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Headache/SAH Flashcards

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1
Q

How can headaches be categorised into two groups?

A

primary e.g. migraine, cluster headache, tension headaches

Secondary- SAH, brain tumour, meningitis

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2
Q

What are the red flags for a headache?

A
  1. first/worst headache with acute onset
  2. postural association
  3. > 50
  4. systemic symptoms e.g. fever, weight loss
  5. neurological signs
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3
Q

Unilateral headache. What are the differentials?

A

cluster headache, migraine

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4
Q

Bilateral headache. Differentials?

A

tension headache, migraine

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5
Q

Ocular headache. Differentials?

A

cluster headache, migraine

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6
Q

Occipital headache. Differentials?

A

haemorrhagic, meningitis

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7
Q

Diffuse headache differentials?

A

raised ICP

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8
Q

Sudden onset headache differentials?

A

SAH

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9
Q

Acute headache differentials?

A

meningitis, migraine, venous sinus thrombosis, temporal arteritis, intracranial haemorrhage

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10
Q

Differentials for chronic headache?

A

migraine, medication overuse, tension

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11
Q

Patient with headache has facial pain. What are the differentials?

A

trigeminal neuralgia, ENT/dental causes

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12
Q

Patient with headache and jaw claudication. What is the likely cause?

A

temporal arteritis

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13
Q

What are associated symptoms of migraine?

A

N/V, photophobia/phonophobia, sensory aura

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14
Q

Headache last a few seconds and is recurrent. What is the likely cause?

A

trigeminal neuralgia

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15
Q

Headache lasts <4 hr. What is the likely cause?

A

cluster headache

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16
Q

Headache 4-72hr, what is the likely cause?

A

migraine

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17
Q

Headache worse on awakening. Differentials?

A

raised ICP, obstructive sleep apnoea

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18
Q

Headache worse during night. Likely source?

A

cluster headache

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19
Q

Headache worse at the end of the day/work. Which headache is this?

A

tension headache

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20
Q

Which headaches can worsen during menstruation?

A

migraine

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21
Q

Which specific questions should you ask about in the history of headache?

A

HTN, analgesia, alcohol/cocaine, sleep, diet, caffeine intake, travel history (infective causes), fam hx migraine and SAH

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22
Q

Which specific things can you do to examine for temporal arteritis and meningitis, SAH?

A

neck stiffness for meningitis and SAH

scalp tenderness- temporal arteritis

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23
Q

What is a key question to ask when querying SAH?

A

when did the headache reach its peak onset? SAH reach peak pain within 5 mins.

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24
Q

What percentage of SAH are observable on CT?

A

99%

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25
If SAH is suspected but the CT is normal, what is the next investigation?
lumbar puncture at least 12 hours after onset of headache to detect xanthochromia
26
Which meningeal layer houses CSF?
subarachnoid space
27
What are the risk factors for SAH?
smoking, cocaine use, HTN, fam hx SAH, connective tissue disorders, (AD polycystic kidney disease)
28
What are complications of LP?
headache (most common, improves with lying), infection, bleeding, nerve damage, back pain
29
Management of post LP headache?
IV fluids, bed rest, simple analgesia, caffeinated drink?
30
Acronym for headache differentials?
``` VITAMIN CDEF vascular- SAH infection- meningitis trauma- traumatic brain injury autoimmune- temporal arteritis metabolic- DKA/HHS iatrogenic- post LP neoplastic- brain tumour functional- stress ```
31
In suspected meningitis, what is the first step of management/investigation?
start antimicrobials
32
Differentials for sudden onset headache
Raised ICP, encephalitis, meningitis, SAH
33
When should LP be performed in patient with sudden onset headache and nil findings on CT brain
After 12 hours of headache onset and within 12 days of symptoms onset
34
List two checks that should be made for safety prior to commencing LP
fundoscopy/CT head (to show evidence of raised ICP) | Clotting and platelets
35
Which findings in LP would indicate positive result?
xanthochromia if SAH, positive gram stain/PCR if meningitis
36
List three complications from LP
headache, introduction of infection, nerve injury, meningeal herniation
37
Differential for acute headache?
VICIOUS Vascular: SAH, intracranial, sinus thromboembolism Infection/inflammation: meningitis, encephalitis, abscess Compression: tumour ICP Opthlalmic: acute glaucoma Unknown: cough, exertion Systemic: phaochromocytoma, sinusitis, tonsilitis, CO
38
Differential for chronic headache?
MCD TINGS ``` Migraine Cluster headaches Drugs Tension headaches ICP Neuralgia (trigeminal) Giant cell arteritis Systemic: HTN ```
39
List three drug classes that can cause headaches
analgesics caffeine vasodilators: CCB, nitrates
40
Patient with acute headache and papilloedema. What are you worried about?
venous sinus thrombosis
41
Which sign is positive in meningism?
kernig's
42
Name two features of tension headache
bilateral, non-pulsatile, band-like
43
What is the distribution of headache in migraine?
unilateral
44
Patient with rapid onset pain around one eye. The attack lasts 2 hours and happens every day for 5 weeks. Which type of headache do they have?
cluster headache Rapid onset very severe pain around/behind one eye.  Red, watery eye, nasal congestion  Miosis, ptosis  Attacks last 15min–3hrs, 1-2x/day, mostly nocturnal  Clusters last 4-12wks, remission lasts 3mo-3yrs. Can be chronic vs. episodic.
45
Treatment for cluster headache?
oxygen and sumitriptan
46
Name two triggers for trigeminal neuralgia
washing area, shaving, eating, talking
47
What are the symptoms of trigeminal neuralgia
``` Paroxysms of unilateral intense stabbing pain in trigeminal distribution (usually V2/3) ```
48
Name a treatment for trigeminal neuralgia
gabapentin
49
What worsens increased ICP headaches?
worse in AM, stooping, worse sitting or standing
50
Name a risk factor for migraines
obesity
51
Describe the pathophysiology of migraine
Vascular: cerebrovascular constriction → aura, dilatation → headache.  Brain: spreading cortical depression  Inflammation: activation of CN V nerve terminals in meninges and cerebral vessels.
52
List four triggers for migraine
``` CHOCOLATE  CHeese  OCP (oral pill)  Caffeine  alcohOL  Anxiety  Travel  Exercise ``` Lack of sleep, stress, hunger, mesntruation
53
Describe three symptoms of migraines?
Prodrome-> aura -> headache Prodrome: hours-days Aura: mins before headache Headache- unilateral throbbing
54
What are the features of prodrome?
yawning, food cravings, changes in sleep/appetite/mood
55
What are the types of auras?
 Visual: distortion, lines, dots, zig-zags, scotoma, hemianopia  Sensory: paraesthesia (fingers → face)  Motor: dysarthria, ataxia, ophthalmoplegia, hemiparesis (hemiplegic migraine)  Speech: dysphasia, paraphasia
56
Differential for migraine?
```  Cluster / tension headache  Cervical spondylosis  HTN  Intracranial pathology  Epilepsy ```
57
Treatment for migraine?
aspirin, ibuprofen, triptan, amitriptyline
58
When should triptan be taken ideally for migraine if patient has auras?
In patients who experience aura with their migraine, it is recommended that 5HT1-receptor agonists are taken at the start of the headache and not at the start of the aura (unless the aura and headache start at the same time).
59
What is the first line prophylaxis for migraine?
avoidance of triggers, propranolol and topiramate (antiepileptic), TCAs (amiltiptyline)
60
List three complications of SAH
1. rebleeding 2. Cerebral ischaemia 3. Hydrocephalus 4. Hyponatraemia 5. Seizures
61
What is Terson's syndrome?
vitreous haemorrhage of the eye associated with SAH
62
Only when should LP be performed for suspected SAH?
if negative CT findings, 12 hours after onset
63
Which drug is used to manage delayed ischaemia in SAH?
nimodipine
64
Name a cardio complication of SAH?
LVF- tako-tsubo cardiomyopathy
65
Who should you image with headache?
SNOOP- SSSNOOPPP: systemic symptoms e.g. fever, secondary risk fx, seizures, neuological symptoms, onset, older, progression, papilloedema, precipitated by cough or exertion or sleep. CSF- change in nature of headache, S- systemic symptoms of signs, F-focal neurological deficit
66
List three features of postdrome migraine?
euphoria, depression, poor concentration, fatigue
67
First line triptan for headache?
sumitriptan
68
What are examination findings of raised pressure headaches?
optic disc swelling, impaired visual acuity, restricted visual fields, 3rd and 6th nerve palsy, focal neurological signs

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