Neuro 12. Headache (Hb)

Front 1

7 Red Flags?

Back 1

• Sudden-onset headache

• Worsening headache

• Headache with cancer, HIV, systemic illness(e.g. fever, meningism, rash)

• Focal symptoms + signs

• Papilloedema

• Cough, exertion or Valsalva-triggered headache

• Headache during pregnancy/post-partum

Front 2

Another red flag

what is a thunderclap headache?

Back 2

Sudden onset of severe headache

a severe headache that takes seconds to minutes to reach maximum intensity

Front 3

What is the most common caue of headace?

Back 3

Tension

Front 4

Possible causes of acute single episode of headaches?

Back 4

+ meningism = meningitis, encephalitis, SAH

head Injury

Venous sinus thrombosis

Sinusitis

Tropical illness

Low pressure headache

Acute Glaucoma

Front 5

If the headache is acute, severe, felt over most of the headand accompanied by neck stiff ness (≈ meningeal irritation)

what must you exlude and include their individual presenting symptoms

Back 5

meningitis: fever, photophobia, stiff neck, purpuric rash, coma

Encephalitis: fever, odd behaviour, fits, or consciousness (decrease)

SAH: sudden-onset, ‘worst ever’ headache, oftenoccipital, stiff neck, focal signs, consciousness

Front 6

How should you instantly manage episodes of acute single episode with meningim?

Back 6

Admit urgently for CT head

if -ve = LP look for signs of infectionor blood products in the CSF

Front 7

Where where a head injury headache be felt?

Back 7

Headache is common at the site of trauma but may be more generalized.

Front 8

How long does a head injury headache last?

Back 8

It lasts ~2wks; often resistant to analgesia.

Front 9

With head injury when/why should do a CT?

Back 9

To exclude subduralor extradural haemorrhage if drowsiness ± lucid interval, or focal signs

Front 10

How would venous sinus thrombosis present?

Back 10

Subacute or sudden headache, papilloedema.

Front 11

How does sinusitis present?

Back 11

causes dull, constant ache over frontal or maxillary sinuses, with tenderness± postnasal drip

Common with Coryza

Front 12

When is sinusitis pain worse?

Back 12

On bending over

Front 13

Where is Ethmoid or spenoid sinus pain felt

Back 13

Deep in the midline at the root of the nose

Front 14

how long does sinusitis last?

Back 14

1-2 weeks

Front 15

Things to related to tropical illness as a cause??

Back 15

travel history, flu like illness, typhus

Front 16

What can be the case of a low pressure headache?

Back 16

CSF leak - post LP or skull fracture

Front 17

Acute Glaucoma typically presents in whom and what kind of headache is it?

Back 17

Typically elderly, long-sighted people.

Constant, aching paindevelops rapidly around one eye, radiating to the forehead.

Front 18

What symptoms are associated with acute glaucoma?

Back 18

Markedlyreduced vision,

visual haloes,

nausea/vomiting

Front 19

What signs are associated with acute glaucoma?

Back 19

Red, congested eye;

cloudy cornea;

dilated, non-responsive pupil, may be oval; decrease acuity.

Front 20

What may trigger an acute glaucoma attack?

Back 20

dilating eye-drops, emotional upset or sitting in the dark, egthe cinema.

Front 21

Management of acute glaucoma?

Back 21

Seek expert help at once.

If delay in treatment of >1h is likely,start acetazolamide 500mg IV over several minutes.

Front 22

Causes of recurrent acute attacks?

Back 22

Migraine

Cluster headache

Trigeminal Neuralgia

recurrent (Mollaret's meningitis

Front 23

Migraine symptoms?

Back 23

•Visual or other aura lasting 15–30min followedwithin 1h by unilateral, throbbing headache.

•Isolated aura with no headache;

•Episodic severe headaches without aura, often premenstrual, usually unilateral, withnausea, vomiting ± photophobia/phono phobia (‘common migraine’).

There may beallodynia—all stimuli produce pain

Front 24

2 associations of Migraine?

Back 24

Obesity

patent foramen ovale

Front 25

What about prodrome?

Back 25

Precedes headache by hours/days

yawning, craving, mood/sleep change

Front 26

Different types of aura?

Back 26

Visual

Somatosensory

Motor

Speech

Front 27

Visual Aura examples?

Back 27

chaoticcascading, distorting, ‘melting’ and jumbling of lines, dots, or zigzags, scotomata orhemianopia;

Front 28

Samatosensory examples?

Back 28

paraesthesiae spreading from fi ngers to face

Front 29

Motor examples?

Back 29

dysarthria and ataxia (basilar migraine), ophthalmoplegia,

hemiparesis

Front 30

Speech aura examples?

Back 30

(8% of auras) dysphasia or paraphasia, eg phoneme substitution

Front 31

What is the criteria if there is no aura?

Back 31

≥5 headaches lasting 4–72h + nausea/vomiting (or photo/phonophobia)+ any 2 of:

• Unilateral

• Pulsating

Impairs (or worsened by) routine activity.

Front 32

What percentage are triggers seen in and what are they?

Back 32

50%

CHOCOLATE

Chocolate

Hangovers

Orgasms

Cheese

Oral contraceptives

Lie-ins

Alcohol

Tumult

Exercise

Front 33

Migraine DDx?

Back 33

Cluster or tension headache, cervical spondylosis, (increased) BP, intracranialpathology, sinusitis/otitis media, caries. TIAS may mimic migraine aura.

Front 34

Migraine Rx

Back 34

NSAIDS

Triptans (Rizatriptan, sumatriptan)

Cafergot (Ergotamine)

Front 35

When are triptans contraindicated?

Back 35

IHD

coronary spasm

Uncontrolled Incrased BP

recent lithium,

SSRIS,

ergot use

Front 36

Triptans SE?

Back 36

arrhythmias or angina ± MI

Front 37

Dangers of ergotamine?

Back 37

Gangrene

Vascular damage

Front 38

CI ergotamine?

Back 38

the pill

PVD

IHD

Pregnancy/breastfeeding

Hemiplegic migraine

Raynaud's

liver/renal impairment

BP increase

Front 39

What is last resort in chronic migraine?

Back 39

Botutim tocin type A injections

12 weekly

Front 40

what are triptans?

Back 40

5HT1B/1D agonists, constricting cranial arteries. They also inhibit release of substanceP, and pro-infl ammatory neuropeptides, blocking transmission from the trigeminal nerveto 2nd-order neurons in the trigeminal nucleus caudalis, hence use in any process that activatestrigeminal fibres, including migraine, cluster headache and subarachnoid haemorrhage.

Front 41

Non-pharmacological therapies?

Back 41

Warm/cold packs to the head, or rebreathinginto paper bag (increase PaCO2) may help abort attacks

Spinal manipulation, riboflavin

magnesium

Front 42

1st line Prevention Rx and when?

Back 42

frequency 2 or more a month or not responding to drugs—

Propranolol

amitriptyline (SE: drowsiness, drymouth, vision),

topiramate 2 (SE: memory),

Ca2+ channel blockers.

Front 43

2nd line

Back 43

Valproate,

pizotifen (effective, but unacceptable weight gain in some),

gabapentin,

pregabalin,

ACE-i,

NSAIDS

Front 44

When should you try other drugs

Back 44

if after 3 months one doesnt work

Front 45

What is migraine?

Back 45

a primary brain disorder resulting from altered modulationof normal sensory stimuli and trigeminal nerve dysfunction43 is replacing theold idea that vascular events are primary (constriction during aura, with dilatationcausing pain).

Front 46

What is the caue of cluster headache thought ot be?

Back 46

may be superfi cial temporal artery smooth muscle hyperreactivityto 5HT.

Front 47

The presentation of cluster headache?

Back 47

Rapid-onset of excruciating pain around one eye that may becomewatery and bloodshot with lid swelling, lacrimation, facial flushing, rhinorrhoea,miosis ± ptosis (20% of attacks). Pain is strictly unilateral and almost always affectsthe same side.

Front 48

When do cluster headaches commonly happen an how long do they last, and how long does the cluster last?

Back 48

lasts 15-160mins

occurs once or twice a day

clusters last 4- 12 weeks, followed by pain-free periods of monthsor even 1–2yrs

Front 49

Cluster headache, Rx acute attack?

Back 49

100% O2 for ~15min via non-rebreathable mask (not if COPD

sumatriptan or zolmitriptan at onset

Front 50

Presentation of trigeminal neuralgia?

Back 50

Paroxysms of intense, stabbing pain, lasting seconds, in the trigeminalnerve distribution. unilateral, typically affecting mandibular or maxillarydiv isions.

face screws up with pain (hence tic doloureux)

Front 51

Triggers of trigeminal neuralgia?

Back 51

Washingaffected area,

shaving,

eating,

talking,

dental prostheses

Front 52

Typical patient

Back 52

Male

>50

Front 53

Secondary causes of TN?

Back 53

Compression of the trigeminalroot by- anomalous or aneurysmal intracranial vessels

tumour,

chronicmeningeal inflammation,

MS,

zoster,

skull base malformation (eg Chiari)

Front 54

In TN is an MRi necessary?

Back 54

Yes to exclude secondary causes

Front 55

Rx TN?

Back 55

Carba mazepine

lamotrigine

Phenytoin

Gabapentin

Front 56

Surgical option

Back 56

Micro vascular decompression?

Front 57

When to suspect Recurrent Mollaret's meningitis?

Back 57

Suspect if fever/meningism with each headache.Send CSF for herpes simplex PCR (HSV2).

Is there access to subarachnoid spaces viaa skull fracture, or a recurring cause of aseptic meningitis (SLE, Behçet’s, sarcoid)?

Front 58

Cause of headaches of subacute onset?

Back 58

Giant cell arteritis

Front 59

When you should try to exclude GCA?

Back 59

>50yrs old with a throbbing headache that haslasted a few weeks

Front 60

presentation of GCA?

Back 60

Tender, thickened, pulseless temporal arteries; jaw claudication (due to ischaemia pathognominic)

visual symptoms - blindness, diplopia

ESR >40mm/h.

Front 61

How to diagnose GCA?

Back 61

Biopsy of 1cm

Front 62

GCA Rx?

Back 62

Prompt diagnosis and steroids avoid blindness.

Front 63

3 causes of chronic headache?

Back 63

Tension headache

Raised ICP

Medication overuse (analgesic rebound) headache

Front 64

When to suspect tension headache?

Back 64

bilateral, non-pulsatile headache ± scalpmuscle tenderness

'band-like headache'

without vomiting or sensitivity to head movement

Front 65

Rx Tension HeadacheS?

Back 65

Stress relief, eg massage or antidepressants (amitryptyline), may be helpful

Front 66

Presentation or raised OCP?

Back 66

worse on waking, lying, bending forward,or coughing

Also vomiting,

papilloedema,

seizures,

false localizing signs,

oddbehaviour.

Front 67

Common causes of analgesis rebound headache?

Back 67

mixed analgesics(paracetamol + codeine/opiates),

ergotamine

triptans

Front 68

Rx analgesic rebound headaches?

Back 68

Analgesia must bewithdrawn—aspirin or naproxen may mollify the rebound headache

Front 69

what should a headache examination include?

Back 69

Full general exam inc:

-ocular - acuity, tenderness, strabismus

-teeth and scalp

-percussion over frontal and maxillary sinuses

Full neurological examination

Front 70

Headache due to IC haemorrhage presenetation?

Back 70

instantaneous

sever pain spreding over vertex to occiput - sudden blow to the back of the head

may drop to knees or loose consciousness

vomiting

flocal neurological signs

Front 71

Non neurological caues of headache?

Back 71

Sinuses - well localised, worse in morning, affe4cted by posture

Ocular - refraction errors results in muscle contraction hedaches - resolves with glasses

acute glatucome = + misting of vision, haloes

Dental disease

Front 72

A cluster headache is the most common form of what?

Back 72

Trigeminal Autonomic Cephalagia

combination of facial pain and autonomic dysfunction

Front 73

Other trigeminal autonomic cephalagias

Back 73

Hemicrania Continua

Parozysmal Hemicrania

Front 74

Hemicrania continua?

Back 74

unilateral moderately sever facial pain with exacerbations and tearing and partial horner's

Rx - Indometacin

Front 75

Paroxysmal hemicrania?

Back 75

Same as hemicrania but alast 2-45 mins multiple times a day

Rx - indometacin

Front 76

Short-lasting Unilateral Neuralgiform pain with conjunctival injection and tearing?

Back 76

secs to mins

no response to indometacin

some response to lamotrigine