I have a bad headache

CNS Trauma

100

What common populations suffer from subdural haematomas?

elderly 

alcoholics

200

Types of traumatic cerebral haemorrhage syndromes and the blood vessels that tear

• Intracerebral Haematoma - vessels in brain parenchyma
• Subarachnoid Haemorrhage - vessels adjacent to subarachnoid space
• Subdural Haemorrhage - veins crossing the subdural space 
• Extradural Haemorrhage - vessels in skull

300

Clinical features of RICP

• Vomiting - from movement of medulla, stim. of vomiting centres  
• Headache - stim. of pain-sensitive nerve endings (from stretched BVs)
• Papilloedema - compression of veins around CNII, increased CSF pressure in optic nerve sheath  
• Advanced stages: Cushing's triad: bradycardia, HTN w widened pulse pressure, Irregular breathing (Cheyne-Stokes breathing)

400

What are the 4 CNS pathological responses to injury? Explain the mechanism

1. Neuronal Chromatolysis - neuron body swells from neurofilament accumulation (GFAP) → Nissl substance migrates → axon re-growth post. severing
2. Phagocytosis - via microglial cells, can cause foam cells if vacuolated by the accumulated lipid from dead cells
3. Gliosis - astrocytes activate & proliferate to protect neurons metabolically & fill damaged areas from phagocytes → glial scaring
4. Cerebral oedema - due to BBB breakdown + around tumours

500

Define an arteriovenous malformation, explain the histopathology and clinical manifestation

abnormal, congenital arteriovenous connections which are prone to bleeding (abnormal blood vessel clusters surrounded by gliotic brain tissue - blood quickly bypasses capillaries)

Histopathology:

• abnormal blood vessel clusters surrounded by gliotic brain tissue
• iron-containing haemosiderin pigment within gliosis = evidece of previous bleeding

Clinical manifestations 

• epilepsy 
• focal neurological signs 
• major problem: life threatening intracranial haemorrhage = from the fragile blood vessels

Pharmacotherapy headache

100

5x triggers of migraines

• Hormonal changes (menstruation) --> drop in oestrogen (↑ sensitivity of pain signals & BV changes)  
• OCP, HRT
• Bright or flickering lights 
• Anxiety, stress 
• Foods containing tyramine (e.g. some cheese) 
• Caffeine or chocolate 
• Dehydration, hypoglycaemia, certain smells 

200

What most be considered when prescribing for females with migraines with aura 

dont use cocp as increased risk of ischaemic stroke

300

Drugs used in acute treatment of migraines

Drugs used in the Acute treatment of Migranes

• triptans 
• nsaids 
• paracetamol 
• antiemetics

400

MOA of monoclonal antibodies used in prophylactic treatment of migraine and how they are taken

fremanezumab

• Selectively binds to CGRP = inhibiting it's ability to stimulate GCRP receptors = inhibits activation of trigeminal system 
• Administered by subcutaneous injection monthly or 3 monthly   

atogepant 

• Competitive antagonists of calcitonin gene-related peptide (CGRP) receptors = block the action & effect of CGRP = ↓ trigeminal system activation & ↓ pain signalling 
• Taken orally daily in patients with >4days/mo migranes 

500

Explain the main pathophysiological contributor to the occurence of migraine 

• Neuropeptide: Calcitonin gene-related peptide (CGRP) = involved in the dilation of intercranial blood vessels (throbbing), release of PGs & pain signalling (stimulation of serotonergic receptor subtypes of 5HT1 can block the release of CGRP to relieve symptoms) 
• + some serotergenic receptor subtypes e.g. 5HT1C

Clinical approach headache

100

Features of papilloedema 

• Prominent optic disc with blurred margins 
• Engorgement of vessels 
• Kinked vessels 

200

What is RCVS

• Recurrent thunderclap headaches that recur frequently over 2-3 month period 
• Can be triggered by drugs & exercise (sexual intercourse) 
• More common in Males
• Neuroimaging: smooth tapered vessels with focally dilated segments 

300

Phases of a migraine attack

1. interictal phase
2. prodrome/premonitory 
3. aura 
4. headache 
5. postdrome

400

Investigations for a thunderclap headache

• CTB/CTA 
• LP - 12-24hrs after presentation (takes a while for the blood from SAH to track down into the SpC) --> xanthochromia (coloured supernat) = SAH
• MRI/MRA/MRV
• Cerebral angiography 

CNS Tumours

100

MC primary brain tumour 

glioma (MC > glioblastoma > grade IV astrocytoma) 

200

Main mutation present in astrocytomas 

Isocitrate dehydrogenase-1 (IDH-1) mutation (GOF mutation)

300

MC primary brain tumour of childhood and most common location

Pilocytic astrocytoma 

Cerebellum

400

Clinical features of neurofibromatosis 1 (4+)

Common: 

• Neurofibromas = benign tumous of peripheral nerves = multiple polypoid skin nodules 
• Café au lait spots = pigmented skin lesions 

Less common: 

• Hamartomas of the iris (Lisch nodules) 
• Optic nerve gliomas 
• Bone abnormalitis 
• Risk of neruofibrosarcoma (malignant nerve tumours) 

500

Most common sites of metastasis to the Brain  

• Lung 
• Breast 
• Skin (melanoma) 

Metastasis are more common than primary brain tumours 

Random

100

MC complication of colloid cysts 

blockage of CSF flow through the foramen of monro = hydrocephalus

200

Criteria for a tension headache

• Headache lasting 30min-7days 
• With at least 2 of the following:
  • Bilateral location
  • Pressing/tightening (non-pulsating) quality
  • Mild-moderate intensity 
  • Not aggravated by routine physical activitiy (e.g. walking, stairs) 
• Both of the following: 
  • No N+V (anorexia may occur) 
  • No more than 1: photophobia or phonophobia 
• Worse by the end of the day 
• Not attributed to another disorder 

300

How does the tempo and rate of progression of a headache provide a clue to the cause?

• Sudden = Vascular 
• Seconds-minutes-hours = Inflammation, endocrine, iatrogenic 
• Days-weeks = malignant tumours 
• Months-years = benign tumours, degeneration, inherited 

400

Clinical presentation of tuberous sclerosis

• Epilepsy 
• Mental retardation 
• Renal cell carcinoma
• Skin manifestations; Angiofibromas, Retinal Hamartomas
• Benign tumours: Rhabdomyomas, Angiomyolipomas, Tubers, Candle wax drippings