Med Year 3 > headaches > Flashcards

headaches Flashcards

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1
Q

what are primary headaches

A

disorders where there is no known secondary underlying pathology eg migraine

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2
Q

what are secondary headaches

A

underlying disease that is causing the headaches

  • SOL
  • Intracranial hypertension
  • Vasculitis
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3
Q

what would you not want to miss on an examination?

A
  • swollen optic discs
  • papilloedema = raised ICL requiring emergency brain imaging
  • visual field test: peripheral field loss and enlarged blind sports combined with headaches
  • test eye movements, failure to abduct/adduct eye = nerve palsy
  • abnormal plantar test
  • ataxia and headache = lesion in posterior fossa of the brain
  • white plaque on tongue = oral hairy leukoplakia
  • purpuric rash, non-blancing = meningococcal septeicaemia (medical emergency, requires emergency AB)
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4
Q

what does a blanching rash all over suggest

A

livedo reticularis = antiphospholid AB syndrome or lupus

  • at risk of venous clot in sinuses in brain
  • also seen in vasculitis
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5
Q

what investigations could you do for headaches if neurological exam requires it?

A

CT scan, MRI, CSF monometer (measure ICP when performing LP), spinal fluid, neutrophils in CSF, biopsy (uncommon in headaches)

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6
Q

what do the colours of CSF mean?

A

clear = normal

yellow fluid = xanthochromic fluid = breakdown of blood in fluid = subarachnoid haemorrhage

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7
Q

what could biopsies indicate

A

high ESR, and inflammatory infiltrates in histology; common in GCA

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8
Q

what are the emergency symptoms of a headache

A 
thunderclap onset
acute onset with papilloedema 
acute onset with neurological signs
head trauma / injury
photophobia and nuchal rigidty 
reduced consciousness 
acute red eye / acute angle closure glaucoma 
new onset headache in 3rd trimester pregnancy
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9
Q

what is giant cell arteritis

A

inflammation of the lining of your arteries, most often in your head

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10
Q

what are the symptoms of GCA

A

jaw claudication, visual disturbance, temporal arterty is prominent and tender, diminished pulse, other cranial nerve palsies, limb claudication

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11
Q

what is the 2 week suspected cancer referral

A

-headache with features of raised ICP: wakes from sleep, valsalva manoeuvres, papilloedema, headache present upon waking and easing once up, tinnitus, transient visual loss when changing posture, vomiting, seizures

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12
Q

red flags for secondary headaches

A
  • undifferentiated headache of recent origin and present for >8 weeks
  • recurrent headaches triggered by exertion
  • orthostatic headache (occurs in upright position, suggesting low CSF pressure)
  • new onset headache in those >50, immunosuppressed/HIV
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13
Q

what is the type of pain in a migraine

A

throbbing pain lasting 4 hours -3 days, mostly unilateral, aggravated by physical activity

can be chronic or episodic

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14
Q

what are the associated symptoms with a migraine?

A

sensitivity to light, nausea, aura

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15
Q

what is aura

A

neurological feature preceding headache, may affect one eye only, sensory symptoms: unilateral parasthesia and numbness affecting hand and up the arm, spreading to face, lips and tongue.

visual symptoms = flickering lights, spots etc

20-30% suffer with it

lasts 5-60 minutes

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16
Q

what is a cluster headache

A
  • more common in men
  • most severe pain ever
  • unilateral - sharp, boring, burning, throbbing or tightening side locked
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17
Q

what are the associated symptoms of cluster headaches

A
  • on the same side as the headache:
  • red or water eye
  • nasal congestion or runny nose
  • swollen eyelid
  • forehead and facial sweating
  • constricted pupil/drooping eyelid
  • restlessness
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18
Q

how do you manage cluster headaches

A

12-15L O2, using non re-breathe mask
subcutaneous or nasal triptans acutely

prophylactic: verapamil, lithiuum, prednisolone (steroids but max 2 weeks)

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19
Q

how long does a cluster headache last and how often does it occur

A

15-180 minutes

episodic: 1 every other day to 8 per day, with remission >1 month
chronic: continous remission <1 month in a 12 month period

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20
Q

what is a tension-type headache

A

band-like ache, mostly featureless, can have mild photo or photobia but no nausea

not aggravated by ADL

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21
Q

how long do tension headaches last

A

30 mins - continous, >15 days per month for more than 3 months = chronic

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22
Q

what is a menstrual headache

A

migraine occuring between 2 days before and 3 days after first day of their period, for 2/3 consecutive cycles

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23
Q

what is a medication overuse headache

A

headaches have developed or worsened while they were taking triptans or opiods >10 days a month

or

paracetamol or NSAIDs >15 days a month

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24
Q

treatment of a tension headache?

A
  • aspirin, paracetamol etc, no opioids

prophylactic: 10 sessions of acupuncture over 5-8 weeks

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25
acute treatment of a migraine?
oral triptan, NSAID, 900mg aspirin (one of them, if not responding, combine NSAID and triptan for 1 dose) anti-emetic in addition (bc migarines can cause gastric stasis leading to nausea) eg domperidone if ineffective: non-oral metoclopramide, non-oral NSAID or triptan
26
prophylactic treatment of a migraine?
topiramate or propanolol amitryptilline (blocks action of seretonin which is a vasoconstrictor) riboflavin, 400mg OD, may be effective
27
what meds are contraindicated in migraine with aura?
the oral CP
28
if all other treatment is ineffective, what do you give for menstrual related migraine?
frovatriptan, 2.5mg BD or zolmitriptan on days migraine is expected
29
migraine in pregnancy treatment?
paracetamol, triptan or NSAID
30
how do you manage a medication overuse headache
stop taking all overused meds abruptly for 4-8 weeks , prophylactic treatment for underlying disorder
31
what is the pathology of migraines
vascular changes (aura - intracerebral vasoconstrictoin and hence headache due to reactive vasodilation) arterial vasoconstriction induced by ergotamine = relieves migraine headaches
32
what triggers migraine attacks
``` relaxing after stress menstruation bc oestrogen decline jet lag oral cp (oestrogen in pills makes blood easier to clot) cheese - contains tyramine flickering lights ```
33
how do triptans work
strong agonist actions at seretonin 5-HT receptor, in arterial smooth muscle causing vasoconstriction acts on 5-HT receptors in CNS
34
what is the second line treatment for migraines
ACE-I and ARBs or CCB bc calcium causes vasoconstriction
35
what is meningitis and what is the main triad of symptoms
medical emergency; inflammation of the meninges (dura, arachnoid and pia mater) headache, neck stiffness and photophobia
36
causes of meningitis
irritation due to infection, blood or trauma viral infection more common but bacterial - higher mortality
37
RF for meningitis
extremes of age - babies and young adults more commonly get bacterial meningitis living in close proximity immunosuppression eg asplenia absence of vaccination history impaired blood brain barrier
38
pathophys of bacterial meningitis
transmitted via droplet spread but requires frequent close contact can spread from otitis media or URT in susceptible people entry of bacteria into the CSF meningococcal disease = neisseria mengitides
39
differential diagnoses for meningitis?
encephalitis (HSV causes this) - but causes confusion which meningitis doesn't subarachnoid haemorrhage brain malignancy sepsis from any source
40
associated symptoms of meningitis?
fever, non-blanching rash, kernig's sign - stiffness of hamstring (cannot straighten leg when hip is flexed), brudzinki's sign (neck stiffness causes patient hips and knees to flex when knee is flexed)
41
how do you examine for meningitis?
``` look for signs and symptoms fundoscopy for papillodema glass test neuro exam cognitive assessment ```
42
if a patient comes in to PRIMARY care with a non-blanching rash what do you do
give benzylpenicillin 1.2g IV before admitting
43
what investigations do you do for meningitis?
``` CSF sample blood cultures for organism serology for viruses throat swab for bacteria and virus urine pneumococcal antigen CT or MRI of brain to rule out signs of intracranial pathology ```
44
what organisms cause meningitis
meningococcus, pneumococcus, haemophilus influenzae, listeria monocytogenes also HSV etc
45
how do you analyse CSF for meningitis?
high protein and low glc: in bacterial (protein leaks out of damaged BBB and bacteria eat glc) WCC high, no RBC should be present will be turbid
46
how do you first manage bacterial meningitis (that is non septic)
if raised ICP = call ICU LP prior to antibiotics if possible antibiotics: ceftriazone: 2g/12h, and add amoxicillin 2g/4h if >60 or immunocompromised give dexamethasone 10mg/6h IV if meningism features
47
what is the prophylactic treatment for bacteria meningitis
give people in close contant ciprofloxacin 500mg 1 dose
48
how do you treat viral meningitis
supportive management only if viral encephalitis suspected, give IV acoclovir
49
what are the types of intracranial SOLs
tumours; benign or malignant, primary or secondary infection: presenting with brain abscess, subdural empyema, granuloma, parasitic vascular: extradural, subdural, arachnoid and parenchymal haemorrhages hydrocephalus
50
what causes hydrocephalus
non-communicating or obstructive eg tumours, cycts, intraventricular haemorrhage communicating: meningitis or SAH overproduction: choroid plexus papilloma
51
what are the symptoms of a primary brain tumour
raised ICP leads to: - headache worse in morning - vomiting - blurring of vision - deterioration of conscious level - hypertension - bradycardia also: symptoms of neurological defecits and hormonal effects, and fatigue
52
what are the symtpoms associated with the frontal lobe
weakness, dysphagia, personality changes and dementia
53
what are the symptoms associated with the parietal lobe
sensory symptoms, dressing apraxia, visual field defects
54
what are the symptoms associated with the temporal and occipital lobes
dysphasia, visual field defects
55
how does ICP affect the posterior fossa
dysmetria, in-coordination, gait ataxia, cranial nerve palsies, tremors
56
how do you diagnose a brain tumour
CT, MRI, bloods, neuro exam and CSF
57
what is a glioma
commonest primary tumour, grade 1-4 rapidly life-threatening if grade 4 management is surgery, steroids, radio and chemo, symptomatic treatment
58
what is a meningioma
benign tumour of arachnoid cap cells treatment is surgical excision cause: trauma, radiation, oncogenic virus and hormones but rest still unclear
59
what is a vestibular schwannoma
benign tumour arising from nerve sheath of vestibular nerves very slow growing presents with ipsilateral hearing problems and tinnitius affects 5,7th and lower CN treatment - surgical excision if feasible otherwise radiosurgery
60
what is a subdural haematoma
bleeding from veins so haematoma in between dura and arachnoid = only gradually raises the ICP so delay between injury and presentation = even upto 9 months
61
signs and symptoms of SDH
fluctuating levels of consciousness, slow, sleepiness, headache, personality change and unsteadiness seziures, localising neuro symptoms eg unequal pupils
62
what are the differentials
stroke, dementia, CNS masses
63
imaging of a SDH
crescent-shaped but inside the skull on MRI or CT
64
management of a SDH
reverse clotting abnormalities, larger ones>10mm or midline shift need craniotomy or burr hole washout
65
what is an extradural haemotoma
collection of blood in potential space between skull and dura mater
66
what are the causes of an extradural haematoma
traumatic skull fracture | laceration of the middle menigneal artery
67
how does an EDH present
lucid interval (detiororating consciousness after any head injury that intially presented no LOC) severe headahce, vomiting, confusion and seizures follow brisk reflexes if bleeding continues, ipsilateral pupil dilates, coma etc
68
what are the tests for an EDH
CT (lens-shaped), broken skull may show up on x-ray
69
managing EDH
clot evacuation and ligation of BV
70
how to measure ICP
external ventricular drain with strain-gauge pressure transducer fibre-optic intra-parenchymal transducer airpouch balloon
71
general routine measures to control ICP
-head up tilt, 30-45 degrees keep neck straight and avoid tight ETT taps avoid hypotension = use cerebral vaspressors maintain adequate sedation maintain euvolaemia (proper amount of blood in body) to reduce cerebral oedema maintain normal CO2
72
how do you manage an acute rise in ICP
``` heavy sedation CSF drainage osmotic therapy hyperventilation barbiturate therapy decompressice craniectomy ```
73
what is osmotic therapy
``` mannitol - osmotic diuretic reduces ICP by reducing brain volume; draws free water out of tissue into circulation so dehydrates brain parenchyma usual bolus dose 100ml effects are: 2-60 mins; last 4-24 hours may be rebound increase in ICP ```
74
what are barbiturates
phenobarbitone, thiopentone reduce brain metabolism and cerebral blood flow - lowers ICP
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