Neurology > Headache > Flashcards

Headache Flashcards

(15 cards)

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1
Q

Trigeminal Neuralgia

What are the branches of the trigeminal nerve?

Cause

Clinical features

Management

A

The trigeminal nerve is made up of three branches:

Ophthalmic (V1)
Maxillary (V2)
Mandibular (V3)

CAUSE

  • unclear but thought to be caused by compression of the nerve
  • associated with multiple sclerosis (5-10%)

CLINICAL FEATURES

  • intense facial pain that comes on spontaneously and last anywhere between a few seconds to hours: electricity-like shooting pain
  • triggers: touching area, spicy food, caffeine and citrous fruits.

MANAGEMENT

  • First line: Carbamazepine
  • Surgery to decompress or intentionally damage the trigeminal nerve is an option
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2
Q

Red flags to ask about

A
  • Fever, photophobia or neck stiffness (meningitis or encephalitis)
  • New neurological symptoms (haemorrhage, malignancy or stroke)
  • Visual disturbance (temporal arteritis or glaucoma)
  • Sudden onset occipital headache (subarachnoid haemorrhage)
  • Worse on coughing or straining (raised intracranial pressure)
  • Postural, worse on standing, lying or bending over (raised intracranial pressure)
  • Severe enough to wake the patient from sleep
  • Vomiting (raised intracranial pressure or carbon monoxide poisoning)
  • History of trauma (intracranial haemorrhage)
  • Pregnancy (pre-eclampsia)
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3
Q

Tension Headaches

Clinical Features

Triggers

Management

A

CLINICAL FEATURES
- mild ache across the forehead and in a band-like pattern around the head (may be due to muscle ache in the frontalis, temporalis and occipitalis muscles)

TRIGGERS

  • Stress
  • Depression
  • Alcohol
  • Skipping meals
  • Dehydration

MANAGEMENT

  • Reassurance
  • Basic analgesia
  • Relaxation techniques
  • Hot towels to local area
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4
Q

Sinusitis

Pathology

Clinical features

Management

What are you worried about?

A

PATHOLOGY
- a headache associated with viral inflammation in the ethmoidal, maxillary, frontal or sphenoidal sinuses.

CLINICAL FEATURES

  • facial pain behind the nose, forehead and eyes
  • tenderness over the effected sinuSES
  • Exacerbated by movement

MANAGEMENT

  • usually resolves within 2-3 weeks
  • Nasal irrigation with saline can be helpful
  • Prolonged symptoms can be treated with steroid nasal spray
  • Antibiotics are occasionally required.

WORRIED ABOUT

  • Frontal sinusitis as the bacteria can erode backwards to the brain
  • Refer to ENT for CT scan
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5
Q

Migraine

Types

Clinical Features

Who does it affect?

Lasting how long?

Hemiplegic

A

TYPES

  • Migraine without aura
  • Migraine with aura
  • Silent Migraine (aura without headache)
  • Hemiplegic Migraine

CLINICAL FEATURES lasting 4-72 hours

  • Pounding or throbbing in nature
  • Usually unilateral but can be bilateral
  • Discomfort with lights (photophobia)
  • Discomfort with loud noises (phonophobia)
  • With or without aura (visual changes e.g. lines or sparks in vision, blurring of vision or loss of different visual fields)
  • Nausea and vomiting

WHO DOES IT AFFECT
- Women (twice as much as men)

HEMIPLEGIC MIGRAINE

  • can mimic stroke
  • Typical migraine symptoms
  • Sudden or gradual onset
  • Hemiplegia (unilateral weakness of the limbs)
  • Ataxia
  • Changes in consciousness
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6
Q

Migraine

Triggers

A 
Stress
Bright lights
Strong smells
Certain foods (e.g. chocolate, cheese and caffeine)
Dehydration
Menstruation
Abnormal sleep patterns
Trauma
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7
Q

Migraine

Acute management

Prophylaxis

A

ACUTE MANAGEMENT
Often patients will go to a dark quiet room and sleep. Options for medical management are:

  • Paracetamol
  • Triptans (serotonin receptor agonists)
  • NSAIDs (e.g ibuprofen or naproxen)
  • Antiemetics if vomiting occurs (e.g. metoclopramide)

PROPHYLAXIS

  • Avoidance of triggers
  • Propranolol
  • Topiramate (this is teratogenic and can cause a cleft lip/palate so patients should not get pregnant)
  • Amitriptyline
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8
Q

Cluster Headaches

Clinical Features

Typical patient

A

CLINICAL FEATURES

  • Unilateral headache usually around eye
  • come in clusters of attacks (lasting 15 mins to 3 hrs) and then disappear)
  • Typical patient: 30-50 year old man who smokes
  • Red, swollen and watering eye
  • Pupil constriction (mioisis)
  • Eyelid drooping (ptosis)
  • Nasal discharge
  • Facial sweating
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9
Q

Cluster Headaches

Management

A

MANAGEMENT

  • Triptans
  • High flow 100% oxygen

PROPHYLAXIS:

  • Verapamil
  • Lithium
  • Prednisolone for 2-3 weals to break up cycle
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10
Q

Giant Cell Arteritis / Temporal Arteritis

Pathology

Associated with

A

PATHOLOGY:
-systemic vasculitis of the medium and large arteries. It typically presents with symptoms affecting the temporal arteries

ASSOCIATION
- Polymyalgia Rheumatica

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11
Q

Giant Cell Arteritis / Temporal Arteritis

Clinical Features

A
  • Severe unilateral headache typically around temple and forehead
  • Scalp tenderness my be noticed when brushing hair
  • Jaw claudication
  • Blurred or double vision
  • Irreversible painless complete sight loss can occur rapidly
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12
Q

Giant Cell Arteritis / Temporal Arteritis

Diagnosis

Other investigations

A

A definitive diagnosis is based on:

  • Clinical presentation
  • Raised ESR: usually 50 mm/hour or more
  • Temporal artery biopsy findings (finding multinucleate giant cells)

Other investigations:

  • Full blood count may show a normocytic anaemia and thrombocytosis (raised platelets)
  • Liver function tests can show a raised alkaline phosphatase
  • C reactive protein is usually raised
  • Duplex ultrasound of the temporal artery shows the hypoechoic halo sign
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13
Q

Giant Cell Arteritis / Temporal Arteritis

Management

A
  • Steroids: 40-60mg prednisolone
  • Proton pump inhibitor (e.g. omeprazole) for gastric prevention while on steroids
  • Bisphosphonates, calcium and vitamin D to prevent osteoporosis when on steroids

Once the diagnosis is confirmed they will need to continue high dose steroids (40-60mg) until the symptoms have resolved. They then need to slowly wean off the steroids. This can take several years. This is a similar process to managing polymyalgia rheumatica.

  • Aspirin 75mg daily decreases visual loss and strokes

Refer to: vascular surgeon, rheumatology, ophthalmology

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14
Q

What do you need to tell patient when they start steroids?

A

[Don’t Stop]

DON’T – Don’t stop taking steroids abruptly. There is a risk of adrenal crisis
S – Sick Day Rules (may need to double dose of steroids if they become unwell)
T – Treatment Card
O – Osteoporosis prevention with bisphosphonates and supplemental calcium and vitamin D
P – Proton pump inhibitor for gastric protection

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15
Q

Medication Over-use headache

Clinical Feature

A

CLINICAL FEATURES
- Migraine or tension-type headache seen particularly with migraine medications and analgesics

MANAGEMENT
- Withdrawal of the e.g. analgesic that usually causes an exacerbation before an improvement

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