Headache Flashcards by Lee Parker

Define Cushing’s triad

Autonomic response to raised ICP characterised by:

Increased BP
Irregular breathing
Bradycardia

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The majority of extra-dural haematomas occur where and result from damage to which artery?

Temporal region where skull fractures will lead to rupture of the middle meningeal artery

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What is the classic history associated with an extradural haemotoma?

Headache as a result of an acceleration-deceleration trauma or blow to the side of the head

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Where does a subdural haemotoma most commonly occur?

Around the frontal and parietal lobes

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Give 3 risk factors for the development of a subdural haemotoma

Old age
Alcoholism
Anticoagulation

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What is the classical position of pain in a subarachnoid haemorrhage?

Sudden occipital headache

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Recall the ‘shape’ of an extradural and subdural haematoma on CT respectively

Extradural - Convex

Subdural - Concave

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Outline 5 structures that can be implicated in the pathology of headache.

Trigeminalvascular system
Meninges
CSF containing structures
Muscle
Nerves

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Give 5 examples of pathological processes that can lead to headache

Neurogenic inflammation
Inflammation
Infection
Pressure
Obstruction

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What is the most common form of primary headache?

Migraine

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Give 3 disease mechanisms that can lead to secondary headaches

Space occupying lesions
Intracranial hypertension
Vasculitis/ arteritis

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Give 2 medications that you should ask about when taking a history relating to headache

Oral Contraceptive Pill

2. Codeine

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On clinical examination, papilloedema is a sign of what disease mechanism?

Raised intracranial pressure

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What 2 visual field changes are associated with raised ICP?

Peripheral field loss

2. Enlarged blinds spots

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What are the 2 potential causes of a 6th nerve palsy in the context of headache?

Raised intracranial pressure

2. Giant cell arteritis

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The combination of headache and ataxia points towards what disease process?

A lesion in the posterior fossa pressing on the cerebellum

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What is oral hairy leukoplakia and what organism causes this clinical sign?

White patch on the lateral border of the tongue - caused by infection with EBV

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What is the clinical significance of oral hairy leukoplakia?

It is an indication of immunodeficiency - i.e. patient is susceptible to opportunistic infections.

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Define levido reticularis

Mottled reticulated vascular patterns that appear on the skin.

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Give 3 conditions in which levido reticularis may be seen

Antiphospholipid syndrome
Lupus
Vasculitis

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Xanthochromic spinal fluid can indicate which condition?

Subarachnoid haemorrhage

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Which 2 blood results are required for the investigation of potential giant cell arteritis

2. CRP

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What is the immediate intervention for giant cell arteritis?

60mg prednisolone orally and referral for temporal artery biopsy

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What percentage of migraine sufferers experience auras?

20-30%

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Give 4 neurological conditions in which cortical spreading depression has been observed

1. Cerebrovascular accident 2. Subarachnoid haemorrhage 3. Traumatic brain injury 4. Epilepsy

Name 3 anti-emetics that can be used in the management of headache associated nausea/ emesis

1. Domperidone 2. Prochlorperazine 3. Metoclopramide

Why are soluble tablets preferential when prescribing for migraine patients?

Migraine is often associated with gastric stasis and poor absorption - hence the feelings of nausea and emesis

What is the mechanism of action of Triptans?

Strong agonist action at the 5-HT (serotonin) receptors. Have been shown to induce vasoconstriction in vascular smooth muscle.

Name 2 triptans used in the treatment of migraine

1. Sumatriptan | 2. Zolmitriptan

Specifically in the CNS, name two brain structures targeted by triptans

Pre and post synaptic receptors in the: 1. Midbrain 2. Trigeminal nucleus caudalis

Which brain structure has been particularly implicated in the generation of migraines?

Trigeminal nucleus caudalis

Which medical conditions is a contra-indication for the use of triptans?

History of ischaemic heart disease or TIA

Recall the 4 criteria that are considered indications for prophylactic migraine treatment

1. Quality of life is severely affected 2. Two or more attacks per month 3. Migraine attacks do not respond to acute drug treatments 4. Frequently, very long and uncomfortable auras occur

Name 2 anti-epileptic medications that can be used as second line prophylactic treatment for migraine

1. Sodium Valproate | 2. Topirimate

Name 4 drugs that have an evidence base for migraine prophylaxis by suppressing susceptibility to cortical spreading depression.

1. Sodium Valproate 2. Topirimate 3. Propanolol 4. Amitriptyline

What are the differential diagnoses of meningitis? (3)

1. Encephalitis 2. Non-infectious causes of meningeal irritation e.g. blood, trauma or drugs 3. Subdural empyema

Infective encephalitis is most commonly caused by which organism?

Herpes Simplex Virus (HSV)

What are the 4 main risk factors for the development of meningitis?

1. Extremes of age 2. Living in close proximity 3. Absence of vaccination history 4. Immune suppression/ deficiency

Name 8 countries that have a high incidence of pneumococcal penicillin resistance

1. Canada 2. Greece 3. Italy 4. Mexico 5. USA 6. Poland 7. Spain 8. Turkey

Give 3 important contra-indications to performing a lumbar puncture

1. Papilloedema/ any sign of raised ICP 2. Coagulation defects 3. Signs of infection at the site of the needle insertion

Name the nerve that is supplied by the spinal nerve roots S2, S3 and S4

Pudendal nerve

What is the primary sensory function of the pudendal nerve

Supply sensory innervation to the external genitalia and anus in both sexes

Give 3 examples of a true dry CSF tap (LP)

1. Arachnoiditis 2. Meningeal infiltration 3. True low CSF pressure

What separate blood test should always be carrie out alongside an LP?

BM (blood glucose)

An extremely high WBC count in a CSF sample is indicative of what?

A bacterial infection

Extremely high protein levels in a CSF sample points towards which two infective agents?

1. TB | 2. Fungal

Give an example of a 3rd generation cephalosporin antibiotic

Ceftriaxone

If Listeria is suspected in cases of bacterial meningitis, which antibiotic should be added to the administered regime?

Ampicillin

Which antibiotic should be given to a patient with bacterial meningitis that is allergic to cephalosporins?

Choramphenicol

What is a hypnic headache?

A rare form of headache that only occurs at night and wakes people from sleep

A combination of headache, malaise, sweats and proximal muscle weakness in patients aged over 55 could be indicative of what condition?

Giant cell arteritis

Describe the typical visual symptoms associated with raised ICP

Transient visual obscurations

Give 3 clinical signs to look for on neurological examination in patients with suspects raised ICP

1. Papilloedema 2. Restricted visual fields 3. Enlarged blind spots

What is the clinical sign pronator drift indicative of?

Subtle pyramidal tract dysfunction

Recall the 4 main categories of intracranial space occupying lesions

1. Tumours 2. Infection 3. Vascular 4. Hydrocephalus

Name 4 infective condition that can present as an intracranial space occupying lesion

1. Brain abscess 2. Subdural Empyema 3. Granulomas (e.g. tuberculosis) 4. Parasitic

Give 3 potential causes of obstructive hydrocephalus

1. Tumours 2. Cysts 3. Intra ventricular haemorrhage

Give 2 potential causes of communicating hydrocephalus

1. Meningitis | 2. Sub arachnoid haemorrhage

What is the cause of overproduction hydrocephalus? (Rare)

A benign tumour type: Choroid plexus papilloma

List 4 symptoms of raised ICP

1. Headache 2. Vomiting 3. Blurred vision 4. Deterioration of conscious level

List 3 clinical signs of raised ICP

1. Papilloedema 2. Bradycardia 3. Hypertension

Give 4 symptoms associated with frontal lobe damage

1. Limb weakness 2. Dysphasia 3. Personality changes 4. Dementia

Give 3 symptoms associated with parietal lobe damage

1. Sensory symptoms 2. Dressing apraxia 3. Visual field defects

Give 2 symptoms associated with temporal lobe damage

1. Dysphasia | 2. Visual field defects

Suggest 5 potential effects of a space occupying lesion in the posterior fossa

1. Dysmetria 2. Gait ataxia 3. Cranial nerve palsy 4. Tremors 5. Nystagmus

Recall the components of a cerebellar examination referred to through the mnemonic DANISH

``` D - Dysdiadochokinesis A - Ataxia N - Nystagmus I - Intension tremor S - Scanning dysarthria H - Heel-shin test positivity ```

What are the two 'locational' categories for brain tumours?

1. Supratentorial | 2. Infratentorial

What is the most common form of benign brain tumour?

Meningioma

Name 5 clinical syndromes that have been associated with familial brain tumours

1. Neurofibromatosis 1 2. Neurofibromatosis 2 3. Von Hippel Lindau syndrome 4. Tuberous Sclerosis 5. Li-fraumeni syndrome

From what cell type do meningiomas arise from?

Arachnoid cap cells

Bilateral vestibular schwannoma is associated with which clinical syndrome?

Neurofibromatosis

Name the 5 most common types of primary brain tumour

1. Meningioma 2. Pituitary tumour 3. Metastasis 4. Glioblastoma 5. Oligodandroglioma

What is a normal ICP?

< 15 mmHg in adults

Why can ICP be negative on standing up?

Venous sinuses are rigid structures

Outline the percentage components of the contents of the skull (3)

1. Brain parenchyma 80% 2. CSF 10% 3. Blood 10%

Recall the average intracranial volume for an adult

1400-1700 mls

Suggest 3 potential causes of an increased blood volume in the intracranial cavity

1. Raised arterial PCO2 2. Venous obstruction 3. Raised temperature

Recall the equation for calculating cerebral perfusion pressure

CPP = ABP - ICP

What is the gold standard for measuring ICP?

EVD with strain gauge pressure transducer

List the 5 'general routine' measures suggested for the management of ICP in ICU

1. Head up tilt: 3--45 degrees 2. Keep neck straight 3. Avoid hypotension 4. Maintain adequate sedation 5. Maintain euvolemia and norm-hyper osmolar state 6. Maintain a normal PCO2

Give the 6 potential options for the management of a sustained acute rise in ICP

1. Heavy sedation +/- Paralysis 2. CSF drainage 3. Osmotic therapy (mannitol) 4. Hyperventilation 5. Barbiturate therapy 6. Decompressive craniotomy

Why can mannitol only be used in the short term as an osmotic diuretic in the treatment of acutely raised ICP?

Long term treatment would cause the mannitol to cross the BBB and thus invert the osmotic gradient, leading to retention of fluid within the brain parenchyma and causing 'rebound' raised ICP.

How can hyperventilation help to elevate a raised ICP in the short term?

A reduction in PCO2 causes cerebral vasoconstriction thus reduces intracranial blood volume

Give 2 examples of barbiturate drugs

1. Phenobarbitone | 2. Thiopentone

Give 6 tumour types that commonly can metastasise to the brain

1. Bronchus 2. Breast 3. Stomach 4. Prostate 5. Thyroid 6. Kidney

Give 4 pathophysiological processes that have been implicated in the aetiology of migraine

1. Cortical spreading depression 2. Neurogenic inflammation 3. Vasodilation and vasoconstriction 4. Patent foramen ovale

What is the first line investigation for a suspected subarachnoid haemorrhage?

CT brain

Headache Flashcards

(87 cards)