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S2.3 Neurology > Headache > Flashcards

Headache Flashcards

1
Q

What are the different types of primary headache?

A 
Tension-type
Migraine
Medication overuse
Trigeminal autonomic cephalalgias
Trigeminal neuralgia
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2
Q

What are the symptoms/signs of a tension-type headache?

A

Most common
Mild bilateral headache often pressing or tightening, with no associated features
Unaffected by physical activity

Frequent = 11-14days/month
Chronic >15

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3
Q

What are the signs/symptoms of a migraine?

A 
Chronic/episodic
Headache
Nausea
Photophobia
Phonophobia
Functional disability
Anticipatory anxiety
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4
Q

What can trigger a migraine?

A 
Stress
Hunger
Sleep disturbance
Dehydration
Diet
Environmental stimuli
Oestrogen cycle
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5
Q

What is the sequence of events in a migraine?

A 
Premonition
Aura (33%) - neurological symptoms
Early headache
Advanced headache
Postdrome
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6
Q

What are ‘transformed migraines’?

A

Headaches that increase in frequency, often becoming daily, but with reduced migrainous symptoms
Can occur with/without medicaation
In those with medication overuse, discontinuing dramatically improves frequency

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7
Q

What difference does gender make in migraine?

A

Migraine without aura can get better in pregnancy, however migraine with aura usually does not

First migraine can occur during pregnancy, particularly with aura

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8
Q

What are the signs/symptoms of medication overuse headache?

A

Headache present 15+day/month worsening/developing while on regular medication

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9
Q

What medications are risk factors for medication overuse headaches and what frequency often causes them?

A

Triptans/ergots/opioids/combination analgaesics >10 days/month

Simple analgaesics >15 days/month

Caffeine also

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10
Q

What are the signs/symptoms of trigeminal autonomic cephalalgias?

A

Unilateral head pain (predominantly V1)
Severe, excruciating

Cranial autonomic symptoms

  • conjunctival injection
  • nasal congestion
  • eyelid oedema
  • forehead/facial sweating
  • miosis, ptosis (Horner’s syndrome)
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11
Q

What is a cluster headache? Signs/symptoms?

A 
Type of TAC
Mainly orbital, temporal pain
Strictly unilateral
Rapid onset
Duration 15m - 3hr
Rapid cessation
Migrainous symptoms often present
Episodic, circadian rhythmicity
Bouts of 1-3 months with remission periods ~1month
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12
Q

What is paroxysmal hemicrania? Signs/symptoms?

A 
Headache mainly orbital/temporal
Unilateral and rapid onset/cessation
Duration 2-30 minutes
Agitation/restless during
Prominent ipsilateral autonomic symptoms
Neck movements can precipitate (10%)
No/less circadian rhythm
Indomethacin responsive
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13
Q

What is SUNCT? Signs/symptoms?

A

Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing

Unilateral orbital, supraorbital, temporal pain
Stabbing/burning
Duration only seconds-minutes

Cutaneous triggers
- wind/cold, touch, chewing

High daily frequency (up to 200), no refractory period

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14
Q

What is trigeminal neuralgia?

Signs/symptoms?

A

Unilateral maxillary/mandibular pain (> opthalmic)
Stabbing
5-10 seconds duration

Cutaneous triggers
- wind/cold, touch, chewing

Frequency similar to SUNCT (up to 200/day), with refractory period
Autonomic features uncommon

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15
Q

How are tension-type headaches treated?

A

Aspirin/paracetamol
NSAIDs
Limit to 10days/month to avoid MOH
Preventative rarely required, but TCAs can be used (amitriptyline, dothiepin, nortriptyline)

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16
Q

How are migraines treated?

A

Abortive treatment

  • aspirin/NSAIDs
  • triptans
  • limit to 10 days/month to prevent MOH

Prophylactic

  • propranolol, candesartan
  • anti-epileptics (topiramate, valproate, gabapentin)
  • TCAs (amitriptyline, dothiepin, nortriptyline)
  • venlafaxine

More difficult in pregnancy (avoid anti-epileptics)
Combined OCP contraindicated in migraine with aura

17
Q

What are the different types of Trigeminal Autonomic Cephalalgias?

A

Cluster headache
Paroxysmal hemicrania
SUNCT/SUNA

18
Q

What is the treatment for cluster headache?

A

Acute
- subcutaneous sumatriptan/nasal zolmatriptan, 100% O2

Bout
- Occipital depomedrone

Preventative

  • verapamil
  • lithium methysergide
  • topiramate
19
Q

What are the treatments for paroxysmal hemicrania?

A

No abortive treatment
Prophylaxis with indomethacin
Alternatives include COX-II inhibitors, topiramate

20
Q

What are the treatments for SUNCT/SUNA?

A

No abortive treatment

Prophylaxis with lamotrigine, topiramate, gabapentin, carbamazepine

21
Q

What are the treatments for trigeminal neuralgia?

A

No abortive treatment
Prophylaxis with carbamazepine, oxcarbazepine
Surgical interevention - glycerol ganglion injection, steriotacticradiosurgery, decompressive surgery

22
Q

What is a secondary headache and what are risk factors/causes?

A

Headache with identifiable structural/biochemical cause

Tumour
Meningitis
Vascular disorders
Systemic infection
Head injury
Drug-induced
23
Q

What features predict sinister headache? Red flags?

A

Serious intracranial pathology unlikely in longstanding episodic headache
But, presentations like to have sinister cause include:
- associated head trauma
- first/worst
- sudden (thunderclap)
- new daily persistent
- change in pattern/type (particularly >50yo, immunosuppressed, cancer)

Focal/nonfocal neurological symptoms, abnormal neurological exam
Neck stiffness/fever

High pressure signs
Low pressure signs

Giant cell arteritis signs
- jaw claudication, visual disturbance, prominent/beaded temporal arteries

24
Q

What signs suggest high pressure in headache?

A

Worse lying down
Wakes patient
Physical exertion/valsalva precipitate
Risk factors for cerebral venous sinus thrombosis

25
Q

What signs suggest low pressure in headache?

A

Precipitated by sitting/standing up

26
Q

What features suggest a space occupying lesion and/or raised ICP?

A

Progressive headache with associated symptoms/signs

Warning features

  • worse in morning or wakes
  • worse lying flat
  • focal symptoms/signs
  • non-focal symptoms e.g. cognitive or personality change, drowsiness
  • seizures
  • visual obscurations, pulsatile tinnitus
27
Q

What are signs of intracranial hypotension?

A

Post-LP (can be spontaneous as well)
Clear postural component to headache
Develops/worsens soon after assuming upright posture, resolves shortly after lying down
Once becomes chronic, often loses postural component

28
Q

What is giant cell arteritis? what are the features, signs, symptoms, management?

A

Arteritis of large arteries
Should be considered in any patient over 50 presenting with new headache

Diffuse, persistent, severe headache
Systemically unwell
Scalp tenderness, jaw claudication, visual disturbance
Prominent, beaded, enlarged temporal arteries may be present
Elevated ESR almost universal
Raised CRP/platelet other useful markers

High dose prednisolone should be started if diagnosis likely, with temporal artery biopsy arranged

29
Q

Causes/differential diagnoses of thunderclap headache?

A 
Primary
SAH
Intracerebral haemorrhage
TIA/Stroke
Carotid/vertebral dissection
Cerebral venous sinus thrombosis
Meningitis/encephalitis
Pituitary apoplexy
Spontaneous intracranial hypotension
30
Q

Features of SAH? When to suspect and what action to take?

A

1/10 patients with thunderclap have SAH

  • 85% aneurysm
  • 50% mortality, 20% of survivors become dependent
  • rebleed risk 40% in first month

All patients who present with sudden severe headache that peaks within minutes and lasts for >1 hour

  • examination often normal
  • NEVER consider patient ‘too well’ for SAH

CT brain as early as possible
LP (must be at least 12 hours after onset)
- CT +/- LP unreliable after 2 weeks, angiography required

31
Q

Symptoms signs of meningitis and encephalitis?

A

CNS infection should be considered in any patient with headache and fever

Meningism - nausea/vomiting, photo/phonophobia, stiff neck

Encephalitis
- altered mental state/consciousness, focal symptoms/signs, seizures

Rash?

32
Q

Causes of raised ICP?

A 
Glioblastoma multiform
Cerebral abscess
Venous infarct with focal haemorrhage
Meningioma
Hydrocephalus
Papilloedema
33
Q

Management in suspected intracranial hypotension?

A

MRI brain and spine

Treatment

  • bed rest, fluids, analgaesia, caffeine
  • IV caffeine
  • epidural blood patch

S2.3 Neurology (18 decks)

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