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headache Flashcards

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1
Q

What could cause an acute single headache?

A

Illness, sinusitis, head injury, subarachnoid haemorrhage, meningitis, drugs, toxins, stroke, thunderclap headache

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2
Q

What could cause a dull headache increasing in severity?

A

Medication overuse, HRT, contraceptives, temporal arteritis, benign intracranial hypertension, tumour, cerebral venous sinus thrombosis

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3
Q

What could cause a dull headache unchanged over months?

A

Chronic tension headache, cerebral venous sinus thrombosis

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4
Q

What could cause a triggered headache?

A

Coughing, sex, exertion, strain, food & drink, sleep/lack of

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5
Q

What could cause a recurrent headache?

A

Migraines, cluster headache, episodic tension headache, trigeminal neuralgia, post-herpetic neuralgia

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6
Q

Which headaches do people complain most about and which are the worrying ones?

A

People complain more about dull unchanged headaches (chronic) or recurrent headaches. The worrying ones are the acute single headaches or those increasing in severity

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7
Q

What are red flags of headaches?

A

Acute/subacute onset eg. Thunderclap. Meningism symptoms (photophobia, phonophobia, stiff neck, vomiting), systemic symptoms (fever, rash, weight loss). Focal signs (visual loss, confusion, seizure, hemiparesis, diplopia, 3rd nerve palsy, horner’s syndromes, papilloedema), orthostatic headaches, strictly unilateral headache

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8
Q

What are some focal signs?

A

Double vision, horner syndrome, 3rd nerve (oculomotor) palsy

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9
Q

What causes double vision?

A

Damage to any of the 3 nerves that innervate muscles of the eye or muscles themselves

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10
Q

What is horner syndrome? Presentation?

A

Sympathetic supply to the eye is affected so the eye looks droopy, eyelid pushed in and the pupil is smaller: ptosis, miosis, anhidrosis, enopthalamus

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11
Q

What is 3rd nerve (oculomotor) palsy? What can cause it? Presentation?

A

Damage to the oculomotor nerve.

  • Can happen because posterior communicating artery aneurysm can sit close to oculomotor nerve and rupture/haemorrgae.
  • The signs are ptosis (droopy eyelid) and pupil dilation because nerve innervates levator muscle and constricts pupil - dilated pupil with eye pointing in wrong direction (out of alignment with the others)
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12
Q

How does a subarachnoid haemorrhage present? What can cause it?

A
  • Sudden generalised headache usually at back of head.
  • Presents with meningism (stiff neck, photophobia) because blood in subarachnoid space irritates meninges.
  • Can be due to ruptured aneurysm, arteriovenous malformations etc.
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13
Q

What drug should you give for subarachnoid haemorrhage?

A

Nimodipine & try to control BP to prevent further bleeds

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14
Q

How to diagnose subarachnoid haemorrhage? What do you see in each investigation?

A

CT brain (see white blood - acute bleeding). Lumbar puncture (pink/red spinal fluid, RBC and xanthochromia - yellow discolouration due to bilirubin) indicating haemorrhage. MRA & angiogram if blood obscuring anatomy

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15
Q

How do they coil aneurysm?

A

Catheter through vessel in groin, feed up through cerebral arteries and fill it with platinum coils to sclerose/seal aneurysm

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16
Q

How can acute intracerebral bleed become fatal?

A

Can cause a large bleed which increases intra-cranial pressure. Brain can start seep under areas of weakness (coning) eg. Falcine herniation or tentorial herniation or herniation through foramen magnum, meaning that brain squeezes out of the skull. Once brainstem is affected it can be terminal.

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17
Q

What is papilloedema and what is it caused by?

A

Optic disc swelling due to raised intra-cranial pressure (swelling at back of eye)

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18
Q

What are carotid & vertebral artery dissections? What do they cause? Which are more common and what can they result from?

A

These vessels have layers of tissue which can split and collect blood between them causing turbulent flow. They cause headache and neck pain, and potentially stroke (due to blood clot risk). Carotid dissections more common, can happen due to trauma (eg car accidents)

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19
Q

Who is predisposed to dissections?

A

People with ehlers danlos syndrome (collagen problem)

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20
Q

how is diagnosis of dissections made?

A

MRI/MRA, doppler, angiography

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21
Q

What is treatment for dissections?

A

Aspirin or anticoagulants x 6 months to prevent clot & stroke.

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22
Q

Where is headache in vertebral artery dissection

A

Occipital headache (back of head and neck)

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23
Q

Where is headache in carotid artery dissection?

A

Phantom of opera distribution (around eyes/forehead)

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24
Q

What can cause chronic subdural haemorrhage?

A

Slow venous bleed (veins thin so easy bleed). Common in elderly due to falls, or due to anticoagulants (thin blood)

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25
What seen on CT of chronic subdural bleed?
Black blood & hypodense
26
What can a significant subdural bleed cause and how is this treated?
Can cause falcine herniation (brain pushed over to other side). Drill hole and drain blood.
27
Who most commonly gets temporal arteritis?
Women over 55
28
What does temporal arteritis cause?
Inflammation of the temporal arteries so constant unilateral headache and tender scalps, jaw pain, shoulder tenderness
29
How can temporal arteritis cause blindness?
Involvement of posterior ciliary arteries
30
What is seen on blood test of temporal arteritis?
Elevated inflammatory markers - ESR and CRP
31
How do temporal arteries look? What does biopsy show?
Inflamed and tortuous. Disruption of internal elastic lamina. Biopsy shows inflammation & giant cells (with lots of nuclei)
32
What drugs for temporal arteritis?
High dose steroids & aspirin
33
What is cerebral venous thrombosis and its pathophysiology?
Blood clot in dural venous sinus or cerebral vein (DVT of brain). Big headache because raised ICP (blocked veins, so blood cannot get out of brain - build up - high ICP). These veins are fragile so can haemorrhage with blocks.
34
What are causes of cerebral venous thrombosis?
Thrombophilia, pregnancy, dehydration, behcet's disease
35
What are causes of meningitis?
Infections or malignancies (seeding of cancer cells In meninges)
36
What types of infection cause meningitis? Which are most common? Which are most dangerous?
1. virus (most common) (coxsackie, ECHO, mumps, EBV). Bacterial (most dangerous) - meningococci, pneumococci, haemophilus tuberculous. Fungal - cryptococci. Granulomatous (sarcoid, lyme, brucella, syphylis)
37
How does meningitis present?
Headache, fever, malaise, stiff neck, photophobia, confusion.
38
What is treatment for meningitis? What is the main principle?
Give antibiotics fist before investigations.
39
What investigations should be done for meningitis? What would be see in each? In what order should they be conducted and why?
Blood/urine culture, lumbar puncture (increased WBC, decreased glucose, bacterial culture), CT/MRI before lumbar puncture because bacterial meningitis can cause brain to swell (cerebral oedema)
40
What does bacterial meningitis specifically cause and how do you treat this?
Cerebral oedema (brain swells) - needle in to decompress high pressure
41
How does sinusitis present? What is characteristic of the pain? What can you see on imaging?
Headache, fatigue, fever, blocked nasal passages, anosmia, loss of voice, post-nasal drip, local pain/tenderness. Imaging shows sinus opacification (infection) -frontal pain starts after rising & clears in afternoon
42
Why can a brain tumour cause a headache?
Pressure created by tumour causes headache
43
Common demographic of pseudotumor cerebri/idiopathic intracranial hypertension?
Young obese women
44
Why is it called pseudotumor cerebri?
Similar presentation as tumour but no tumour
45
What does pseudotumor cerebri present with and why?
Headache, double vision, tinnitus, visual obscuration (swelling of optic nerves), papilloedema, visual field loss
46
What can pseudotumor cerebri be triggered by?
Weight gain, OCP, steroids, diuretics, antibitics, vitamin E, hormones
47
What is treatment for pseudotumor cerebri?
Weight loss, diuretics, optic nerve decompression, lumboperitoneal shunt, stenting of stenosed venous sinuses
48
What headaches does low pressure cause and why ?
Orthostatic headaches - rupture of meninges and leak of CSF. Lying down pressure is ok but when they stand up pressure drops
49
What is needed for diagnosis of orthostatic headache and what do they see?
MRI (meningeal enhancement)
50
What are causes of orthorstatic headache?
After lumbar puncture or spontaneous
51
What is treatment for orthostatic headache?
Rehydration, caffeine, blood patch (inject into epidural space and will patch hole)
52
What is a chiari malformation? What pain does it cause and why?
Brain normal but sits very low within skull, cerebellar tonsils very low so go through foramen magnum. Sneezing/coughing increases ICP and tonsils go even lower, snagging on meninges and causing intense short lasting pain.
53
What treatment for chiari malformation?
Treat cough. Operation to remodel base creating space/preventing snagging on meninges
54
Why headache with obstructive sleep apnoea?
Carbon dioxide retention (potent vasodilator) so vasodilates brain vessels causing headache
55
How is obstructive sleep apnoea diagnosed? What is the treatment?
Sleep study. Nocturnal NIV (non-invasive ventilation) and remodelling surgeries
56
What is trigeminal neuralgia and what does it cause? What is the cause? Triggers?
Affects trigeminal nerve so causes electric shock like pain in distribution of sensory nerve in either of divisions of trigeminal nerve. Triggers can be inocuous (eg wind, shaving)
57
What medications are used for trigeminal neuralgia? Other treatment?
Anticonvulsants (carbamazepine, lamotrigine, gabapentin), posterior fossa decompression
58
What is trigeminal neuralgia linked with?
ms
59
What does atypical facial pain consist of?
Low grade constatnt pain around cheeks, neck, face, ear, throat. No numbness, sensory loss or lacinating pain
60
What is the demographic of atypical facial pain
Middle aged women (depressed/anxious)
61
Treatment for atypical facial pain?
Painkillers. Unresponsive to conventional analgesics, opiates, nerve blocks. Mainstay with tricyclic antidepressants
62
What is a post-traumatic headache? Who is it high/low in and why?
Headache after traumatic head injury. No amnesia or severity of headache, depends on nature of headache (high in victims of car accidents, low in perpetrators, low in sports -psych element
63
Mechanisms of post-traumatic headache?
Neck injury, scalp injury, vasodilation, depression
64
How do you manage a post-traumatic headache?
Reassure them they don’t have brain damage and it will pass. Prevent analgesic abuse by using modulatory drugs (amitriptyline) - use tricyclic antidepressants (amitriptyline). Only use NSAIDS if necessary (ibuprofen, naproxen).
65
What is cervical spondylosis? What type of pain does it cause
narrowing of joint space due to worn disc. Constant pain at back of head bilateral. Worse when moving neck
66
Who does cervical spondylosis most commonly affect?
older
67
How do you manage cervical spondylosis?
Rest, deep heat, massage, anti-inflammatory analgesics, be careful with chiropractor manipulation
68
What are migraines? What are they caused by? What can they present as?
Repeated attacks, usually one sided. Caused by spreading electrical depression across cerebral cortex. Can present as headache, headache + focal signs or just focal signs
69
How long do migraines usually last?
3-12h
70
What are the phases of a migraine?
Prodrome, aura, headache, resolution, recovery
71
What happens during prodrome of a migraine?
Mood changes, fluid retention, food craving, yawning
72
What is an aura? What are positive symptoms and negative symptoms?
Visual phenomena, sensory aura of weakness, pins needles, weakness, speech arrest. Positive symptoms: flashes, zig zags. Negative symptoms: darkness, black. Combination of both together characteristic of migraines (scintillations & blindspot). Can have elemental visual disturbance (Little patch growing and growing)
73
What is the headache associated with in migraines?
Head and body pain (unilateral), nausea, photophobia
74
What happens during resolution of a migraine?
rest & sleep
75
What happens during recovery of a migraine?
Mood disturbed, food intolerance, feeling hungover
76
What should be used to treat an acute attack of a migraine? What do these drugs do?
Take painkillers quickly. Aspirin/ibuprofen, paracetamol, metoclopramide (anti-emetic). Can cause gastric paresis so soluble preparations. Triptans (exclusively for migraines but don’t treat aura - take asap and combine with NSAIDS). Nap
77
How can TMS help migraines?
TMS can interrupt complex networks that trigger/perpetuate migraines
78
What lifestyle issues can migraines cause?
Sensitive head, over react to stimulation
79
What can be triggers for migraines?
Diet (chocolate, alcohol, dairy, citrus), dehydration, stress, hypoglycaemia (don’t skip meals), sleeping too much or too little, hormonal changes, electronic use
80
What OTC drugs can be used for migraine prophylaxis?
Co-enzyme Q, magnesium, riboflavin, EPO, feverfew, nicotinamide
81
What other drugs can be used for migraine prophylaxis?
Tricyclic antidepressants (amitriptyline), beta blockers (propranolol), serotonin antagonists, calcium channel blockers, anticonvulsants, greater occipital nerve blocks, botox (crown of thorns), POP for those with hormonal changes
82
What is erenumab? What does it do?
Monoclonal antibody that disables calcitonin gene related peptide or its receptor, reducing frequency & severity of migraines
83
What is a tension type headache? How is it treated?
Due to tense muscles around head and neck bilaterally. Treat with painkillers (NSAIDS preferred), paracetamol. If very prone tricyclic antidepressants
84
What is a cluster headache? What is it classified as? What symptoms?
Severe unilateral pain classified as trigeminal autonomic cephalgia. At least 1 of following ipsilaterally: conjuctival redness & lacrimation, nasal congestion/rhinorrhea, eyelid oedema (autonomic features)
85
How long do cluster headaches last?
45 minutes - 3 h untreated
86
Treatment of acute cluster headache? Why?
Inhaled oxygen (oxygen inhibits neuronal activation in trigeminocervical complex), sumatriptan
87
What drugs are used for prevention of cluster headaches?
Verapamil, prednisolone, lithium, valproate, gabapectin, topiramate, pizotifen
88
What are some key differences between migraine and cluster headaches?
Migraine more in women, cluster more in men. Migraine monthly attacks, cluster daily attacks, migraine 3-12 hours, cluster 45min-3h. Nausea common in migraine, uncommon in cluster. Migraine pulsating hemicranial pain, cluster steady really severe localised unilateral pain in each cluster. Migraine has visual/sensory aura, cluster has eyes watering, nose blocked, ptosis. Migraine makes you want to lay in dark, cluster restless/agitated.
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