10.4 Headache and Migraine aura

Question 1

What can headaches be a warning sign of?

Answer 1

Cerebral tumours 
Raised ICP 
Intracranial haemorrhage 
Aneurysms  
Meningitis, Encephalitis 
Giant cell arteritis

Question 2

What are the sources of head pain?

Answer 2

Blood vessels - meningeal arteries 
Meninges
Scalp: bone and periosteum 
Skull: bone and periosteum 
Face: trigeminal nerve 
Neck: muscles, spine and ligaments 
Sensory nerves: direct activation and true nociceptors

Question 3

What are the important things to rule out with headache

Answer 3

Meningitis
Raised ICP
Giant cell arteritis

Question 4

What are the physical tests for meningitis?

Answer 4

Kernigs sign: pain on stretching straight leg

Brudzinksis sign: active flexion of hips and knees with passive flexion of neck

Question 5

What can cause a rise in ICP?

Answer 5

Lesion
Bleeding
Oedema
Increased CSF

Question 6

What is the progression of raised ICP?

Answer 6

There will be initial compensation by compressing the CSF spaces but once these have been compressed the parenchyma shifts and the ICP will raise steeply and cerebral perfusion will fall

Question 7

What are the signs of raised ICP?

Answer 7

Headache worse when lying down

Papilloedema (compression of optic nerve - late)

Question 8

What is cushings triad?

Answer 8

Irregular respirations
Bradycardia
Systolic hypertension

Question 9

What are the consequences of raised ICP?

Answer 9

Optic nerve compression
Decreased cerebral perfusion pressure
Hypertension and bradycardia
compression/herniation of brainstem or cerebellum

Question 10

What are the dural membranes that prevent brain shift?

Answer 10

Falx cerebri (between hemispheres) 
Tentorium cerebelli (occiptal lobes from cerebellum)

Question 11

What are the types of herniation?

Answer 11

Subfalcine: movement of the frontal lobe under the falx cerebri

Central: movement through the tentorium cerebelli

Uncal/transitional: movement of the temporal lobe downard compressing the brainstem

Tonsilar herniation: cerebellar tonsils through foramen magnum

Question 12

What should be the approach in suspected raised ICP?

Answer 12

Imaging - CT
Look for mass, compression of ventricles, midline shift, sulcus effacement

If no lesion consider obstructive hydrocephalus (check ventricles), venous thrombosis, benign intracranial hypertension

Question 13

What are the symptoms of saggital sinus thrombosis and what can it progress to and how do you diagnose?

Answer 13

Chronic headache with symptoms of raised ICP: postural headache, visual changes, papilloedema

Can progress to stroke and seizures - diagnosed with CT or MR venogram (empty delta sign - contrast will not fill saggital sinus)

Question 14

What is the management for raised ICP?

Answer 14

Shrink/remove lesion 
Anticoagulants for venous thrombosis 
Treat oedema with corticosteroids
Lumbar puncture and remove CSF (only if no lesion) 
Neurosurgical drainage device

Question 15

How does CSF get from choroid plexus to ventricle?

Answer 15

Leaves vessel through fenestration and then must pass through choroid epithelium to reach the ventricle

Question 16

Where is lumbar puncture done

Answer 16

L4/5 at the level with the iliac crests

Question 17

What is the presentation of benign intracranial hypertension

Answer 17

Headache
Visual changes
Sometimes report watery sounds in head
VI nerve palsy (stretch/compression)

Question 18

What is the cause of benign intracranial hypertension?

Answer 18

Imbalance between CSF production and absorption (mainly faulty absorption) with raised ICP (>25cm), in the absence of a mass lesion, venous thrombosis or hydrocephalus

Question 19

What are the predisposing factors of benign intracranial hypertension?

Answer 19

Female, youth, obese, some drugs and rapid steroid withdrawel

Question 20

What is the treatment for benign intracranial hypertension?

Answer 20

CSF drainage, Diamox (acetazolamide), diuretics, weight loss, shunting, short course of steroids

Question 21

What is the presentation of sub arachnoid haemorrhage and what is it usually secondary to?

Answer 21

Unilateral headache rapidly spreading to becoming generalised then causing meningism. May have impaired consciousness or focal neurological signs due to aneurysm compressing cranial nerves, cerebral hernication or ischaemia secondary to vasospasm

Usually secondary to an aneurysm

Question 22

What is the diagnosis of SAH?

Answer 22

CT potentially lumbar puncture 12 hours later if still suspicious
Follow up CT/MR angiography

Question 23

What is the CT appearance of SAH?

Answer 23

Irregular - tracks sulci and enters other CSF spaces

Question 24

What is the CT appearance of subdural bleed?

Answer 24

Crescent around the brain often secondary to atrophy, fall or minor trauma

Dark if chronic, light if acute

Question 25

What is the CT appearance of an epidural bleed?

Answer 25

Almond shaped with the blood bulging INTO the brain

Question 26

When should you consider an intraparenchymal bleed?

Answer 26

Patient who has a progressive or slow onset stroke, focal neurological signs, declining conscious state, headache, risk factors (HT, coagulopathy)

Headache is the presenting complaint but focal neurological defects or altered conscious state indicate it is not benign

Question 27

What is the presentation of giant cell arteritis?

Answer 27

Headache often localised, with arterial tenderness or visible/palpable swelling

Can have jaw claudication, polymyalgia, rarely occulomotor nerve palsies, Raised ESR and CRP

Question 28

How do you diagnose and treat giant cell arteritis?

Answer 28

Diagnosed by biopsy and treated with steroids +/- MTX as steroid sparing agent

Question 29

What is the proposed mechanism of migraine?

Answer 29

Abnormal neural firing in brainstem structures that project to the cerebral vasculature, leading to altered serotinergic tone, altered vascular reactivity and spasm, inflammatory changes, autonomic features and (usually) resulting in vascular pain

Question 30

What is the classical presentation of migraine?

Answer 30

Episodic, unilateral, throbbing headache, associated with nausea and photophobia

Question 31

What are the common accompanying features of a migraine?

Answer 31

Zig zag lines
Dots/blobs
Often moving or shimmering
Classically becoming more extensive during the migraine

Can also have: vertigo, dysphasia, hemiparesis or hemisensory changes

Question 32

What is the treatment of migraines?

Answer 32

Avoid triggers
Acute treatment: analgesia, specific anti-migraine drugs
Prophylaxis: propanolol (or other B blockers), valproate
Treat co-existing tension headaches if possible

Question 33

what are the benign headaches?

Answer 33

Tension headache 
Cervicogenic headache 
Optical neuralgia 
Cluster headaches 
Paroxysmal hemicrania 
Trigeminal neuralgia

Question 34

What are the DDs for acute, severe headache with neck rigidity?

Answer 34

Subarachnoid haemorrhage, meningitis, encephalitis, systemic infectionn

Question 35

What are the DDs for acute severe headache without neck rigidity?

Answer 35

Migraine, cluster headache, occipital neuralgia, carotid or vertebral artery dissection, acute hydocephalus, pressor responses, benign sex headache

Question 36

What are the DDs for sub acute headache with raised ICP?

Answer 36

Expansion mass lesion, venous thrombosis, progressive hydrocephalus, benign intracranial hypertension

Question 37

What are the DDs for sub acute headache not associated with ICP?

Answer 37

Migraine, tension headache, systemic illness, giant cell arteritis