Headache Flashcards by Jia Ying Tan

Headaches can be split into Primary and Secondary Types, what would be signs of a secondary headache? [6]

Trauma
First or worst ever headache
Thunderclap onset
A new daily & persistant headache
A change in the headaches pattern or type
Other symptoms such as jaw claudication, fevers, neuro signs/symptoms or worsened by position

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What could cause a thunderclap headache [4]

intracranial aneurysm (saccular ‘berry’ aneurysms)- accounts for around 85% of cases, conditions associated with berry aneurysms include hypertension, adult polycystic kidney disease, Ehlers-Danlos syndrome and coarctation of the aorta
arteriovenous malformation
pituitary apoplexy
mycotic (infective) aneurysms

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What causes most subarachnoid haemorrhages? [1]

Aneurysms

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Do we order CT head or lumbar puncture to diagnose SAH?

NCCT Head: acute blood, hyperdense/bright on CT in basal cisterns, sulci, ventricles
If CTH within 6h and normal, dont do LP
If CTH >6h and normal, do LP because LP should be at least 12h following onset of sx to allow development of xanthochromia.

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Define a thunderclap headache? [2]
Describe a few other associated features with SAH.

Thunderclap headache: High intensity [1] peaking instantly or within 1-5 minutes of onset [1]
* nausea and vomiting
* meningism (photophobia, neck stiffness)
* coma
* seizures
* ECG changes including ST elevation may be seen- this may be secondary to either autonomic neural stimulation from the hypothalamus or elevated levels of circulating catecholamines

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What types of CNS infection cause thunderclap headache [3]

If the patients headache comes with fever, rash or: [1]
Meningitis [1]
Encephalitis [1]

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What is the triad of meningism [4]

Describe presentation of encephalitis [3]

What could raise [4] or lower Intracranial pressure [2]?

Headache, neck stiffness, and photophobia, often with nausea and vomiting.

Encephalitis- Altered mental state, seizures, focal neuro symptoms/signs

Raised ICP:

Hydrocephalus
Cerebral Abscess
Glioblastoma/Meningioma
Venous sinus infarct

Lowered ICP:
- Dural CSF leak either spontaneously or after LP

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What are the specific signs of raised ICP? [6]

Progressively worse headache
Worse in morning/wakes them up
Worse on flat, valsalva (poop/cough/strain) or on exertion
Neurological symptoms
Seizures
Visual obscurations and pulsatile (whooshing) tinnitus

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What indicates an intracranial hypotension [3] and how do we approach it? [2]

Headache appearing/worsening on standing and lessening/resolving on lying down [2]

Sagittal MRI of brain and spine will show an empty subarachnoid space [1]

Conservative: Bed rest, fluids, analgesia, caffeine [1]

Epidural Blood patch (to stimulate healing of a CSF leak) [1]

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What is an epidural blood patch? [3]

A treatment for leaking CSF that causes lowered ICP [1]

Put some of the patients blood in their epidural space [1] which will cause irritation leading to healing of the leak [1]

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What is Giant Cell Arteritis [3] and what about a headache would indicate it [2]?

Giant cell granulomatous inflammation of the arteries [1] causing narrowing which can cause an infarction [1] to the brain and/or optic nerve [1]

The headache is diffuse persistant and may be severe

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What are the symptoms of giant cell arteritis? [4]

What is an associated condition [1]

Diffuse, persistant and severe headache
Jaw claudication (pathognomonic)
Visual Disturbance eg blindness, diplopia
Scalp Tenderness

Associated with PMR

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GCA
Ix [5]
Dx [1]
Mx [1]

ESR/CRP/Platelets all elevated
Anemia, high ALP
Confirm with a temporal artery biopsy
Treat with prednisolone 60mg

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What are the main types of Primary Headache? [4] + [3]

Indicate the most common cause of primary headache*

Tension-Type*
Migraine
Medication Overuse Headache
Trigeminal Neuralgia

And the Trigeminal Autonomic Cephalagias:

Cluster headache
Paroxysmal Hemicrania
SUNA/SUNCT

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TTH
Presentation [4]
Cause/mechanisms [1]

Mild, bilateral
Described as ‘tight band’
Worse towards end of day
Not aggravated by ADL

Mechanism
- Muscular due to persistent contraction

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What are the subtypes of Tension Type headache? [2]

Episodic - <15 days a month

Chronic - >15 days a month

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TTH
Approach [3]
Rx [3]
Second line [2]

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Reassurance
Reduce psychological stress
Reduce analgesic over-use

Aspirin, paracetamol or NSAIDs

2nd line: TCA

Define Migraine? [4]
Describe subtypes [2]
Nature of headache [3]

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Chronic episodic attacks [1] featuring phono/photophobia, functional disability and nausea. [3]

Types:

Migraine with Aura (33%)
Common migraine

Nature of headache: unilateral throbbing headache, 2-48h, less than 2x weekly

What triggers a migraine? [8]

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Barometric pressure/humidity.
Sleep (lack or excess).
Dietary intake, e.g. cheese, caffeine, alcohol.
Stress (either excess or in periods of relief)
Physical exertion.
Loud noise.
Bright light.
Hormonal changes such as puberty, menses and menopause.

What is an “aura”? [4]

Describe visual [3], basilar [4], hemiplegic [1] and retinal auras [1]

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A set of transient neurological symptoms [1] lasting 15-60 minutes.[1]
Can be of visual, sensory or motor type [1]
Often precedes headache [1]

Visual forms:
- Foritifications (zigzags)
- Flashing lights
- Scintillating scotoma
(migraine with occipital origin)

Basilar

Bilateral visual symptoms
Unsteadiness, vertigo,
Dysarthria
Limb paresthesia, LOC

Hemiplegic
- Unilateral paralysis persisting few days after headache settled

Retinal
- Unilateral visual loss reversible

What defines a Chronic Migraine? [3]

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Headaches >15 days a month for >3 months [2]

Of which atleast 8 a month must be migraines [1]

Migraine management

2 approaches [7]

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First line: simple analgesia, anti-emetics

Abortive:

Triptan 5HT AGONIST & NSAIDs
Adjunctive metoclopromide

Prophylactic: considered when headaches occur more than 3-4x a month.

Propanolol
Anti-epileptics topiramate 5HT ANTAGONIST
Tricyclic Antidepressants Amitripytyline
Acupuncture
Botulinum toxin A

What should we be aware of in pregnant women with migraines? [2]

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Dont give antiepileptics to those of child-bearing age as they’re teratogenic

Treat pregnant women with paracetamol or propanolol/Amitriptyline prophylactically

Define a medication overuse headache? [2]

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Headache >15 days a month [1] developed or worsened on regular symptomatic medications [1]

What causes a medication overuse headache? [5] List the duration of time used to induce such a headache

- Triptans - Ergots - Opiods More than 10 days a month Or simple analgesics used more than 15 days a month Also caffeine overuse

Where do Trigeminal Autonomic Cephalagias present with pain?

In the orbital, supraorbital and temporal regions

What do SUNA/SUNCT stand for? [2] | What are the autonomic symptoms that accompany Trgimenial autonomic cephalalgias [3]

Short Lasting Unilateral Neuralgiform headache With either Autonomic symptoms Redness, lacrimation, lid swelling Horner's syndrome Nasal congestion

Cluster headache | - Clinical features [5]

- Unilateral sharp/throbbing pain - Rapid onset and 15 min-2h minutes duration - Incredibly severe - Often comes with migranous symptoms such as nausea, aura and photo/phonophobia - Patient restless and agitated Also remember Autonomic symptoms with all TACs

Why are cluster headaches so named? Triggers [1] Pattern [1]

They are episodic, occuring in clusters [1] typically lasting 1-3 months with anything from 1-8 a day during an attack [1] The bouts may be triggered by alcohol [1] and may feature continuous background level pain They may show circadian rhythmicity with bouts coming the same time every year and attacks the same time each day [1]

How do you treat a cluster headache? Acute [2] Abortive Prevention [2]

Acute: 100% O2, injectable sumatriptan, Abortive: steroids, greater occipital nerve blockade (depomedrone) Prevention: Verapamil, lithium, methylsegide for prevention

Describe a paroxysmal hemicrania? [5]

``` Unilateral sharp/throbbing pain Rapid onset, duration 2-30 minutes Very severe Possible continuous background pain 2-40 attacks per day without circadian rythm ```

How do we treat Paroxysmal Hemicrania? | SE [2]

``` Prophylactic Indomethacin (An NSAID) systemic upset, nephrotoxic ```

Describe SUNCT? [5]

``` Unilateral Stabbing/pulsing pain Short 10-240 second duration Triggered by wind/cold/touch/chewing 3-200 attacks a day Comes with conjunctival injection (red eye) and tears ```

How do we treat SUNCT? [1]

Lamotrigine prophylactically (an anti-epileptic, same for SUNA)

Describe Trigeminal Neuralgia [4]

``` Unilateral stabbing pain [1] unlike TACs its to the maxillary/mandibular regions [1] 5-10 second duration Also triggered by wind/cold/touch/chew 3-200 a day Unlikely to have autonomic symptoms ```

How do we treat Trigeminal Neuralgia? [3]

Gabapentin for pain relief Carbamazepine prophylactic Surgical vascular loop decompression

Name a tricyclic antidepressant and what headaches its used for? [3]

Amitriptyline - Prophylaxis of Tension Type Headaches - Prophylaxis of Migraines

How do you differentiate the types of TACs? Frequency Duration Pain characteristic

Frequency: CH = 1-8 PH = 1-40 SUNCT = 3-200 Duration: CH = 15-180 mins PH=2-30mins SUNCT = 5-240 seconds I.e. frequency and duration are inversely proportional Pain is sharp and throbbing in CHs & PHs but stabbing/pulsing or burning in SUNCT All have a very severe pain CH most likely to show circadian rythmicity

``` Summary of Treatments for Headache Types: Thunderclap TTH Migraine MOH Trigeminal neuralgia Cluster headache Paroxysmal hemicrania SUNA/SUNCT ```

Thunderclap - Probably SAH - Coiling/clipping Tension Type Headache - Aspirin/NSAID/Paracetamol + Amitryptiline Migraine - Aspirin/NSAID/Triptan + Propanalol/Anti-epileptic/Amitryptiline Medication Overuse Headache - Use less meds Trigeminal Neuralgia - Carbamazepine Cluster Headache - 100% O2/SC Sumatriptan + Verapamil Paroxysmal Hemicrania - Prophylactic Indometacin NSAID SUNA/SUNCT - Anti-epileptic Lamotrigine

# SAH Further investigation and management

After spontaneous SAH is confirmed, the aim of investigation is to identify a causative pathology that needs urgent treatment: * CT intracranial angiogram (to identify a vascular lesion e.g. aneurysm or AVM) * +/- digital subtraction angiogram (catheter angiogram) Management of a confirmed aneurysmal subarachnoid haemorrhage supportive * bed rest * analgesia * venous thromboembolism prophylaxis * discontinuation of antithrombotics (reversal of anticoagulation if present) * vasospasm is prevented using a course of oral nimodipine * intracranial aneurysms are at risk of rebleeding and therefore require prompt intervention, preferably within 24 hours * most intracranial aneurysms are now treated with a coil by interventional neuroradiologists, but a minority require a craniotomy and clipping by a neurosurgeon

Complications of aneurysmal SAH [5]

* re-bleeding - happens in around 10% of cases and most common in the first 12 hours, if rebleeding is suspected (e.g. sudden worsening of neurological symptoms) then a repeat CT should be arranged, associated with a high mortality (up to 70%) * hydrocephalus- temporarily treated with an external ventricular drain (CSF diverted into a bag at the bedside) or, if required, a long-term ventriculoperitoneal shunt * vasospasm (also termed delayed cerebral ischaemia), typically 7-14 days after onset, ensure euvolaemia (normal blood volume)- consider treatment with a vasopressor if symptoms persist * hyponatraemia (most typically due to syndrome inappropriate anti-diuretic hormone (SIADH)) * seizures

Headache Flashcards

(41 cards)