Neuro - Headache Flashcards
(114 cards)
1
Q
What is a headache?
A
usually a symptom of life
2
Q
What are the patterns of an acute single headache?
A
→ Febrile illness → sinusitis → First attack of migraine → Following a head injury → Subarachnoid haemorrhage → Meningitis → tumour → drugs → toxins → stroke → Thunderclap (sudden onset) → low pressure
3
Q
What are the patterns of an dull headache, increasing in severity?
A
→ Usually benign → Overuse of medication (e.g. codeine) → Contraceptive pill, hormone replacement therapy → Neck disease → Temporal arteritis → Benign intracranial hypertension → Cerebral tumour → Cerebral venous sinus thrombosis
4
Q
What are the possible causes of a dull headache that’s unchanged over months?
A
→ chronic tension headache
→ depressive, atypical facial pain
5
Q
What are the possible causes of a triggered headache that’s unchanged over months?
A
→ coughing, straining, exertion
→ coitus
→ food and drink
6
Q
What are the possible causes of a recurrent headaches that’s unchanged over months?
A
→ migraine
→ cluster headaches
→ episodic tension headache
→ trigeminal or post-herpetic neuralgia
7
Q
What are the red flags of headaches?
A
→ onset (thunderclap, acute, subacute)
→ meningism (photophobia, phonophobia, stiff neck, vomiting)
→ systemic symptoms (fever, rash, weight loss)
→ neurological symptoms or focal signs (visual loss, confusion, seizures, hemiparesis, double vision, 3rd nerve palsy, Horner syndrome, papilloedema)
→ orthostatic-better lying down
→ strictly unilateral
8
Q
What is 3rd nerve (oculomotor) palsy?
A
→ weakness of the oculomotor nerves
→ completely closed eyelid and deviation of the eye outward and downward
→ eye cannot move inward or up
→ pupil is typically enlarged and does not react normally to light
9
Q
What is Horner Syndrome?
A
→ combination of signs + symptoms due to disruption of nerve pathway from brain to face + eye, usually on one side
→ decreased pupil size, drooping eyelid, decreased sweating on affected side of face
10
Q
What are the signs of a subarachnoid haemorrhage?
A
→ sudden generalised headache “blow to the head” or “thunderclap” onset
→ meningism - stiff neck + photophobia
11
Q
What proportion of SAHs are fatal?
A
around 50%
12
Q
How are SAHs treated primarily?
A
→ Vasospasm may stop the leak.
→ Nimodipine and BP control due to high risk of further bleed
13
Q
How were aneurysms treated once upon time?
A
aneurysms used to be clipped or wrapped
14
Q
What causes SAHs?
A
→ most are caused by a ruptured aneurysm
→ few from arteriovenous malformations
→ some are unexplained
15
Q
How are aneurysms treat now?
A
→ catheter inserted through the groin to access the cerebral arteries
→ the aneurysm is filled with platinum coils
16
Q
What are the general categories of causes of headaches?
A
→ structure
→ pharmacological
→ psychological
17
Q
How are SAHs assessed + diagnosed?
A
→ early neurological assessment will confirm beed + establish the cause → Brain CT → lumbar puncture (RBC + xanthochromia) → MRA (MR angiogram) → angiogram
18
Q
What is coning?
A
→ brain has a capacity for volume + pressure
→ when volume in brain increases, intracranial pressure (ICP) increases
→ when ICP crosses a threshold, brain can no longer be contained and herniates through weak points
→ hernias = coning
19
Q
What causes coning?
A
acute intracranial bleeding
20
Q
What are other signs of raised ICP?
A
→ papilloedema = optic disc swelling
21
Q
How can larger arteries in the neck cause headaches?
A
through artery dissections (abnormal, and usually abrupt, formation of a tear along the inside wall of an artery)
22
Q
What is an artery dissection?
A
→ layers of blood vessels tissue can split, causing blood to seep between the layers
→ causes turbulent flow of blood
23
Q
What are the secondary symptoms of arterial dissections?
A
→ strokes + clots (turbulent flow of blood with coagulant factors can cause this)
→ headaches + neck pain
24
Q
What are the stats on strokes caused by arterial dissection?
A
→ causes 20% of ischaemic strokes under 45
→ carotid artery strokes > vertebral artery strokes
→ mean age of 40
25
What can cause arterial dissections?
→ traumatic
| → spontaneous
26
What tests can be used to diagnose artery dissection?
→ MRI / MRA
→ doppler
→ angiography
27
What is the treatment for artery dissection?
→ aspirin
| → anticoagulants
28
How do carotid artery dissection headaches present?
→ in a "phantom of the opera mask" distribution
| → in the frontal part of the face
29
How do vertebral artery dissection headaches present?
→ occipital headaches
| → in the back of the head + neck
30
What is temporal arteritis?
inflammation of the temporal artery
31
What is the demographic of people with temporal arteritis?
→ over the age of 55
| → 3 times commoner in females
32
What are the signs and symptoms of temporal arteritis?
→ constant unilateral headache
→ scalp tenderness
→ jaw claudation
→ 25% polymyalgia rheumatica-proximal muscle tenderness
33
What are the clinical features + diagnostic tests for temporal arteritis?
→ inflamed temporal artery is visible on ultrasound
| → biopsy should show inflammation + giant cells
34
How is temporal arteritis treated?
high dose steroids + aspirin
35
What is CVT?
→ cerebral venous thrombosis
| → thrombosis in dural venous sinus or cerebral vein
36
What are the signs and symptoms of CVT?
→ unusual no. of headaches due to raised ICP
→ non-territorial ischemia called "venous infarcts"
→ haemorrhage
→ thrombophilia
→ pregnancy
→ dehydration
→ behcets (inflammation of blood vessels + tissues)
37
What is meningitis?
inflammation of meninges
38
What are the different causes of meningitis?
→ viral (coxsackie, ECHO, Mumps, EBV)
→ bacterial (meningococci, pneumococci, haemophilus, tuberculous)
→ fungal (cryptococci)
→ granulomatous (sarcoid, lyme, brucella, behcets, syphilis)
→ carcinomatous
39
What are the presenting symptoms of meningitis?
```
→ malaise
→ headache
→ fever
→ neck stiffness
→ photophobia
→ confusion
→ alteration of consciousness
```
40
What is the key principle of managing someone who's suspected to have meningitis?
→ treat before diagnosis
| → meningitis is fatal
41
How is meningitis treated?
antibiotics if bacterial
42
How is meningitis diagnosed?
→ blood + urine culture
→ CT or MRI scan
→ then lumbar puncture
43
What is analysed in a lumbar puncture for meningitis?
```
→ increased white cell count
→ decreased glucose
→ antigens
→ cytology
→ bacterial culture
```
44
Why should CT scans + MRIs be done before lumbar puncture in meningitis?
→ swollen meninges = raised ICP
→ needle from lumbar puncture could lead to rapid decompression
→ could lead to coning
45
How does bacterial meningitis present on a scan?
cerebral oedema with effacement of ventricles + sulci + inflamed meninges
46
What is sinusitis?
inflammation of sinuses
47
What are the symptoms of sinusitis?
```
→ malaise
→ headache
→ fever
→ blocked nasal passages
→ loss of vocal resonance
→ anosmia
→ nasal or post-nasal catarrh (build-up of mucus)
→ frontal pain characteristically stats 1-2 hours after rising + clears in the afternoon
```
48
How do sinuses appear on X-rays for people with sinusitis?
opacification of sinuses (whiter and denser sinuses)
49
What kind of tumours can cause headaches?
→ literally any tumour in the brain
| → glioblastoma multiforme
50
Why do tumours in the brain cause headaches?
they raise ICP
51
What is idiopathic intracranial hypertension?
→ also called pseudotumour cerebri
| → high pressure around the brain + raised ICP
52
What are the signs + symptoms of IIH?
```
→ often young obese women
→ headache
→ visual obscurations
→ diplopia
→ tinnitus
→ papilloedema
→ visual field loss
```
53
What drugs can cause IIH?
→ hormones
→ steroids
→ antibiotics
→ vitamin E
54
How can IIH be treated?
```
→ weight loss
→ diuretics
→ optic nerve sheath deocmpression
→ lumboperitoneal shunt
→ stenting of stenosed venous sinuses
```
55
What does a CT scan for IIH look like?
→ cerebral oedema w effacement of ventricles + sulci
| → no mass lesion
56
What is a low pressure headache?
headache due to low ICP
57
What can cause a low pressure headache?
→ CSF leak due to tear in dura
| → traumatic post lumbar puncture or spontaneous
58
What are the hallmarks of a low pressure headache?
→ headache starts when they get up due to low volume of CSF in head
→ headache stops when they lie down due to higher volume of CSF in head
→ X-rays show meningeal enhancement
59
What is the treatment for low pressure headaches?
→ rehydration
→ caffeine
→ blood patch
60
What is a blood patch?
→ blood is injected into epidural space
| → tear is sealed due to coagulants in blood
61
What is chiari malformation?
→ normal brain that sits very low within the skull
| → cerebellar tonsils descend through the foramen magnum
62
What causes the headache in chiari malformation?
→ tonsils descend further when the patient coughs + tugs on the meninges
→ creates a cough headache
63
How is chiari malformation treated?
→ treat whatever's causing the cough
| → surgery can remodel bone of skull to take away some bone and create some space
64
What is obstructive sleep apnoea?
→ muscles that support the soft tissues in your throat, such as your tongue and soft palate, temporarily relax
→ when these muscles relax, your airway is narrowed or closed, and breathing is momentarily cut off
65
What are the signs and symptoms of obstructive sleep apnoea?
```
→ characteristic body habitus
→ history of loud snoring + apnoea spells
→ hypoxia + CO2 retention
→ non-refreshing sleep
→ depression
→ impotence
→ poor performance at work
```
66
How does OSA cause headaches?
→ CO2 = vasodilator
→ so CO2 retention = increased vasodilation
→ leads to morning headaches
67
How is OSA assessed + treated?
→ requires nocturnal NIV
| → surgery to remove and ease obstruction causing sleep apnoea
68
What is trigeminal neuralgia? What are the signs + symtoms?
→ electric shock like pain in distribution of trigeminal sensory nerve in the face
→ can be a symptom of MS
69
What are the causes of trigeminal neuralgia?
→ neurovascular conflict at the point of entry of the nerve into the pons
→ triggered by innocuous stimuli e.g. chewing gum, etc.
70
How is trigeminal neuralgia treated?
```
anticonvulsants :
→ carbamazepine
→ lamotrigine
→ gabapentin
surgery :
→ posterior fossa decompression
```
71
What is atypical facial pain?
syndrome that encompasses a wide group of facial pain problems
72
What demographic does atypical facial pain occur in?
→ most commonly in middle aged women
| → depressed + anxious
73
What are the signs + symptoms of atypical facial pain?
→ daily, constant, poorly localised deep aching or burning
→ facial or jaw bones, may extend to the neck, ear or throat
→ not lancinating
→ not conforming to to the strict anatomical distribution of any nerve
→ no sensory loss
→ pathology in teeth, temporomandibular joints, eye, nasopharynx + sinuses must be excluded
74
How is atypical facial pain treated?
→ unresponsive to conventional analgesics, opiates + nerve blocks
→ mainstay of management tricyclics
75
What proportion of people present with post-traumatic headaches?
→ 36% at discharge
→ 24% in the next 6 months
→ 16% at 12 months
76
Who is predisposed to having post-traumatic headaches?
→ correlates with previous history of headaches
| → unrelated to duration of post-traumatic amnesia
77
How does post-trauma headache depend on nature of head injury?
→ High in victims of car accidents
→ Low in perpetrators of car accidents
→ Low in sports injuries
78
What pathologically causes post-traumatic headaches?
→ Neck injury
→ Scalp injury
→ Vasodilation due to autonomic damage
→ Depression - often delayed
79
How do you manage + treat post-traumatic headaches?
→ Explanation
→ Prevent analgesic abuse
→ Non-steroidal anti-inflammatories - ibuprofen, naproxen
→ Tricyclic antidepressants - Amitriptyline
80
What cervical spondylosis?
→ narrowing of joint space due to worn disc
| → commonest cause of new headache in older patients
81
What are the symptoms of cervical spondylosis?
```
→ Usually bilateral
→ Occipital pain can radiate forwards to the frontal region
→ Steady pain
→ No nausea or vomiting
→ Worsened by moving the neck
```
82
How do you manage + treat cervical spondylosis?
```
→ Rest
→ deep heat
→ massage.
→ Anti-inflammatory analgesics
→ Over-manipulation may be harmful
```
83
What is a migraine?
```
headaches, characterised by:
→ tendency to repeated attacks
→ triggers
→ easily hung-over
→ visual vertigo
→ motion sickness
```
84
What forms do migraine attacks come in?
→ just pain
→ pain + focal symptoms
→ just focal symptoms
85
What causes migraines?
spreading of electrical depression across the cerebral cortex
86
What are the different phases of a migraine?
```
→ prodrome
→ aura
→ headache
→ resolution
→ recovery
```
87
What is a part of the prodrome phase of migraines?
```
→ changes in mood
→ urination
→ fluid retention
→ food craving
→ yawning
```
88
What is involved in the aura phase of migraines?
```
→ visual
→ sensory (numbness / paraesthesia)
→ weakness
→ speech arrest
→ scintillations + blindspots
→ positive + negative
→ expanding Cs
→ elemental visual disturbances
```
89
What is a part of the headache phase of migraines?
```
→ hemicranial head pain
→ body pain
→ nausea
→ photophobia
→ vomiting
→ phonophobia
```
90
What is a part of the resolution phase of migraines?
period of time when the headache dies down
→ sweeter + more comforting type of pain
→ rest + sleep
91
What is a part of the recovery phase of migraines?
→ mood disturbed
→ food intolerance
→ feeling hungover
92
How long does a whole migraine cycle take?
48 hours or so
93
How do you treat an acute migraine attack?
→ Aspirin/ibuprofen (Non-steroidals) and paracetamol and metoclopramide (anti-emetic)
→ Soluble preparations to aid absorption
→ Triptans-tablets, melts, nasal sprays, s/c injections (vasoconstrictions) + synergise with NSAIDS
→ Hit the headache hard and fast
→ Opiates-caution! Analgesic abuse potential
→ A short nap
→ TMS (transcranial magnetic stimulation) interrupts complex networks that trigger and perpetuate migraine
94
What are some of the lifestyle issues experienced by those with migraines?
→ Migraineurs have sensitive heads even in between attacks.
→ Over-react to any sort of stimulation.
→ Can’t ignore the world around them, it overstimulates their brains.
95
How can people with migraines change their lifestyles to help themselves?
→ avoid trigger e.g. dietary, environmental, hormonal, weather, dehydration, stress
→ Drink 2 litres water/day
→ Avoid caffeinated drinks
→ Don’t skip meals
→ Fresh food - Avoid ready meals & take-aways due to preservatives + additives
→ Don’t oversleep or have late nights + keep electronics downstairs
→ Analgesic abuse
96
What treatments can be used against chronic migraines?
→ Over-the-counter preparations: feverfew, coenzyme Q10, riboflavin, magnesium, EPO, nicotinamide
→ Tricyclicantidepressants (TCAs) : amitriptyline 7pm (makes you drowsy tho)
→ Beta-blockers : Propranolol, Atenolol (drops BP and pulse)
→ Serotonin antagonists: pizotifen, methysergide
→ Calcium channel blockers : flunarazine, verapamil
→ Anticonvulsants: valproate, topiramate, gabapentin
→ Greater occipital nerve blocks (injectable into the nerves to numb pain)
→ Botox in a crown of thorns distribution (injectable)
→ Suppress ovulation for those triggered by it (progesterone only pill or implant/injection)
→ Erenumab
97
What counts as a chronic migraine?
more than 14 migraines a month
98
Why can oestrogen not be given to those who suffer from migraines?
oestrogen can trigger migraines
99
How does Erenumab work?
→ Injectable drug erenumab (Aimovig)
→ cut number of days people had migraines from an average of 8 a month to between 4 and 5 a month.
→ Monoclonal antibody
→ disables calcitonin gene-related peptide or its receptor (CGRP mAbs)
→ Episodic migraine, chronic migraine, or cluster headache.
100
What is a tension type headache? What are the signs?
pain + tight muscles around head and neck bilaterally, as though head is in a vice
101
How can a tension type headache be treated?
→ NSAID’s preferred: Ibuprofen, Naproxen, Diclofenac
→ Paracetamol
→ Tricyclic antidepressants : Amitriptyline 50-75mg daily (30-60% derive some symptomatic relief)
→ SSRIs (probably less effective)
→ Biofeedback and relaxation (unproven)
102
What is a cluster headache?
→ Severe unilateral pain lasting 15-180 minutes untreated
| → Classified as a trigeminal autonomic cephalgia (headache)
103
What are the symptoms of a cluster headache?
→ Forehead and facial sweating
→ Miosis and/or ptosis
→ A sense of restlessness or agitation
→ Frequency between one on alternate days to 8 per day
→ Not associated with a brain lesion on MRI
At least one of the following, ipsilaterally:
→ Conjunctival redness and/or lacrimation (flow of tears)
→ Nasal congestion and/or rhinorrhoea (free discharge of thin nasal fluid)
→ Eyelid oedema
104
How are cluster headaches treated acutely?
→ Inhaled oxygen
| → S/C or Nasal Sumatriptan
105
Why does inhaled oxygen help with cluster headaches?
Oxygen inhibits neuronal activation in the trigeminocervical complex
106
What can prevent cluster headaches?
```
→ Verapamil
→ Prednisolone
→ Lithium
→ Valproate
→ Gabapentin
→ Topiramate
→ Pizotifen
```
107
What's the difference in distribution between migraines + cluster headaches?
→ mig = 1:2, M:F
| → cluster = 9:1, M:F
108
What's the difference in duration between migraines + cluster headaches?
→ mig = 3-12 hours
| → cluster = 45 min - 3 hours
109
What's the difference in frequency between migraines + cluster headaches?
→ mig = 1 to 8 attacks monthly
| → cluster = 1 to 3 attacks daily (often at night)
110
What's the difference in remission between migraines + cluster headaches?
→ mig = unusual to have long remissions
| → cluster = long remissions are common
111
What's the difference in nausea between migraines + cluster headaches?
→ mig = nausea + vomiting frequent
| → cluster = nausea is rare
112
What's the difference in pain between migraines + cluster headaches?
→ mig = pulsating hemicranial pain
| → cluster = Steady, exceptionally severe, well localised pain, unilateral in each cluster
113
What's the difference in symptoms between migraines + cluster headaches?
→ mig = Visual or sensory auras seen
| → cluster = Eye waters, nose blocked, ptosis etc
114
What's the difference in activity between migraines + cluster headaches?
→ mig = Patients lie in the dark
| → cluster = Patients pace about
