10-21 Headaches Flashcards
1. To differentiate life-threatening HAs from non-life-threatening HAs. 2. To dx common types of 1° HA, including migraine, tension-type, and cluster HA 3. To recognize some of the less common entities presenting with head and facial pain
primary vs. secondary HA
1°: head pain syndrome occurring w/o cranial or systemic pathology (e.g. migrant, tension-type, cluster, others)
2°: occurs in temporal association w/ cranial, extracranial pathology (infx, hemorrhage, incr ICP, tumor, etc.)
**pts can have both au même temp
Red flags: mnemonic
SNOOPER isn’t PC:
S - Systemic symptoms (fever, wt loss) or Secondary risk factors (cancer, HIV)
N - Neuro sx or abnl s’s
O - Onset: sudden
O - Older: new onset and/or progressive HA
P - Previous HA hx (if HA is 1st, different, or ∆ing)
E - Effort-induced
R - Recent trauma
P - Positional
C - Change in personality
RED FLAG ETIOLOGY: Meningitis/encephalitis
—Usually have fever (grace à IL-1), could be
—Mental status ∆s, stiff neck (Brudzinski/Kernig’s signs (lost in deep coma))
—Develop focal neurologic deficits
—May have seizures
—Headache often diffuse, may be pulsatile. May have N/V
RED FLAG ETIOLOGY: HSV encephalitis
Most common sporadic encephalitis —Fever, cognitive ∆s (loss of smell), evolving neuro deficits (necrotizing) —MRI abnormal early —EEG with abnl periodic complexes —CSF......get PCR —Treatable (acyclovir)
RED FLAG ETIOLOGY: Brain Tumor/Mass Lesion
—Primary or metastatic
—HA often not initial sx
—Raised ICP
—Focal deficits, seizures, diplopia (VIth nerve palsies), papilledema
—Progressive HA, may be worse w/ recumbency
—HA can be focal, holocranial, various features
—Neuroimaging (esp MRI w/ Gd)
RED FLAG ETIOLOGY: Stroke and TIA’s
— Pt has risk factors —If hemorrhage, N/V more likely (blood irritates meninges) —Deficit —A chance to prevent a stroke —HA: localized or holocranial
RED FLAG ETIOLOGY: SAH (subarch hem)
—Sudden, dramatic (worst HA of my life) maybe s/p exertion
—N/V
—Severe HA
—May have sz
—Aneurysm, AVM, other
—Fever, stiff neck, stupor, coma
—Brudzinski/Kernig signs
—Imaging (non contrast head-CT; see blood in Sylvian fissure), LP, angiography
—Sentinel (warning) leak = sudden HA w/ n/v & sz
RED FLAG ETIOLOGY: trauma
—causes epidural hematoma (crescent-shaped)
—Often s/p concussion
—Lucid interval
—Rapid arterial bleeding (middle meningeal artery) →rapid ↑ in ICP as there is no “epidural space”
—Neurosurgical emergency
RED FLAG ETIOLOGY: subdural hematoma
—Generally slow/venous bleeding (bridging/emissary veins) (acute subdural as in boxing)
—May have no hx of head trauma
—Blood accumulates in the (potential) subdural space therefore slower increase in ICP
—Mental status changes, headache, evolving neurologic deficits
RED FLAG ETIOLOGY: Giant Cell Arteritis (a.k.a Horner’s Dz, Temporal arteritis)
—Think 50! Age > 50, ESR >50 —High CRP —Any type of NEW headache, or worsening of a pre-existing HA type —Risk of blindness, stroke —tx w/ Steroids —dx w/ Temporal a. biopsy
RED FLAG ETIOLOGY: Intracranial HTN
*presents like mass lesion
—Often idiopathic
—Risk to vision
—Headache, diplopia, papilledema, VIth n palsies
—Risk of visual loss
—Obesity, venous sinus thrombosis
—Post-partum, infection, dehydration, head trauma
—Image first (“symptomatic” vs. “idiopathic”)
—If no contraindication, then LP for opening pressure
RED FLAG ETIOLOGY: central venous sinus thrombosis
yup that too
RED FLAG ETIOLOGY: intracranial hypotension
—CSF leak
—Classic example: post-LP headache
—Seen after trauma, spontaneously, after surgery
—Positional HA (early on)
—LP, MRI, myelography —Isotope (Indium 111) cisternography.
—Tx: bedrest, analgesia, IV caffeine; mod/severe—> epidural blood patch
1° HA’s: Tension-Type Headache
**Bad name —Defined as what migraine is not —Lasts 30 minutes-7 days —Often bilateral, non-pulsating, mild or moderate, not worse with activity —No N/V —Either or neither photo- phonophobia
1° HA’s: Migraine dx criteria
—recurrent: 5 or more attacks lasting 4-72 hours
—2 or more of: a) unilateral b) pulsating c) moderate/severe, d) worse with activity
1 or more of: a) n or v B) photo-AND phonophobia
1° HA’s: migraine prodrome
hypothalamus involved
1° HA’s: childhood precursors to migraine
motion sickness, episodic vomiting, vertigo
sleep helps…?
migraines!
T/F Migraines are hereditary
true, they USUALLY are
Auras
—10-15% have it
—before, during, after or all by itself
—short neuro deficit includes: visual ∆s, paresthesias, hemiplegia or aphasia
—visual aura: Scintillating scotoma = most common visual aura preceding migraine; ask “Do you see anything in the dark?”; originates in occipital lobe; no response to meds
Cheiro-oral aura
numbness rises up the arm to face over 10-15 mins
—originates in sensory cortex
Why is migraine often misdiagnosed?
Connections though trigeminal nucleus caudalis and superior salivatory nucleus cause confusion:
—With TTH (neck symptoms) something about radiating to face, causing tension in the neck?
—With “sinus” headache b/c migraine radiates into sphenopalatine ganglion
Cluster HA’s
—Less frequent —More common in males (vs. migraine more common in females) —Most severe pain known —tearing and runny nose —Up to 8 attacks per day —Attacks last 15-180 minutes —Ipsilateral autonomic signs —Patients often restless —Gratifying to treat
Post-traumatic HA: causes? DDX? prognosis?
—causes: s/p concussion, whiplash
—DDx: r/o brain bleed
—prognosis: 70% remission w/in 1 yr; rest likely never will recover
—cognitive ∆s, mood disturbances and sleep problems can co-occur w/ post-concussive syndrome
drug-induced HA
—Analgesic rebound: occur in migraineurs; limit analgesic to 2 days/wk; washout can take 3 months!
—Vasodilators (hydralazine, isosorbide, nifedipine)
—IVIg
—Many others
TMJ-dysfunction induced HA
Pain on use
Sinus HA’s
—Acute sinusitis does cause headache —Recurrent acute sinusitis unusual (think migraine) —Chronic sinusitis often asymptomatic —Most “sinus” headache is migraine —“Sinus” problems —order CBC, plain films and/or MRI/CT
occipital neuralgia
—positive Tinel’s sign (tapping)
—may respond to nerve block/e-stim
Trigeminal neuralgia
—Aka tic doloureux
—Lancinating pains (can’t shave, wind hurts!)
—V2 especially
—Trigger points, refractory period
—R/o: Idiopathic, compressive lesions; MS (bilateral, young pt) —> Get MRI
—Tx w/ Carbamazepine
HA during sex
SAH or benign “orgasmic headache”
status migranosus
migraine lasting >72 hrs
migraine pathophys
serotinergic transmission problem; trigeminovascular system
