretch due to RIP)

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4
Q

What is the cause of oral hairy leukoplakia?

A

EBV

Severe immunodeficiency

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5
Q

Cause of a purpuric rash

A

Meningococcal sepsis

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6
Q

Cause of livedo reticularis

A

Antiphospholipid Ab syndrome

Vasculitis

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7
Q

1st line Tx for acute migraine

A 
Oral triptan ((5-HT1 receptor agonist - constricts cerebral blood vessels) (or another triptan) + NSAID
OR oral triptan + paracetamol

Can prescribe antiemetics (e.g. domperidone, prochlorperazine, metoclopramide) because nausea/vomiting is a Sx in >50% of migraine sufferers

NOT codeine / other opiates - can increase nausea because of gut stasis

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8
Q

At what age do we consider giant cell arteritis

A

> 50

More common in women

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9
Q

Most common serious SE of GCA

A

blindness due to optic nerve ischaemia

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10
Q

What drugs must you consider overuse of causing a headache?

A

For 3 months or more:
Triptans / opioids / ergots or combination analgesic medications for 10 days or more per month
Paracetamol, aspirin, or NSAIDs alone or in combination for 15 days or more per month

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11
Q

Acute treatment for a cluster headache

A

Nasal triptan +/- oxygen (100% at 12L/min via non-rebreath mask)
Arrange home and ambulatory oxygen

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12
Q

When to diagnose migraine with aura

A

if they have neurological symptoms that:

  • are fully reversible
  • develop gradually, either alone or in succession over at least 5 minutes
  • last for 5-60 minutes
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13
Q

Is this likely to be a tension, migraine or cluster headache?

  • Can be unilateral or bilateral
  • pulsating pain
  • moderate-severe pain
  • causes avoidance of daily activities
  • sensitivity to light, nausea, vomiting, aura
  • 4-72 hours adults, 1-72 hours young people aged 12-17
A

Migraine (can be with or without aura)

(Episodic migraine - <15 days per month)
(Chronic migraine - > 15 days per month for more than 3 months)

Note, aura only occurs in 20-30% of pts

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14
Q

Is this likely to be a tension, migraine or cluster headache?

  • Unilateral (usually around eye, or one side of face)
  • Variable types of pain
  • Severe-very severe
  • Makes pt restless and agitated
  • on same side as pain can get a watery/red eye, nasal congestion, runny nose, swollen eyelid, sweating, drooping eyelid
  • 15-180 minutes
A

Cluster headache

(Episodic cluster - 1 every other day to 8 per day with remission for >1 month)
(Chronic cluster - 1 every other day to 8 per day with remission for <1 month

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15
Q

Is this likely to be a tension, migraine or cluster headache?

  • Bilateral
  • pressing/tightening - non pulsatile
  • mild-moderate severity
  • doesn’t really affect activities of daily living
  • no other symptoms really
  • 30 minutes - continuous
A

Tension headache

Episodic tension - <15 days per month
Chronic tension - >15 days per month for >3 months

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16
Q

Sensory symptoms associated with a migraine aura

A

Visual disturbance (e.g. scintillating scotoma)
Paraesthesia
Numbness affecting hand and progressing up the arm before involving the face/lips/tongue. Leg can be affected

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17
Q

Recognised triggers for migraine (with aura)

A

Contraceptive pills (particularly withdrawal period between cycles) (contraindicated in women with migraines with aura, or all women with migraine >35 - increased risk of CV events)
Jet lag
Cheese (tyramine - red wine, cheese, chocolate, citrus fruits)
Relaxing after stress
Menstruation (fall in oestrogen)
Flickering lights on TV

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18
Q

Contraindications to prescribing triptans in migraine

A

history of TIA or cerebrovascular accident

History of IHD / MI / poorly controlled HTN (because triptans have vasoconstricting actions)

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19
Q

Criteria for consideration of preventative Tx for migraines: any 1:

A

QoL / business duties / school attendance severely affected
2 or more attacks per month
Migraine attacks do not respond well to acute Tx
Frequent, very long, uncomfortable auras

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20
Q

Prophylactic Tx of migraines

A

1st line: propranolol or low dose amitriptyline

Women who get migraines prior to menstruation can be given transdermal oestrogen patches 3 days before onset of menstruation

2nd line: antiepileptics (e.g. sodium valproate, topiramate)
(Topiramate has a risk of fetal malformations) (Also used for epilepsy)
Or antihypertensives (ACEi, AngII receptor blockers, CCBs)

Remember to use propranolol over topiramate in pts of childbearing age

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21
Q

when would you prescribe topiramate over propranolol?

A

If the pt is asthmatic

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22
Q

Meningitis: triad of classical symptoms

A

Headache
Neck stiffness
Photophobia

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23
Q

Most common pathogen causing encephalitis

A

herpes simplex virus (HSV)

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24
Q

Symptoms of encephalitis that distinguish it from meningitis

A 
confusion
disorientation
drowsiness
seizures
changes in personality / behaviour e.g. agitation
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25
Q

RFs for meningitis

A

<5yo or >65yo
living in close proximity
Lack of vaccinations
Immune suppression / deficiency

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26
Q

What are you looking for on examination for meningitis?

A 
Purpuric (non-blanching) rash
Signs of sepsis/shock
Assess nick stiffness(chin to chest)
Kernig's sign (positive when the thigh is flexed at the hip and knee at 90 degree angles, and subsequent extension in the knee is painful/resistance)
Perform a full neurological examination
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27
Q

Investigations for meningitis

A

CSF sample
Blood culture
Urine cultures
Serology for viruses causing meningo-encephalitis
Throat swab for Neisseria meningitides and strep pneumoniae
Urine pneumococcal Ag

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28
Q

At what level does the spinal cord end and become the conus medullaris

A

L2

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29
Q

Where do we go for a lumbar puncture? Why?

A 
Between L3 and L4, or L4 and L5
More space between bones
Pt can arch back here to make more space
Lumbar cistern here (cauda equina covered by dura)
Cauda equina here
30
Q

Side effects of a lumbar puncture / spinal anaesthetic

A

CSF can leak through the dura mater –> headache

This does not happen with an epidural because you aren’t puncturing the dura

31
Q

Tx for bacterial meningitis

A

Empirical Abx therapy with IV 3rd generation cephalosporin e.g. cefotaxime, ceftriaxone
+ Dexamethasone 10mg
If >60, + amoxicillin

If penicillin / cephalosporin allergic/contraindicated:
Chloramphenicol
Dexamethasone
if >60, +co-trimoxazole

If Listeria bacterium suspected, ampicillin

32
Q

Symptoms of GCA

A

> 55
malaise
sweats
proximal muscle aching

33
Q

Tx for tension headache

A

10-25mg amitriptyline at night

34
Q

If someone has a right sided pronator drift, what is this a sign of

A

Left hemisphere raised intracranial pressure e.g. space occupying lesion

35
Q

Investigations if pt has a pronator drift

A

Urgent cranial imaging - CT, then consider MRI depending on results
Refer to neuroscience centre
If presence of oedema /swelling in brain, give dexamethasone

36
Q

Examples of space occupying lesions

A

Tumour (primary, secondary, benign, malignant)
Infection (brain abscess, subdural empyema, granuloma, parasitic)
Vascular - acute haemorrhages, chronic (carvernoma/vascular malformation, brain infarction)
Hydrocephalus - build up of CSF in brain

37
Q

What type of haemorrhage would a trauma cause

A

Extradural or subdural haemorrhages

38
Q

What haemorrhages are due to HTN or are spontaneous

A

Subarachnoid or parenchymal

39
Q

Describe the 3 causes of hydrocephalus (build up of CSF in brain)

A

Non-communicating/obstructive: obstruction in the normal flow of CSF e.g. due to tumours, cysts, intraventricular haemorrhage

Communicating: no obstruction in the pathway, but problem with absorption due to meningitis, subarachnoid haemorrhage)

OVerproduction of CSF: rare, due to benign tumour - choroid plexus papilloma

40
Q

What is the structure that produces CSF

A

choroid plexus

41
Q

Signs/symptoms of primary brain tumour

A

Symptoms are due to the raised ICP: headache (1-2weeks, can be worse in morning), vomiting, blurred vision, deterioration of conscious level
Signs: bradycardia, HTN, papilloedema

Symptoms of compression of nearby structures
Symptoms of cortical/meningeal irritation
Hormonal effects if affecting pituitary or hypothalamus
Systemic effects

42
Q

Symptoms of tumour affecting frontal lobe

A

personality changes
dementia
weakness
dysphasia

43
Q

Symptoms of tumour affecting parietal lobe

A 
sensory symptoms
dressing apraxia (inability to correctly get self dressed)
visual field defects
44
Q

Symptoms of tumour affecting temporal lobe

A

dysphasia

visual field defects

45
Q

Symptoms of tumour affecting occipital lobe

A

visual field defects

46
Q

Symptoms of tumour affecting posterior fossa

A 
dysmetria (lack of coordination)
gait ataxia
cranial nerve palsies
tremor
nystagmus
47
Q

Most common primary malignant brain tumour

A

GBM - glioblastoma multiforme (IV)

48
Q

Most common primary benign brain tumour

A

meningioma

49
Q

What signs on scan would make you think something is a met and not the primary tumour

A

Mets are more uniformly enhancing
Lots of swelling/oedema
normally multiple of them

50
Q

Grading of Gliomas

A

Grade I: pilocytic astrocytoma (most benign)
Grade II: low grade astrocytoma
Grade III: anaplastic astrocytoma
Grade IV: glioblastoma multiforme (most malignant)

51
Q

Tx of gliomas:

A

Surgery not useful because high grades are widespread
RAdio/chemotherapy
Steroids
Tx of associated problems

52
Q

Tx of meningioma (benign)

A

surgical excision
small tumours can be observed
Radiotherapy, stereo-radiosurgery, hormonal therapies

53
Q

Typical presentation of a vestibular schwannoma

A

(benign tumour arising from nerve sheath of vestibular nerve)
- ipsilateral hearing problems
- ipsilateral tinnitus
Can also affect the 5th and 7th and lower CNs

54
Q

Tx of vestibular schwannoma

A

Surgical excision

RAdiosurgery

55
Q

Most important investigation for a brain tumour

A

CT, MRI

56
Q

what cures GMB (glioblastoma multiforme)

A

nothing - is about management

57
Q

Where does a meningioma arise from

A

arachnoid cap cells

58
Q

What is pathological raised ICP?

A

> 20mmHg

normal ICP is 15mmHg - lower in children and can be negative in newborns

59
Q

Symptoms of acute raised ICP

A

decreased consciousness
high BP
bradycardia
respiratory depression

60
Q

Symptoms of slowly raised ICP

A

headaches
nausea
vomiting
problems with eyesight

61
Q

Routine measures to control ICP

A
  • head up tilt - 30-45degrees - improves venous drainage and CSF movement
  • keep neck straight and avoid tight tapes - prevent jugular venous obstruction
  • avoid hypotension
  • maintain adequate sedation to reduce metabolic demands
  • maintain euvolaemia
  • maintain normal PCO2 (raised pCO2 causes cerebral vasodilation and increases cerebral blood volume)
62
Q

Management of sustained acute rise in ICP

A

Ensure routine measures have been attempted
Rescan - is there a surgically correctable cause?
Osmotic diuretic - mannitol
Hyperventilation - reduces paCO2
Barbiturate therapy - barbiturate coma reduces function of brain cells - reduced metabolism/blood flow to lower ICP
Removal of space occupying lesion
Decompressive craniectomy (bone alone reduces ICP by 15%, opening dura reduces ICP by 70% but brain can start herniating through defect and infarct)

63
Q

Typical presentation of a extradural/epidural haematoma

A

Often due to trauma
Patients can lose consciousness very briefly and then regain it
Level of consciousness then begins to deteriorate as a haematoma develops

This lucid interval frequently leads to delayed or missed diagnoses which can be fatal

64
Q

Are extradural/epidural haematomas arterial or venous

A

arterial

65
Q

Are subdural haematomas arterial or venous

A

venous

66
Q

Typical presentation of a subdural haematoma

A

Is chronic
ARe venous in origin so may occur even after a trivial injury in vulnerable pts (elderly, alcoholics, debilitated people)
Haematoma develops slowly so clinical presentation can be weeks/months after injury
Headache/Drowsiness/Confusion common in late stages
Fluctuating levels of consciousness over time as haematoma contracts and expands due to osmotic effects

67
Q

Can primary brain tumours metastasize out of the brain?

A

No

68
Q

What drug is used to reduce oedema and provide symptomatic relief in brain tumours

A

dexamethasone

69
Q

Commonest source of brain mets

A 
Bronchus (lung)
Breast
Stomach
Prostate
Thyroid
Kidneys
70
Q

Most common cause of headache?

A

Tension

71
Q

What do we give as prophylaxis to people who have been in close proximity with someone with meningitis

A

Ciprofloxacin

Or rifampicin

TCD (7 decks)

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