10.4 Headache and Migraine aura Flashcards
What can headaches be a warning sign of?
Cerebral tumours Raised ICP Intracranial haemorrhage Aneurysms Meningitis, Encephalitis Giant cell arteritis
What are the sources of head pain?
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
What are the important things to rule out with headache
Meningitis
Raised ICP
Giant cell arteritis
What are the physical tests for meningitis?
Kernigs sign: pain on stretching straight leg
Brudzinksis sign: active flexion of hips and knees with passive flexion of neck
What can cause a rise in ICP?
Lesion
Bleeding
Oedema
Increased CSF
What is the progression of raised ICP?
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
What are the signs of raised ICP?
Headache worse when lying down
Papilloedema (compression of optic nerve - late)
What is cushings triad?
Irregular respirations
Bradycardia
Systolic hypertension
What are the consequences of raised ICP?
Optic nerve compression
Decreased cerebral perfusion pressure
Hypertension and bradycardia
compression/herniation of brainstem or cerebellum
What are the dural membranes that prevent brain shift?
Falx cerebri (between hemispheres) Tentorium cerebelli (occiptal lobes from cerebellum)
What are the types of herniation?
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
What should be the approach in suspected raised ICP?
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
What are the symptoms of saggital sinus thrombosis and what can it progress to and how do you diagnose?
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)
What is the management for raised ICP?
Shrink/remove lesion Anticoagulants for venous thrombosis Treat oedema with corticosteroids Lumbar puncture and remove CSF (only if no lesion) Neurosurgical drainage device
How does CSF get from choroid plexus to ventricle?
Leaves vessel through fenestration and then must pass through choroid epithelium to reach the ventricle
Where is lumbar puncture done
L4/5 at the level with the iliac crests
What is the presentation of benign intracranial hypertension
Headache
Visual changes
Sometimes report watery sounds in head
VI nerve palsy (stretch/compression)
What is the cause of benign intracranial hypertension?
Imbalance between CSF production and absorption (mainly faulty absorption) with raised ICP (>25cm), in the absence of a mass lesion, venous thrombosis or hydrocephalus
What are the predisposing factors of benign intracranial hypertension?
Female, youth, obese, some drugs and rapid steroid withdrawel
What is the treatment for benign intracranial hypertension?
CSF drainage, Diamox (acetazolamide), diuretics, weight loss, shunting, short course of steroids
What is the presentation of sub arachnoid haemorrhage and what is it usually secondary to?
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
What is the diagnosis of SAH?
CT potentially lumbar puncture 12 hours later if still suspicious
Follow up CT/MR angiography
What is the CT appearance of SAH?
Irregular - tracks sulci and enters other CSF spaces
What is the CT appearance of subdural bleed?
Crescent around the brain often secondary to atrophy, fall or minor trauma
Dark if chronic, light if acute
What is the CT appearance of an epidural bleed?
Almond shaped with the blood bulging INTO the brain
When should you consider an intraparenchymal bleed?
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
What is the presentation of giant cell arteritis?
Headache often localised, with arterial tenderness or visible/palpable swelling
Can have jaw claudication, polymyalgia, rarely occulomotor nerve palsies, Raised ESR and CRP
How do you diagnose and treat giant cell arteritis?
Diagnosed by biopsy and treated with steroids +/- MTX as steroid sparing agent
What is the proposed mechanism of migraine?
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
What is the classical presentation of migraine?
Episodic, unilateral, throbbing headache, associated with nausea and photophobia
What are the common accompanying features of a migraine?
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
What is the treatment of migraines?
Avoid triggers
Acute treatment: analgesia, specific anti-migraine drugs
Prophylaxis: propanolol (or other B blockers), valproate
Treat co-existing tension headaches if possible
what are the benign headaches?
Tension headache Cervicogenic headache Optical neuralgia Cluster headaches Paroxysmal hemicrania Trigeminal neuralgia
What are the DDs for acute, severe headache with neck rigidity?
Subarachnoid haemorrhage, meningitis, encephalitis, systemic infectionn
What are the DDs for acute severe headache without neck rigidity?
Migraine, cluster headache, occipital neuralgia, carotid or vertebral artery dissection, acute hydocephalus, pressor responses, benign sex headache
What are the DDs for sub acute headache with raised ICP?
Expansion mass lesion, venous thrombosis, progressive hydrocephalus, benign intracranial hypertension
What are the DDs for sub acute headache not associated with ICP?
Migraine, tension headache, systemic illness, giant cell arteritis
