Headache Flashcards
1
Q
What are the sinister causes of headache?
A
- Vascular: SAH, haematoma (subdural or extradural), cerebral venous sinus thrombosis, cerebellar infarct
- Infection: meningitis, encephalitis
- Vision threatening: temporal arteritis, acute glaucoma, cavernous sinus thrombosis, pituitary apoplexy, posterior leucoencephalopathy
- Intracranial pressure (raised) - space occupying lesion (e.g. tumour, cyst, abscess), cerebral oedema (e.g. secondary to trauma or altitude), hydrocephalus, malignant HTN, idiopathic intracranial HTN
- Dissection: Carotid dissection
2
Q
What are some ‘red flags’ that you can pick up from the history in a presentation of headache?
A
- Decreased level of consciousness
- SAH must be excluded
- Haematomas following head injury - subdural haematoma (fluctuating consciousness) or extradural haematoma (altered consciousness following a lucid interval).
- Meningitis
- Encephalitis
- Sudden onset, worst headache ever
- SAH - like being hit in the back of the head with a bat
- Seizures or focal neurological deficit - (e.g. limb weakness, speech difficulties)
- Suggests intracranial pathologies
- Migranous aura can give neurological signs also
- Abscence of previous episodes
- In people > 50 yrs → temporal arteritis
- Reduced visual acuity
- Temporal arteritis
- Maybe TIA (but rarely causes headache)
- VIVID
- Persistent headache, worse when lying down, coupled with early morning nausea
- Suggests raised ICP
- Note if worse on standing up instead, it suggests low ICP
- Progressive, persistent headache
- Expanding SOL (e.g. tumour, abscess, cyst, haematoma)
- Constitutional symptoms (Infection, Inflammation, Malignancy) - Weight loss, night sweats, fever —
- Chronic infection - e.g. TB
- Chronic inflammation e.g. temporal arteritis
- Malignancy
- PMH
- Malignancies that could metastasise to the brain
- HIV / other immunosuppressive states - higher risk fof intracranial infection (e.g. toxoplasmosis, abscess, TB)
3
Q
What signs and symptoms are characteristic of temporal arteritis (note this is not in the Y3 curruculum)?
A
- New onset headache in someone over the age of 50
- Jaw caudication
- Scalp tenderness
- Possible visual acuity disturbance
4
Q
What are some basic observations that it is crucial to do in a patient with a headache?
A
- GCS - to check for altered consciousness - remember this is a red flag in headaches - could suggest SAH or haematomas (subdural or extradural)
- BP and pulse - check for malignant HTN
- Temperature - suggest intracranial infection
5
Q
List some focal neurological signs in headache presentation and what these suggest in terms of narrowing down DDx
A
- Focal limb deficit - makes intracranial pathology more likely
- 3rd nerve palsy
- Ptosis
- Mydriasis (dilated pupil)
- Down and out eye
- SAH due to a ruptured PCOM (posterior communicating artery) - PCOMs cause headaches
- 6th nerve palsy
- Convergent squint
- Inability to abduct eye
- 6th nerve has the longest intracranial course so is the most likely to get compressed
- 12th nerve palsy
- Tongue deviation
- Due to carotid artery dissection
- Horner’s syndrome
- Partial ptosis
- Miosis (constricted pupil)
- Annhydrosis (dry skin around orbit)
- Interruption of ipsilateral sympathetic pathway
- Due to carotid artery dissection or cavernous sinus dissection
6
Q
What can you elude about the DDx behind the cause of headache from eye inspection?
A
- Exopthalmos - indicates retro-orbital processes such as cavernous sinus thrombosis
- Cloudy cornea, fixed dilated / oval pupil - may suggest acute glaucoma
- Optic disc appearance on fundoscopy - look for pappiloedema, indicating raised ICP
7
Q
What signs / symptoms constitute the umbrella term meningism and what pathologies does this suggest?
A
- Stiff neck
- Photophobia
- Due to either:
- Meningitis - viral or bacterial
- SAH - blood irritating the meninges
8
Q
Which organisms cause
1) Bacterial meningitis?
2) Viral meningitis?
A
1)
2)
9
Q
Flashcard with detail on temporal arteritis management and investigation - pg 5 oxford cases
A
10
Q
What are the non-sinister causes of headache (7)?
A
- Tension-type headache
- Migraine
- Sinusitis
- Medication overuse headache
- TMJ dysfunction syndrome
- Trigeminal neuralgia
- Cluster headache
11
Q
In addition to the SOCRATES pain history, what additional questions should you ask to characterise non-sinister headache causes?
A
- Does the patient suffer from different types of headaches?
- Migraine headache medication can lead to medication overuse headaches
- Any predisposing trigger factors?
- Migraine, tension → fatigue and stress
- Migraine → some food triggers such as cheese, caffeine
- Cluster headaches → alcohol
- Aura - usually visual phenomena such as squiggly lines in visual field or focal neurological deficits e.g. limb weaknesss
- Migraine - note migraine with aura is only 1/3 of presentations of migraine, often without aura
12
Q
Grade the following non-sinister causes of headache by severity
- Migraine
- Cluster headaches
- Tension-type headaches
A
- Cluster headaches
- Migraine
- Tension-type
13
Q
When do cluster headaches tend to occur?
A
- At night
14
Q
1) Describe the characteristic of the headache in tension-type headaches
2) What are the triggers for tension-type headaches?
A
1)
- Pressure or tightness around the head like a tightening band
- Bifrontal
- Episodic with varying frequency
2)
- Stress
- Fatigue
15
Q
MIGRAINE
1) Outline the epidemiology
- More common in which gender?
- Incidence?
2) Characterstic features of pain and associated symptoms, and how long do the episodes typically last?
3) Tell me about auras - what can these be, how common are they?
4) What can aura without migraine possibly suggest?
A
1)
- F > M
2)
- Unilateral
- Severe
- Episodes last between 4 - 72 hours
- Nausea and vomiting
- Photophobia / phonophobia
- Aura (see below)
3)
- Auras could be visual disturbances such as squiggly lines in the field of vision
- OR could be focal neurological deficits such as limb weakness
- Either way they occur before the onset of the migraine and typically last up to 30 mins and are quite in advance of the migraine onset
- Migraine with aura is 1/3rd, migraine without aura is 2/3rds
4)
- Aura without migraine could suggest either
- Epilepsy
- TIA (less common - this is more loss of function rather than increased activity in aura)
16
Q
Describe the pain in sinusitis - site, characteristic, associations, exacerbating factors and time course
A
- Facial pain
- Tight, like in tension headaches
- In conjunction with corryzal symptoms
- Exacerbated by movement
- Time course reflects infection
17
Q
Describe the nature of medication overuse as a non-sinister cause of headache
Overuse of what medication causes this?
Is it more common in men or women?
A
- Resembles either migraine or tension-type headaches
- Overmedication with analgaesics
- 5x more common in F. F > M
18
Q
1) Outline the epidemiology of TMJ syndrome
2) Outline the presentation of TMJ syndrome
NOTE: this is not in the Y3 curriculum
A
1)
- 20-40yrs
- F > M
2)
- Dull ache in muscles of mastication that may radiate to the jaw / ear
- Click noise when moving jaw sometimes
19
Q
1) Outline the epidemiology of trigeminal neuralgia
2) Describe the characteristics of pain in trigeminal neuralgia and the duration
3) What are some triggers for trigeminal neuralgia?
4) When does it tend to occur, or tend to not occur?
A
1)
- 60-70yrs
- F > M
2)
- Unilateral
- Stabbing, sharp
- Facial
- Involves one or more divisions of the trigeminal nerve
3)
- Shaving
- Eating
- Laughing
- Talking
- Touching affected area
4)
- Unlike migraines or cluster headaches, it tends to occur at night
20
Q
1) Outline the epidemiology of cluster headaches - just in terms of gender dominance
2) When do cluster headaches happen?
3) What is the nature of the pain in cluster headaches?
4) What else might you notice on examination of a patient with cluster headaches?
A
1)
- M > F
2)
- In ‘clusters’ of 6-12 weeks every 1-2 years
- Tend to happen at the same time every day like an ‘alarm clock’ going off
3)
- VERY severe pain
- Pain focused over one eye
- Wakes patients up - nocturnal
- Episodes last 20-30 minutes
4)
- Red, watery eye
- Rhinorrhoea
- Horner’s syndrome
- Ptosis
- Miosis
- Annhydrosis
21
Q
Treatment for migraine?
A
- Triptans e.g. sumatriptan (5HT-1 antagonists)
- Analgaesics (aspirin, paracetamol)
- Anti-emetics (metoclopramide)
22
Q
What are the gold-standard investigations for suspected SAH and what would they show?
A
- CT Head - can see fresh blood
- Lumbar puncture - look for xanthochromia (yellow CSF) due to breakdown of blood cells from SAH
- Note: it is important to only do LP after CT Head due to the risk of brain stem herniation through the foramen magnum if there is something raising the ICP
- After the initial investigations cerebral angiography to find the source of the bleed - usually a ruptured aneurysm or cerebral artery
23
Q
1) What is in the initial management for SAH?
2) If the cause of the SAH is a ruptured cerebral aneurysm
A
1)
- Nimodipine (CCB) - prevents spasm of ruptured cerebral artery, thus preventing ischaemia e.g. stroke
2)
- Coiling
OR
- Surgical clipping of the aneurysm via open craniotomy (less commonly used)
24
Q
Outline the prognosis in SAH
A
- 50% die before arriving at hospital
- 17% die in hospital
- 17% survive but with lasting neurological defects
- Only 17% survive without any lasting sequelae
25
A patient presents with attacks every couple of months where he sees a shimmering light in the corner of his eyes and hears a ringing in his ears. This occurs towards the end of the day and lasts half an hour. He is fully conscious throughout and never feels dazed or confused afterwards. What do you think the diagnosis is?
Therefore what can be used as treatment and prophylaxis?
* Migraine aura without headache
* Treatment - triptans e.g. sumitriptan
* Prophylaxis - propanolol
26
1) How does frontal sinusitis typically present?
2) What is the most common type of sinusitis?
3) How to treat frontal sinusitis?
4) Why is frontal sinus particularly dangerous, and therefore what investigation does it necessitate?
1)
* Green mucus
* Localised pain above eyes
* Maybe deviated nasal septum
* Forehead tender to gentle tapping
2)
* Maxillary sinusitis
3)
* Treat with antibiotics (e.g. amoxicillin) and antral lavage (draining of the frontal sinuses)
4)
* Bacteria may erode backwards into the brain causing meningitis or a brain abscess
* Investigate with CT head
27
On fundoscopy, what might you find in some types of headache which is worrying and what might this suggest?
* Pappilloedema
* Suggests headache due to a pathology causing raised intracranial pressure such as a SOL - space occupying lesion (tumour, haematoma, abscess, cyst)
28
If you suspect a brain tumour, what is the gold-standard investigation?
* MRI Head
29
A 10 yr old girl presents with persistent headache in the occipital area that is worse in the morning. The parents have noticed that she has become clumsy over the last few months. On fundoscopy, you find she has papilloedema. What is the likely diagnosis and explain the symptoms?
* Papilloedema suggests pathology causing raised intracranial pressure - possibly a space occcupying lesion (tumour, abscess, cyst)
* The pain in the occipital area localises it to being in the occipital area
* Posterior fossa tumours most likely in children
* Cerebellum pathology explains the clumsiness
* Therefore it is likely a medulloblastoma of the cerebellum - important to note that this is also the most common brain tumour in children
30
What are the 3 main causes of a subarachnoid haemorrhage (SAH)?
* Rupture of an arterial aneurysm (45%)
* Trauma (45%)
* Arteriovenous malformations - rupture of hemangiomas, rupture of cerebral veins around the brainstem (10%)
31
Question about the different types of intracranial tumours - not in Y3 curriculum so omitted - but its on pg12 of oxford cases
...
32
List, in order, the structures you traverse as you perform an LP?
1. Skin
2. Subcutis
3. Supraspinous ligament
4. Interspinous ligament
5. Ligamentum flavum (first 'give' as ypu push the needle)
6. Dura mater (second 'give' as you push the needle)
7. Arachnoid space
33
What are the diagnostic indications for LPs?
* MS - oligoclonal bands
* Guillan-Barre - high protein
* SAH - blood or bilirubin (xanthochromia)
* Bacterial meningitis
* Viral Encephalitis
* Malignant cells e.g. CNS lymphoma
* NPH (Normal Pressure Hydrocephalus) - rapid improvement in gait and function after removal of 30ml of fluid
34
What are 2 therapeutic indications for LP?
1. Intrathecal drug administration
2. Temporary reduction in intracranial pressure (idiopathic intracranial hypertension)
35
What would you find on an LP in the following conditions?
1) MS
2) Guillan-Barre
3) SAH (Subarachnoid Haemorrhage)
4) Meningitis
5) Encephalitis
6) Malignancy e.g. CNS lymphoma
7) NPH (Normal Pressure Hydrocephalus)
1)
* Oligoclonal bands
2)
* High protein
3)
* Blood or bilirubin (xanthochromia)
4)
* Bacteria (in bacterial meningitis) e.g. *Neisseria Meningitidis*
5)
* Viruses in viral encephalitis
6)
* Malignant cells
7)
* Improvement in gait and cognitive function after removal of 30ml of CSF
36
What are 4 contra-indications to lumbar puncture?
1. **Raised ICP** - LP in this situation can cause the brainstem to cone through the foramen magnum. Therefore in situations where ICP may be raised such as SOL (tumour, haematoma, abscess, cyst), always image to check for and exclude these first before proceeding
2. **Increased bleeding tendency**
3. **Infection at prospective site of puncture**
4. **Cardiorespiratory compromise**
37
Why may LPs cause headache?
* Low pressure headache following LP
38
What are some complications of LP?
* Low pressure headache
* Bleeding
* Nerve root pain
* Infection
* Meningism due to meninges irritation
39
What are the main signs and symptoms in raised intracranial pressure?
* **Headache** - often worse when lying down
* **Nausea** - first thing in the morning, after lying down all night
* **Papilloedema** - swollen optic disc when visualised by fundoscopy
* **Visual blurring**
* **Cushing's reflex** - paradoxical bradycardia and raised blood pressure with irregular breathing
* **Cushing's peptic ulcer** - causing epigastric pain
40
Give 4 mechanisms of increased intracranial pressure
1. SOL - tumour, haematoma, abscess, cyst
2. Cerebral oedema
3. Increased BP in the CNS - due to vasodilator drugs, malignant HTN, hypercapnic vasodilation, venous sinus thrombosis, SVC obstruction
4. Increased volume of CSF (hydrocephalus) - due to CSF obstruction (e.g. by a tumour) dysfunction of the arachnoid granulations responsible for CSF reabsorption (e.g. SAH or meningitis irritating the granulations, idiopathic intracranial HTN), or increased CSF production (by a choroid plexus papilloma)
41
What is the most common organism causing encephalitis?
* Viral encephalitis - HSV
42
1) How would you treat cluster headaches acutely?
2) Prophylactic against cluster headaches?
1)
* High flow-oxygen and / or nasal or subcutaneous triptan
2)
* Verapimil
