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Flashcards in Headache Deck (61):
1

What mnemonic can be used to remember different sinister causes of headache?

VIVID

2

List some conditions that come under each heading of the mnemonic.

Vascular
• Subarachnoid haemorrhage
• Subdural/Extradural haematoma
• Cerebral venous sinus thrombosis
• Cerebellar infarct
Infection
• Meningitis
• Encephalitis
Vision-threatening
• Temporal arteritis
• Acute glaucoma
• Cavernous sinus thrombosis
• Pituitary apoplexy
• Posterior leucoencephalopathy
ICP raised
• Space-occupying lesion
• Cerebral oedema
• Hydrocephalus
• Malignant hypertension
Dissection
• Carotid dissection

3

List some red flag symptoms of headache

Decreased level of consciousness
Sudden-onset worst headache ever
Seizure or focal neurological deficit
Absence of previous episodes
Reduced visual acuity
Persistent headache – worse when lying down and early morning nausea
Progressive, persistent headache
Constitutional symptoms
Past medical history of malignancy or immunosuppression

4

What cause of headache can also result in a decreased level of consciousness?

Subarachnoid haemorrhage
Subdural/extradural haematoma
Meningitis/encephalitis

5

What must you consider if someone complains of a sudden-onset worst headache ever?

Subarachnoid haemorrhage

6

What does a focal neurological deficit along with a headache suggest?

Intracranial pathology
NOTE: migrainous aura can also give neurological signs (either positive or negative)

7

Which cause of headache is commonly accompanied by reduced visual acuity?

Temporal arteritis

8

What are the four main features of temporal arteritis?

Headache
Jaw claudication
Reduced visual acuity
Scalp tenderness

9

What type of headache is associated with causing early morning nausea/vomiting and a headache that is worse when lying down?

Raised ICP

10

What is likely to cause a headache that is worse when standing up?

Reduced ICP – this is common after an LP and is not considered sinister

11

What does a progressive, persistent headache suggest?

Gradually expanding space-occupying lesion (e.g. tumour, abscess, cyst)

12

List some constitutional symptoms. What can cause such symptoms?

Fever, weight loss, night sweats
It may suggest malignancy, chronic infection or chronic inflammation

13

What are some red flag features of the past medical history of someone presenting with headache?

History of malignancy (headache could be caused by brain metastases)
History of immunosuppression or HIV (increased risk of intracranial infection)

14

What are some important features of the basic observations that may make you suspect a sinister cause of the headache?

Altered consciousness
Blood pressure and pulse (check for malignant hypertension)
Temperature (suggests infection)

15

Describe the appearance of 3rd nerve palsy.

The pupil is down and out
Ptosis
Mydriasis (unless it is pupil-sparing 3rd nerve palsy)

16

What can cause a headache that is accompanied by 3rd nerve palsy?

Subarachnoid haemorrhage
Posterior communicating artery aneurysm

17

Describe the appearance of 6th nerve palsy.

Inability to abduct the affected eye

18

The 6th cranial nerve is the most susceptible to compression due to raised ICP. Explain why.

It has the longest intracranial course of any cranial nerve and so is most susceptible to compression by raised ICP

19

Describe the appearance of 12th nerve palsy.

Protraction of the tongue will make it deviate towards the side of the lesion

20

What can cause headache that is associated with 12th nerve palsy?

Carotid artery dissection

21

Describe the appearance of Horner’s syndrome.

Ptosis
Miosis
Anhydrosis

22

What can cause headache that is associated with Horner’s syndrome?

Carotid artery dissection

23

List some key features of eye examination and the underlying pathology that each of them is associated with.

Exophthalmos – suggests retro-orbital pathology (e.g. cavernous sinus thrombosis)
Cloudy cornea + fixed, dilated pupil – acute glaucoma
Papilloedema – raised ICP

24

What age group is most commonly affected by temporal arteritis?

Over 50 yrs old

25

Describe the pathophysiology of temporal arteritis.

It is characterised by the formation of immune, inflammatory granulomas in the tunica media of medium/large arteries
The inflammation resulting from the immune infiltration can lead to blockage of the lumen of arteries

26

Describe the management of temporal arteritis.

High dose corticosteroids

27

List some non-sinister causes of headache.

Tension-type headache
Migraine
Sinusitis
Medication overuse headache
Temperomandibular joint syndrome
Trigeminal neuralgia
Cluster headache

28

List some important questions that help you characterise non-sinister headaches.

Do you suffer from different types of headache?
Are there any triggers?
How disabling are the headaches?
Does the patient experience an aura before headaches?

29

Describe the features of tension-type headaches.

Very common
Often bifrontal across the forehead
Not very disabling and there are no other features (e.g. photophobia)
Stress and fatigue are common triggers

30

Describe the features of migraines.

Typically a unilateral, throbbing/pulsatile pain
Often focused over one eye
1/3 of migraine sufferers experience an aura
NOTE: some patients can have aura without migraine

31

What is the main treatment used for migraines?

Triptans (5HT receptor agonists)
They cause cerebral artery vasoconstriction and inhibition of trigeminal nerve transmission

32

Describe the features of sinusitis.

Facial pain along with coryzal symptoms
It is a tight pain (similar to tension-type headaches) that is often exacerbated by movement

33

What types of medication are most commonly associated with causing medication overuse headaches?

Analgesics
Migraine medications

34

Describe the features of temperomandibular joint syndrome.

Headache + dull ache in the muscles of mastication
Some patients report clicking/grinding when they move their jaw

35

Describe the features of trigeminal neuralgia.

Unilateral stabbing, sharp facial pain involving one or more divisions of the trigeminal nerve
The pain lasts seconds but can occur many times in a day

36

Describe the features of cluster headaches.

Occur in clusters of about 6-12 weeks ever 1-2 years
Attacks tend to occur at the same time every day
Pain tends to be focused over one eye and is extremely severe

37

Which types of non-sinister headache are more common in:
Women
Men

Women
Migraine
TMJ syndrome
Trigeminal neuralgia
Men
Cluster headaches

38

Even if a non-sinister headache is suspected, why is it important to check:
Blood pressure
H&N exam
Focal neurological signs
Fundoscopy

Blood pressure
Malignant hypertension
Head and neck examination
Meningism
Focal neurological signs
Intracranial pathology
Fundoscopy
Raised ICP

39

List two investigations that can be used to help diagnose a subarachnoid haemorrhage.

CT head
Lumbar puncture – check for xanthochromia (present from 12 hours to 12 days after SAH)

40

What medication is regularly used in the initial management of subarachnoid haemorrhage?

Nimodipine (CCB) – this reduced spasm of the ruptured artery and prevents ischaemia

41

Describe the differences in the types of symptoms experienced in a TIA compared to an epileptic seizure.

TIA – negative symptoms (due to loss of function e.g. loss of vision, numbness, loss of power)
Epilepsy – positive symptoms (due to overactivation e.g. flashing lights, muscle convulsions, paraesthesia)
NOTE: migraine can produce both positive and negative symptoms

42

Describe how epileptic patients feel immediately after a seizure.

They experience a postictal phase where they will feel exhausted or confused

43

Which sinus is most commonly affected in sinusitis?

Maxillary sinus

44

Why is frontal sinusitis dangerous?

The bacteria can erode backwards into the brain and cause meningitis or brain abscesses

45

Which part of the brain do most brain tumours tend to develop in children?

Posterior cranial fossa

46

What is the most common type of brain tumour in children?

Medulloblastoma of the cerebellum

47

List three causes of subarachnoid haemorrhage.

Rupture of an arterial aneurysm (usually berry aneurysms found at the junctions of the circle of Willis)
Trauma
Arteriovenous malformations (e.g. rupture of haemangiomas or cerebral veins)

48

What is the most common type of brain tumour?

Metastases
Most commonly from the lung, breast, colon, melanoma and kidney

49

List four types of axial brain tumour.

Oligodendroglioma
Ependyomas
Astrocytomas
Medulloblastoma

50

List five types of extra-axial brain tumour.

Meningioma
Vestibular schwannoma
Pituitary adenoma
Craniopharyngioma (tumour of the pituitary embryonic tissue)
Prolactinoma

51

What condition predisposes individuals to developing meningiomas and schwannomas?

Neurofibromatosis Type II

52

At what vertebral level should a lumbar puncture be performed?

L3/4

53

Which structures are traversed during a lumbar puncture?

Skin
Subcutis
Supraspinous ligament
Infraspinous ligament
Ligamentum flavum
Dura mater
Arachnoid space (destination)

54

List some diagnostic indications for a lumbar puncture.

Multiple sclerosis (look for oligoclonal bands)
Guillain-Barre syndrome (look for high protein)
Subarachnoid haemorrhage (look for xanthochromia)
Meningitis (look for pathogens)
CNS lymphoma (look for malignant cells)
Normal pressure hydrocephalus (look for improvement in gait and cognitive function after removal of a small amount of CSF)

55

List some therapeutic indications for a lumbar puncture.

Intrathecal drug administration
Temporary reduction in ICP

56

List some relative contraindications for lumbar puncture.

Raised ICP
Increased bleeding tendency
Infection and prospective puncture site
Cardiorespiratory compromise

57

List some risks of lumbar puncture.

Headache
Nerve root pain
Infection at puncture site

58

List some signs and symptoms of raised ICP.

Headache (worse when lying down)
Nausea and vomiting early in the morning
Papilloedema
Visual blurring
Cushing’s reflex
Cushing’s peptic ulcer

59

What is Cushing’s reflex?

A response to raised ICP characterised by:
High blood pressure
Low heart rate
Irregular breathing

60

Describe some mechanisms that can lead to raised ICP.

Space-occupying lesion
Cerebral oedema
Increased blood pressure in the CNS (e.g. due to malignant hypertension)
Hydrocephalus

61

List some mechanisms of hydrocephalus.

Obstruction of CSF drainage
Dysfunction of arachnoid granulations responsible for CSF reabsorption
Increased CSF production