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Headache Flashcards

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1
Q

What is the key feature of a headache caused by low ICP

A

Comes on when they stand up and gets better when they lie down

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2
Q

What is the key feature of a headache caused by high ICP

A

Headache when lying down, gets better when upright

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3
Q

How does a cluster headache present

A

Extremely severe
One-sided
Lasts around 45-90mins at a time but will get 1-8 per day
These episodes can last weeks to months
People often want to keep moving around
May also have nausea, vomiting, lacrimation, rhinorrhea

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4
Q

What are common associated symptoms of headache that should be asked about

A 
Autonomic features such as nausea and vomiting 
Photophobia 
Phonophobia 
Positive visual symptoms
Miosis - constricted pupil 
Ptosis 
Nasal stuffiness - sinus
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5
Q

Which demographic tends to get migraines

A

Young women
Typically teens to 20s
Another peak in the 40s

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6
Q

What are the headache red flags

A 
New onset headache in the over 55s 
Known or previous malignancy - risk of mets
Immunosuppression - risk of infection 
Early morning headache - wakes you up 
Exacerbation by the Valsalva manoeuvre
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7
Q

What are the diagnostic criteria for migraine without aura

A

AT least 5 attacks lasting between 4-72 hours
2 from: moderate/severe pain, unilateral, throbbing or worse on movement
1 from: autonomic features, photophobia or phonophobia

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8
Q

Migraines can be hormonally driven - true or false

A

True

Can be related to the menstrual cycle in women

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9
Q

Describe the pathophysiology of migraines

A

Both vascular and neural influences
Stress can trigger changes in the brain which cause release of serotonin
The blood vessels constrict and dilate
Chemicals can irritate the blood vessels and nerves causing pain

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10
Q

Which is more common - migraine with or without aura

A

Without

Only 20% of people with migraines get auras

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11
Q

What is an aura

A

A fully reversible visual, sensory, motor or language symptom
e.g. visual disturbance, speech problems, word finding difficulty

Visual is most common
Lasts around 20-60 mins

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12
Q

Does an aura always have to occur alongside the headache

A

No
Headache can follow the aura - but will be less than one hour between them
Can also occur simultaneously

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13
Q

What can trigger a migraine

A 
Sleep 
Diet - dark choc, cheese and alcohol are the main ones 
Hormones - menstrual cycle 
Physical exertion
Stress
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14
Q

What non-pharmacological treatments are available for migraine

A

Education - what triggers are and how to avoid them
Headache diary to find trigger and monitor symptoms
Relaxation/stress management
Acupuncture
Regular exercise and healthy diet
Hydration
Reduce caffeine intake

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15
Q

What acute treatment is available for migraines

A

NSAIDs - take ASAP
Paracetamol
Aspirin
Triptans - rizatriptan, sumatriptan

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16
Q

How can triptans be taken

A

Come as tablets, nasal spray, SC injections and wafers that dissolve in the mouth
Wafers take a while to be absorbed
Ideally given at the start of headache

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17
Q

At which point is migraine prophylaxis considered

A

If a person has had more than 3 attack per month

If the migraines are particularly severe

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18
Q

How is migraine prophylaxis administered (generally)

A

Aim to slowly titrate the drug up to the efficient and tolerated dose
Aim for the lowest dose possible
Must trial each drug for at least 3 months

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19
Q

Which drugs can be used for migraine prophylaxis

A

Amitriptyline- 10-25mg
Propranolol - 80-240mg
Topiramate (carbonic anhydrase inhibitor ) - 25-100mg
Candesartan

Gabapentin, sodium valproate, botox

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20
Q

What are the side effects of amitriptyline

A

Dry mouth
Postural hypotension
Sedation

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21
Q

When should beta blockers be avoided

A

In asthmatics, PVD and heart failure

Can affect heart rate and BP

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22
Q

What are the adverse effects of topiramate

A

Weight loss
Paraesthesia
Impaired concentration
Enzyme induction

Reserved drug as it causes so many issues - start low go slow

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23
Q

How is botox used in the treatment of migraines

A

32 botox injections in the scalp every month – used for resistant migraines

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24
Q

What is the risk of prescribing sodium valproate

A

Risky to prescribe to women of child bearing age as it is very teratogenic

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25
What is an acephalgic migraine
Get aura and feel sick but no headache
26
What is a basilar migraine
Severe form | Get vertigo and loss of balance
27
What is a hemiplegic migraine
Develop severe issues similar to stroke when they get their migraines, drowsy and unresponsive, speech and limb issues
28
How might children present with migraine
Recurrent abdominal pain
29
How does a tension headache present
``` Mild to moderate pain Pressing or tingling quality Bilateral No nausea or vomiting No photo or phonophobia ```
30
How can you treat tension headaches
Relaxation physiotherapy Antidepressants - amitriptyline Reassure
31
What are trigeminal autonomic cephalgia's
Group of primary headache disorders | Characterised by unilateral trigeminal pain that occurs alongside ipsilateral cranial autonomic features
32
What are the ipsilateral cranial autonomic features seen in TACs
``` Ptosis Miosis Nasal Stuffiness Nausea/ vomiting Tearing Eye lid oedema ```
33
What are the 4 types of trigeminal autonomic cephalgia's
Cluster headaches Paroxysmal hemicrania Hemicrania continua SUNCT
34
Who gets cluster headaches
Most commonly young men | 30s-40s
35
When do cluster headaches occur
Seem to have circadian and seasonal variation | Bouts will last weeks to months
36
How do you treat cluster headaches
High flow oxygen 100% for 20 mins Sub cut sumatriptan 6mg Steroids- reducing course over 2 weeks Verapamil for prophylaxis
37
Who gets paroxysmal hemicrania
Older people - 50-60 | Women more commonly than men
38
What are the features of paroxysmal hemicrania
Severe unilateral headache Unilateral autonomic features Lasts 10-30 mins Can get 1-40 attacks per day
39
How do you treat paroxysmal hemicrania
Indomethacin | Has an absolute response
40
What is hemicrania continuum
Severe unilateral headache which is present all the time during an exacerbation Also get the autonomic symptoms
41
What is SUNCT
``` Primary headache syndrome Short lived (15-120 secs) Unilateral Neuralgiaform headache Conjunctival injections Tearing ```
42
How do you treat SUNCT
Lamotrigine | Gabapentin
43
What investigations are needed if there is new onset of cranial autonomic symptoms
MRI brain | MR angiogram
44
Who gets idiopathic intracranial hypertension
More common in women | Overweight - getting more common as obesity rises
45
How does idiopathic intracranial hypertension present
Headache that is worse in the morning - diurnal variation Morning N&V Gets better when they stand up Visual loss
46
What investigations need to be done if you suspect idiopathic intracranial hypertension
MRI brain - rule out more sinister causes Should be normal If normal do a LP - will show elevated pressure Visual fields examination
47
When should you not do a LP
In someone with signs of raised ICP Unless they have a brain scan and it is normal
48
How do you treat idiopathic intracranial hypertension
Weight loss - can be the cure Acetazolamide - carbonic anhydrase inhibitor VA or LP shunt - if at risk of blindness Monitor the visual fields and CSF pressure
49
Who gets trigeminal neuralgia
Elderly - over 60 | More common in women
50
What triggers trigeminal neuralgia
Aggravated by touch – shooting pain when touch their face e.g. on shaving, applying makeup, brushing teeth Also made worse by chewing, wind etc
51
How does trigeminal neuralgia present
``` Severe, stabbing pain - excruciating, some commit suicide it is so bad Unilateral Aggravated by touch Lasts 1-90secs Can get 10-100 attacks per day Bouts may last from weeks to months ```
52
How do you treat trigeminal neuralgia
Carbamazepine Gabapentin Phenytoin Baclofen Surgical: Microvascular decompression Decompression better in young patients Percutaneous injection - need repeated - glycerol - ballon compression of the nerve - thermocoagulation (high risk of numbness) Good for elderly or those not fit for surgery
53
Which other structures (non-neurological) can cause facial pain
``` Eyes Ears Sinuses Teeth TMJ ```
54
How does migraine present
Unilateral, throbbing headache Autonomic symptoms include photophobia Aura
55
Which conditions may present with acute headache
``` Sub-arachnoid haemorrhage Meningitis Other serious intra-cranial pathology i.e. post-trauma Cluster headache Eye issues - glaucoma, optic neuritis ```
56
Which conditions may present with chronic headache
Tension headache - most common Migraine Brain tumour
57
How can you treat recurrent vomiting in migraine
Prochloperazine
58
What are the most common types of headache seen in practice
Tension headache | Migraine
59
Which other symptoms may be associated with headache caused by sinusitis
Preceding cold or nasal discharge
60
Which other symptoms may be associated with headache caused by glaucoma
Misting of vision | Haloes around objects
61
Which other symptoms may be associated with headache caused by optic neuritis
Loss of vision
62
Which other symptoms may be associated with headache caused by haemorrhage
Instant onset Vomiting Neck stiffness
63
Which other symptoms may be associated with headache caused by hydrocephalus
Impaired conscious level | Impaired up gaze
64
Which other symptoms may be associated with headache caused by infections
Impaired conscious level Acute onset Neck stiffness Fever
65
Which other symptoms may be associated with headache caused by tumours
Vomiting | Disc oedema
66
Which other symptoms may be associated with headache caused by sub-dural haematoma
Impaired conscious level | Focal neurological signs
67
Which other symptoms may be associated with headache caused by benign intracranial hypertension
Disc oedema | Visual symptoms
68
Which other symptoms may be associated with headache caused by temporal arteritis
Scalp tenderness Jaw claudication Thickened temporal artery
69
Which other symptoms may be associated with headache caused by chronic tension
Anxiety and depression
70
Which other symptoms may be associated with headache caused by cervical spondylosis
Neck and arm pain

Neurology (18 decks)

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