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Hello, everyone. Um Just give me a moment is my voice audible. If anyone can hear me, can you please drop a message in the chat box? Ok, perfect. Thank you for that. And so firstly, um, welcome to the next session um conducted by you medics. We are a group of junior doctors who work across the northwest of United Kingdom, working very stress, uh trying to bring across some amount of, uh, you know, just an overview of some of the conditions that we very commonly see in the hospital, um and how to manage them when you see them essentially. So we do know for a fact that a lot of uh new joiners or people who enter the NHS um might not entirely know what are the facilities available protocols available. So we try to touch up on how this can be accessed and how they can use. So today's topic is gonna be headaches. Um It's gonna cover a few of these important topics that every junior doctor should know. Um I hope this is gonna be useful for you guys every week. We do conduct these sessions on Thursday evenings around the same time. 7 to 8 British standard time. And we're gonna start now. So, firstly, I'm gonna put up a case. Uh, we're just gonna, I'm just gonna give a few minutes for everyone to just read through and then we can discuss about what you can think this, this might be. Ok. So 42 year old boxer comes to A&E, he's been seen too and complains of an intense headache. He says that he's been having this headache since two days. It has been steadily increasing since those are his vitals. Um So what do you think this is if you guys can just drop a message in the, in the chat box? Ok. So any idea what this can be and give you another soup? Ok. Uh That's, that's, that's really nice. So we would like to do so. So rates like he says, it's all over his head onset. He says it's been there since the past two days and it has been increasing. Uh, he says it's been like a dull, intense headache, radiation wise, it's just all over the head. So he's not able to pinpoint where it is, um, associated symptoms. Just say it's difficult to, you know, um, kind of look at, look at the light and then just be touching in his head. Um, time and associated symptoms, things like that. Nothing significant. He, he describes the pain as so intense that, you know, he feels like his head is gonna burst open or like as if the thunder has struck him. So at this point of time, what do we think this can be any guesses? Ok. That's fine. So, um what we are thinking here is probably some, something along the, along the lines of uh bleed in the brain uh or being in the subdural layer or subdural hematoma to be exact. Any particular history you'd like to ask is probably the Boxer has had any recent trauma or if he's on any blood thinners, things like that. Ok. So subdural trauma, this is gonna be the first topic that I'm gonna cover now. So what is the subdural hematoma? Essentially, we have got all of these layers of, of, of the thin of skull and a subdural hematoma is basically a bleed is inside your head. It it basically occurs within the skull, but outside the actual brain tissue, as we all know, the brain has these three meningeal layers, the matter the and the clear matter that basically lies be between the skull and the brain tissue. Uh these meninges are there in place to mainly protect and cover the brain and any trauma might lead to a collection of blood within this subdue layer. So what happens in this case is blood kind of accumulates in this space expands and compresses upon the brain. If you experience a tear, a blood vessel which has caused the sth it is most likely a vein. And in this in this case, most of the times it might even continue to bleed, especially if the, the the people who are involved are like, are like in the geriatric age group on active blood thinner medication or, or, you know, people with tendencies who can bleed often, you see subdural hematomas in almost 25% of people with head injuries. And in our trauma centers, most of the times we do notice that um you know, people who come in with falls, they come in with the classical thunderclap, like headache, a severe headache, they'll describe it as the worst headache of their life. They might be, you know, um I think it's called, it's a 10 out of 10 and things like that. So risk factors wise, like we discussed about this. Now, athletes, um especially those who are in contact sports like rugby. Uh if they have any trauma to the head, most likely they will get a SDH, especially if it's kind of a huge impact in a short period of time. The geriatric population is always susceptible for almost all the medical conditions. In this case. Unfortunately, even a slight fall or, or hit on the head or blow of the blow on the head will cause such uh such bleeds, hemophiliac or blood dis blood disorders in people on blood thinners, all of them are basically susceptible for s th most of the time the bleeds are quite slow and the body is easily able to just absorb whatever blood has accumulated in the space. But sometime this collection of blood keeps accumulating and causes a lot more pressure on the brain and this can lead to a lot of complications. So, symptom wise, stress, you'll see that again. These people who come in with severe headaches, they come in sometimes confusion, slurred speech, seeing two or double vision. Um because of all the blood uh pushing the brain and putting pressure on it, you'll see things like pits, they might lose the consciousness, they might have breathing problems, they might even go into paralysis. And that uh if not treated so in the wards, when you guys, um you know, if you, when, when you guys see on like patients who have had inpatient falls when they, when especially in the g when they have falls, sometimes they might have a change in their personality, they might start becoming confused, they might, they might start having memory loss. And in those cases, there should be a suspicion or uh uh or a area of clinical, you know, kind of suspicion why you want to rule out uh any bleeds especially since um this could easily have been caused by just the fault and we draw a bleed coming to the types. There are three main types that we usually see. There's one more type um which I'll talk about. So there's an acute subacute and chronic. The acute is minor to hours, the subacute is hours, two days and the chronic takes about weeks to months. So basically, it's about duration. Uh A good prognosis is always associated with chronic ones because they have been there for quite long. And usually they're not, these patients are not actively deteriorating over long periods of time. So they expected to make a full recovery. But again, it depends also about how far or how involved the uh Sevele hemorrhage is or how much impact has it, it has all the spaces of the brain. Um So there's another type called hyperacute. Um the hyperacute is also the same. It comes comes somewhat as an acute kind of presentation where these bleeds have to be prioritized mainly because sometimes they become surgical emergencies, investigations wise in sth you look for CTS MRI S imaging of the imaging, basically to guide you on what to do. Most of the times these bleeds appear in, in lower density or you know, in, in, in CTS, they, they sometimes appear much more darker uh indicating that sometimes they might be chronic, especially if they change their densities over time. So the radiographers mainly do a series of these CTS or MRI S. So on presentation to A&E first before treating the patient, we have a clinical suspicion of maybe this can be SDH. We refer the patient to get an urgent CT, we get a CT, we do find the SDH. And then if we think that clinically this patient is gonna be stable. We don't need to, uh, you know, actively kind of treat anything or we feel that monitoring, watchful waiting might be the uh game plan here. What we do is we schedule for another scan, uh, at another interval time at usually 1 to 2 weeks after. In the meantime, we do daily neurological examinations. We try to liaise with neurosurgeons and urology to see whether the extent of the bleed needs any surgical intervention. Of course, in extensive cases where there's a lot of bleed, it has to be drained. Um In that cases, uh we usually we kind of refer them over to have craniotomies or bur holes. Um Of course, this is just done by neurosurgeons. These are widely used two techniques are a craniotomy where, you know, a portion of the skull is removed. The surgeon can then access the hematoma, remove it or bur holes where a small hole is built into the skull and a tube is inserted to drain the hematoma essentially. So, treatment wise, sometimes we also do watchful waiting in cases where there is only a minute bleed. Uh we expect the bleed to resolve or sometimes when the bleed is small and there's no neurological manifestations. We can sometimes keep the patient on very careful watchful monitoring and see whether at any point of time if, if things go. Um you know, so then we might have to immediately do an intervention. So this is the first one, I would say condition that we're talking about and we put up another case now and hoping that we find some good answers here. So a 65 year old female came to A&E with complaints of talking gibberish. She was found by her granddaughter who last saw her in the morning and she was fine and cooking breakfast. She seemed to be favoring her left side now and not using her right hand much. You can see the stats that heart rate is 89 BP is 142 by 86 respiratory is 22 stats is 88%. And what is your working diagnosis here? One cancer breast. Ok. Wonderful. So uh we've got the right answer. Um, stroke. That's right. So stroke, cerebrovascular accident, this is the most important takeaway condition that I wanted to talk about today. Mainly because headaches do present people do present with headaches and they end up being diagnosed with stroke. Um So become actually uh when taking history when tracking patients in, in a just a minute, headache shouldn't just be over, over and shouldn't be taken off consideration. We should actively try to see why a patient is complaining of headache. Um Obviously, analgesic wise, we do start with the pain ladder. Give them an six, see how it goes. But sometimes the headaches might be quite sinister in nature like having a stroke, having a space of brain lesion. So that area of painful, suspicion should always be done. So why, why am I stressing so much is mainly because I've seen many patients come in who usually present only with headache. And then on further imaging, we find out that they have actually had a stroke. So it's a very lifethreatening condition. It's the second most common cause of morbidity in the world and the leading cause of acquired disability, it happens almost one in every five minutes in the UK. Quite a lot of populations above 55 years of age, you see three types of the stroke, ischemic, he and tia, so tia transient ischemic attacks, these usually occur in 24 hours. You don't have any uh kind of lingering uh disabilities or any functional loss. Usually the symptoms come back and then resolve um sometimes the patient himself or herself, they don't even realize that they have had A B because the symptoms come and they just go away, they just put it out as weakness or temporary weakness, things like that. But if they do go in for an intervention at that point of time, even scans might not show that they don't have any evidence of, you know, um any a a any for evidence of that, they may have had APA T is also called a mini stroke. And it is also needs to be taken as seriously as a full blown stroke. So the risk factors here are hypertension, obesity, smoking, a poor diet age over 55 years and diabetes. As you can see, all of these risk factors do come up in a lot of these, a lot of conditions. So it's not something which is new. These factors combined together give a person a high instance of a stroke. So almost everyone knows first and it's the simplest and easiest tool uh to use when you suspect anyone who, you know, and you suspect anyone having a stroke. So you ask the patient to do the first kind of activities. So what do I mean by that facial? Sometimes you might be suspecting a patient of having a facial dr but you might not be able to kind of corroborate it. So you might ask them simple things, like ask them to smile, simply not being able to smile or starting to go from the corner of the mouth, just not there before or eat or eating in a manner that they have not been, you know, uh eating before in which one side has less activity. The other side is basically uh doing all the job. These are all indicators um that we look for in, you know, young age and old age mainly because they might not be expressing whatever they might be undergoing arm weakness. You can ask them to put up their hands and see whether, you know, uh they have any weakness. Most of the times, both facial droop, drooping and arm weakness. They are very common uh that you see speech difficulty is when, for example, in our case, she started talking gibberish and slurred speech. Three of those don't have to be there to be a stroke, any one of them to immediately uh you know, bring about a suspicion of stroke and immediately has to be uh seen in the hospital time is critical here. It is of the most importance. That's why they say act fast when you become fast positive because it is essential that you run against the clock and try to manage this patient as soon as possible. Ischemic versus hemorrhagic. So we talked about the three types of stroke, ischemic hemorrhagic and tia tia is a mini stroke usually resolve in 24 hours. The person might get tia s from time to time and might go unnoticed. But it needs to be treated as a stroke. We have to find out the underlying cause of the stroke. In this case. Uh There are two main classes that we usually see ischemic being the most common where you have about 70 to 85% uh suffering from ischemic strokes compared to hemorrhagic. So in ischemic, as you can see from the diagram, a blood clot basically breaks away from plaque, build up in some in in an artery, most likely the neck, the carotid artery, it goes into the brain and then it just blocks the blood flow to a complete part of the brain at this point of time, AAA huge significant part of the brain is not using its blood supply. It basically will cause a lot of uh neurological symptoms such as the facial weakness, the limb weakness, and sometimes even neurological signs and symptoms are usually elicit. Uh when you take neurological examinations, you'll see like weakness on one side of the limb. Uh and you know, decreased loss of sensation and things like that, especially in this case, in ischemic time is of the essence, mainly because um as long as the embolism is blocking the blood supply, you have irreversible damage to the brain. And basically, the recovery from it basically depends on how fast treatment has been. A hemorrhagic is also important, but sometimes hemorrhagic can be self controlled as well. Here. What happens is an aneurysm in the in the brain basically breaks open and starts bleeding, bleeding out since it's rarely seen. Uh compared to ischemic. Uh we do think that compared to ischemic hemorrhagic is slightly um you know, manageable. But again, he as you, as you can see later on in the further slide, the treatment for both is quite stark and quite different. Uh It is imperative that we actually find out what we're dealing with whether it's ischemic or hemorrhagic mainly because they are very, very important in kind of tailoring our treatment plan for both of these types of ischemic. There are two types, the thrombotic and embolic strokes. Uh like we discussed in ischemic. We do find uh, you know, embolus, thrombus, thrombotic, thrombus, a blood clot that usually occurs in all the in any of the arteries, supplying the blood to the brain. We usually seen in older people usually seen in those with ACSIS, people with diabetes, people with hyperlipidemia, sometimes it can occur suddenly and sometimes they have a slight respondence of occurring most likely in sleep in the early morning. And there are rare instances where they usually occur over a period of hours and even sometimes some days. So, and you, you have different types of strokes. So the second type of stroke is basically the embolic stroke where the blood clot basically forms somewhere else in the body and it travels through the bloodstream to the brain. Usually these embolus uh basically uh are secondary to heart diseases, heart surgeries, they kind of happen very quickly and they are caused by a certain condition as well, which uh I would like, you know, hopefully later on in the presentation, someone can uh pick on that particular condition related to the heart that might cause this embody cause of stroke, hemorrhagic. In hemorrhagic, you have two types, the intracerebral and the subarachnoid kind of uh strokes. This is a very important table of score that uh is used in some of the a across the northwest. So the s the S score is basically a score that used in the emergency room to again just like first kind of have a suspicion of stroke and act as soon as possible. So it has a score of minus two to plus five minus two minus one and zero is no suspicion of stroke. Anything above or equal to one is, is stroke or is proven as stroke unless otherwise indicated. So here has there been loss of consciousness or syncope if there's? Yes, uh it's a minus one. Has it been seizure activity? It's been minus one. Has it been acute, new, acute of, you know, asymmetric facial weakness? It's plus one, asymmetrical arm weakness. It's a plus one, asymmetric leg weakness. It's a plus one is a plus one. It's a plus one. So usually this call is done very briefly by paramedics and nursing staff and by some doctors just before we send them for imaging studies. So in stroke, a few things that we have to mainly look for is identifying the type of stroke and the etiology behind it, stroke blood. So there are the usual stroke, uh blood that we usually do which include the CBC or the complete blood count, the UN, which is the urine electrolytes. And if you suspect an inflammatory conditions leading to a stroke, the CRP as well, you'll obviously, of course, go for a lipid profile mainly because one of the leading factors causing stroke is hyperlipidemia, diabetes, things like that. So we obviously we want a lipid profile to, to be to be 100% sure we want also like A HP A1C. Uh we'd like to do uh carotid Doppler or four as well, mainly because uh kind of build up of plaques on car might lead to the scar type of hemorrhage that we were talking about earlier on. We also do an E CG. So why did we do the ECG? So we're just gonna leave this case here for a few minutes here. So again, a 72 year old gentleman pa came to A&E palpitations and dizziness he was initially seen in, allowed to rest in a day while waiting to review bloods and ECG were done after two hours, when he was seen by the doctor, he was rushed to a CT scan on suspicion of stroke as he started to become f positive in this gentleman's case. What would you think could have led to a stroke? So there's, there's a clue there which we have been talking about since quite long, the EC U was done and previously ECG as well. So anything that you think could, could have been seen or picked up by the ECG, which could have caused the stroke? Wonderful. So if you've got the right answer again, one on uh by the it is afib. So in atrial fibrillation, atrial fibrillation is actually one of the most common causes of stroke. So it causes about 30% of strokes. So as you can all see the ECG atrial fibrillation, no P waves irregular intervals, uh is atrial fibrillation leading to stroke. So what do we do in stroke treatment wise? So for ischemic and hemorrhagic, there's a clear and stark difference that we have to ensure we definitely cannot load people up with medications. Uh thinking that it might be a stroke mainly because of ischemic. As we have all seen in this, this slide is cubic. There's an embolus in his blood to break it down. But in hemorrhage it there's already a release of blood from its normal vessels. So giving them antiplatelet and anticoagulants is going to be kind of counterproductive and it's gonna even increase the chances of further bleeding and you know, even can cause death. So is is like what we usually do is thrombolysis thrombectomy. These are two options that are there in stroke, but these are very much guided by higher tertiary centers, neurology and duration of time. So within the 1st 4 to 6 hours in some centers up to 12 to 24 hours based on their facilities, they are able to give the plates for thrombolysis and basically dissolving the clot. They can even go for intervention, uh interventions like thrombectomy where they remove uh whichever clot. There is. In other cases, we usually give medical management. Uh we load the patient with aspirin in different trust. Again, this is quite different. But as a generalized overview. And according to the nice guidelines, we usually give aspirin 300 mg which is a high dose for almost two weeks in efforts of kind of breaking down the embolism or thrombus. Once we, once we confirm on imaging, that is ischemic stroke. So the main takeaway here is that there have been far too many incident where a person has been suspected of stroke and immediately started on aspirin. But it turns out that you might have been a hemorrhagic stroke and the person goes on to continue to bleed. And sometimes we go to the higher centers get operated. They do, they do have recovery. But, but all the functional loss that has caused in that period of time, uh and neurological deficits has caused sometimes irreversible. So definitely wait for a CT or MRI any patient that walks into A&E with stroke like symptoms has to immediately go for scanning first on scanning. The first scan that usually we go for is a CT angiogram or a CTA. Sometimes even going for Mr Angiogram where we study the vessels and see if there's any chance of any bleed from any vessels or any clot in the vessels. So simply put, when there's a clot, you need to dissolve it when it's when when the blood vessel itself has split and there's a different management for the the stroke. So once you have confirmed that the stroke has been caused due to a uh kind of clot, obstruction of the blood flow, you were classified as stroke and treat in that in that way. So, medical again, aspirin for about two weeks and then you will, based on your trust protocol in my trust, it's aspirin for about two weeks. And afterwards we switch over to the 75 mg and then we kind of monitor the patients. Hemorrhagic stroke is usually caused by elevated blood pressures by aneurysms in the brain which have basically torn or broken apart in these, in these cases. Um First thing to do is to manage the BP. Uh you often see people with high blood pressures in A&E as well. So the risk that it runs with a high BP is caused stroke, but there's a vent of decreasing the BP for these individuals as well. So when you're trying to decrease the BP for individuals with high BP to prevent stroke, there is also a set guidelines on how much of systolic and diastolic has to be decreased over 24 hours. Again, this varies to trust to trust, but usually what happens is around 30. She um of systolic BP needs to be corrected and large uh corrections of BP should not be attempted mainly because that can also cause other side effects and consequences. So, in prevention of stroke, especially in hemorrhagic stroke, where the blood pressures are quite high. What you would like to do first is control the BP slowly bring it down, uh manage the interfering pressures and in cases where it's quite difficult to manage. You have to do surgeries where you go for things like craniotomy, decompressive ectomy, geotactic aspiration, endoscopic aspiration, and catheter aspiration for atrial fibrillation. So, if a patient walks into the hospital with something um with an irregular heartbeat with palpitations and you see on his ECG, he has AFIB, he has a chance of having a stroke in the future. So you do a few spots to make sure that um you know how much of a score he had, you know how much of a chance he has of having a stroke. Um Usually this, the scoring is basically done and kind of advised the patient mainly because we want to start them on blood thinners. So in atrial fibrillation, we'd like to prophylactically prevent them from getting into stroke, meaning because we know that in these individuals, they will kind of get a high BP leading to uh very high chances of stroke. But again, this is done after scoring. Um this is not done for everyone. So not everyone who has atrial fibrillation, it's put on blood thinners. So the last case for today is Peter, a 21 year old has been studying continuously by FS over the past two days. He has started developing a strange headache that feels like it's pulsing. He also seemed to have had it in the past and he felt as if he knew that it was gonna come. They tried six, but it does not seem to be working. This is quite a common presentation that you usually see. So, what do you think the working diagnosis is, um, what is this phenomenon called? Ok. That's, that's great. Uh, good job. I think you have been spot on to the entire presentation. Um, yes, it is migraine. And the phenomenon. What do you think is the name of the, is the, the, the fact that, um he feels that he knows that the, the head coming about him. Yeah. Yeah. Yeah, you are spot on again. Once again. Wonderful, wonderful job. You, you, you've got everything. Uh one point, you've got everything correct. It is a uh this phenomenon is called, so types of headaches. There are many different types of headaches. Just the ones that we talked about are not the only causes of, of headache. There might be a lot more causes, the more the more pressing ones, the ones that need uh immediate interventions to cause the stroke. And of course, the um sub hematoma uh things that are also quite important that we look for is uh conditions like space occupying regions or space occupying tumors and glaucoma. All of these do cause headaches. So, in this particular uh individual, he's been having a migraine and he's been having the phenomenal aura. So migraines uh are basically three types. You have migraines with auras, migraine aura without headaches and also migraines with auras. So basically three different types. Uh Some of them usually have like flashing lights but no headache. Some of them will just come about and go and you just have a mild headache and some of them will proceed with a lot of aura symptoms. So, aura symptoms are usually also called warning signs. They usually see zigzag lines. They'll find they'll feel that there's numbness or tingling, feel dizzy, they'll feel some amount of difficulty in speaking and they will also have that feeling better. A headache is about to come. Um So in migraines, they usually last between two hours, three days, you start feeling very tired, sometimes it may last even for a week. Um As you can see here, pulsating sensation, very natural location, about moderate to severe bone density, usually accompanied by nausea and vomiting, sensitive to light and sound. So they prefer, you know, not being around these, these high uh stimulating effects. Whereas tension headache usually presents like a band like headache. It is basically around the head, mild to moderate pain, usually stimulated by stress. Um It usually lasts anywhere between 30 minutes to seven days. I know that here, it says the migraine lasts only for 4 to 72 hours, but sometimes they do last uh from for about two hours to three days and then they come many times throughout the week. So the the the patient will actually come in with, with symptoms like I've been, I've been having headaches in the past one week and it must, um, kind of be casually, uh, take the history, should be carefully taken because migraine headaches can occur and last for quite a long time, tension headaches. Uh, you usually don't see any nausea or vomiting and they are bilateral location. So, treatment wise in migraines, you use painkillers like ibuprofen, paracetamol and we go up the grading of the pain scale even for them. But with migraines, you have specific medications, you don't actually go up completely the pain ladder that we use. We go to some medications called triptans. Um, of course, we also give pain medi uh medications to prevent sickness because again, with headaches, there's a lot of sickness involved or feeling of being sick involved. So, and the sickness is also described some of the triggers that you usually see for migraines are uh anxiousness, depression, tiredness, not eating properly, skipping meals, sometimes too much caffeine and uh you know, uh for some before their period starts. So management wise, migraine and tension headaches, uh migraines, usually we give painkillers. Triptans advised lifestyle changes, but tension headaches usually stress adequate rest. Uh I mean avoidance of stress, adequate rest and over the counter painkillers should work in some acute cases. You can also provide triptans with naproxen for migraine. And essentially, these are the uh few conditions that I wanted to talk about and headache today. These are my references. I'm just gonna drop the link to next week's class, uh next week's teaching. Noting, please do register first and provide feedback. We always work uh through the feedback and try to see what all we can improve and what all we can kind of share with you all because it is only about half an hour to one hour sessions. We try to cover those which are really, really, really acute and those that are commonly seen. Um So, so that these can be kind of highlighted and they, they can be easily managed by junior doctors once, uh, basically start work. So I hope you have enjoyed today's session and just will share the feedback with you guys and, and we'll see you next week.