15-17. Headaches + Serious Headaches Flashcards
1
Q
When assessing patient with HA or CNS symptoms, what are the major parts of the brain that need to be screened?
A
Brain stem, cerebellum, cerebrum
2
Q
When assessing patient with HA or CNS symptoms, what types of tests are used to screen each part of the brain?
A
Cerebrum: CN exam and consciousness test
Cerebellum: ataxia, vertigo, dysarthria
Brain stem: CN exam
3
Q
What is a sample neurological exam?
A
BRAIN 1. Orientation, mental status exam and mood 2. Gait and cerebellar tests 3. Cranial Nerves II-XII and funduscopic exam PERIPHERAL 4. Light touch or sharp/dull (UE and LE) 5. Muscle testing 6. DTR 7. Pathological reflexes MENINGITIS ONLY 8. The jolt maneuver, Kernig, Brudzinski
4
Q
What are the 3 types of ataxia and what causes the ataxia?
A
Sensory — corrupted input from peripheral nerves through posterior column of spinal cord. THINK: cord damage (posterior column), multiple NR damage (stenosis), polyneuropathy (diabetic neuropathy)
Vestibular — inner ear issue or CN VIII lesion. THINK: viral labyrinthitis, Meniere’s disease
Cerebellar — cerebellar lesion. THINK: MS, stroke, trauma, tumor, alcohol
5
Q
What are some positive tests for sensory ataxia?
A
Gait: wide-based, tentative, watches foot placement
Station: eyes open = normal; eyes closed=abnormal *Romberg positive
Sensory exam: decreased sensation in distal extremities “glove and stocking”
Achilles DTR: depressed or absent
6
Q
What are some positive tests for vestibular ataxia?
A
Gait: driven by the spins, true vertigo
Station: Romberg positive. Swaying. (eyes open & closed)
True vertigo: yes
Nystagmus: yes
7
Q
What are some positive tests for cerebellar ataxia?
A
Gait: very wide-based and very irregular with arms out for balance. Afraid to walk. Trouble turning.
Station: Romberg positive (eyes open & closed)
Limb ataxia: various limbs
Truncates ataxia: flexed at waist
Achilles DTR: intact, but “pendular”
Speech: slurred
True vertigo: maybe
Nystagmus: maybe
8
Q
How do you test for dysmetria in the UE and LE? What would be positive findings
A
UE: finger to target/finger to nose
(+) past-pointing, dysmetria as seen in ipsi lesion of cerebellar hemisphere
(+) terminal intention tremor
LE: heel to shin
(+) squiggly line of the heel limb
9
Q
How would you test for stereognosis/graphesthesia? What lobe of the brain does it test?
A
Stereognosis: patient closes eyes. Place familiar object in patients hand. Ask to identify.
Graphesthesia: recognize letters or numbers drawn on skin.
Both test contra parietal lobe affecting association center (posterior column cord lesion).
10
Q
What is papilledema and what can cause it?
A
Optic disc swelling due to increased intracranial pressure due to:
- optic neuritis
- tumor
- pseudotumor
11
Q
What does a focal deficit refer to?
A
CN deficit is called a focal deficit and suggests patients headache is due to serious disease.
12
Q
Describe the pronator drift and cerebellar drift and what they test
A
Pronator drift=eyes open; cerebellar=eyes closed.
Hold arms outstretched with hands supinated for 2 minutes.
(+) if patient cannot maintain posture or if 1 or 2 arms drop, internally rotate and flex at elbow while wrist flexes and hand pronates — early UMN disease indicator e.g. stroke
(+) Cerebellar lesion is if limb travels in any direction
13
Q
What are 3 conditions that may cause spacticity?
A
Stroke
TBI
Spinal cord injury
Also: cerebral palsy/MS/amyotrophic lateral sclerosis, brain damage due to O2 debt, encephalitis, meningitis
14
Q
Who is more likely to get cervicogenic vertigo?
A
30-50 yo
Females 60-90%
15
Q
What is the diagnostic criteria for CGV?
A
- Dizziness (80-90%)
- Neck pain (must be present)
- Headache (common)
- Tinnitus (30%)
- Hearing loss (less common)
- Earache, feeling of fullness
- Unsteadiness when standing or walking increased by peripheral stimulation
16
Q
What are 3 precipitating factors of vertigo?
A
- Trauma (80-90% patients who have chronic flexion-extension injury syndrome)
- Chronic MSK problems: C/S or shoulder dysfxn
- Anxiety
17
Q
What are 3 key physical exam findings to support CGV?
A
- Neck movement may induce nystagmus
- Pain with palpation of lateral mass of atlas and suboccipital mm
- Induced by neck rotation while head is stationary e.g. Swivel test
18
Q
How would you perform sitting swivel test?
A
Patients on a chair that swivels and closes their eyes.
- They shake their head from side to side. If symptoms of vertigo return, the vestibular system or cervical spine may be responsible. Wait until symptoms subside.
- Hold the patient’s head still while they swivel their body from side to side in the chair. If symptoms return, think cervicogenic vertigo.
19
Q
What is Barre-Lieou Syndrome and what are common symptoms?
A
Suboccipital pain and vertigo precipitated by head rotation.
Some symptoms include hoarseness, fatigue, radiographic changes at C4-6, unilateral facial or eye pain.
20
Q
What are some findings that helps DDX Barre-Lieou Syndrome from cervicogenic vertigo?
A
Visual symptoms, hoarseness, radiographic findings localized to C4-6
21
Q
What is Meniere’s Disease and what are common symptoms?
A
Acute recurrent attacks (lasting several hours) of hearing loss, tinnitus, fullness in one ear.
22
Q
What is thought to cause Meniere’s Syndrome?
A
Change in fluid volume (endolymph) within the labyrinth
23
Q
What is the triad of exam findings suggestive of Meniere’s Disease?
A
No pain AND
- recurrent attacks of vertigo
- hearing loss
- tinnitus (ringing or buzzing)
24
Q
How do you diagnose Meniere’s disease
A
By exclusion: physical exam, MRI, etc to R/O other diagnoses
25
What are some Tx for Meniere’s disease?
Diet is helpful: Low salt diet, No caffeine or alcohol
26
Your patient has fatigue and hoarseness, what do you suspect it is?
Posterior cervical sympathetic syndrome
Aka Barre-Lieou Syndrome
27
How would you treat cervicogenic vertigo?
CMT to stimulate C/S mechanoreceptors
STM for muscle dysfunction, rehab for proprioception, ROM and equilibrium
Others:
EMG biofeedback
Laser or US to increase circulation and improve healing rate of soft tissue
28
How long would you treat cervicogenic vertigo? And what percent of patients get better in that time period?
~ 1 month
In 4 weeks of treatment 85% of patients respond favorably with the interventions
29
In headache world, what is acute?
<10 days
30
What headaches should you consider in trauma patients? List the most serious one first
1. Subarachnoid hemorrhage
2. Subdural or epidural hematoma
3. Posttraumatic headache / postconcussive syndrome / TBI
31
What percent of patients with subdural hematoma have a headache?
20% with chronic subdural hematoma have no identifiable etiology and can present with Sx up to 3 months from known traumatic event
32
How does the severity and onset of subarachnoid hemorrhage compare to subdural hematoma headaches?
Subarachnoid is sudden, severe, thunderclap
Subdural is mild to moderate, nonspecific and slower onset (can take up to 3 months for symptoms to present)
33
What patient population is most as risk of subdural hematoma due to trauma?
Elderly, alcoholics, epileptics, people on dialysis or blood thinners (warfarin), coagulation disorders
34
How long does it take from a traumatic event for someone to experience a headache due to subdural hematoma? What about acute posttraumatic headache (APTH)
Can occur in up to 80% of patients in 3 months after trauma
APTH: 7 days in about 1/2 patients and usually resolves in a few weeks
35
Post traumatic headache symptoms fall into 3 groups. Name the 3 groups and some examples from each group
Physical — headache, dizzy, double vision, blurred vision, nausea, sensitivity to light and noise, sleep disturbance
Mood/emotional — irritable, frustrated, depression, restless
Cognitive — forgetful, poor concentration, taking longer to think
36
Red flag for serious headaches.
New HA in older patient makes you think _____ (possible DDX)
Tumor
37
Red flag for serious headaches:
Trauma makes you think _____ (possible DDX)
Hematoma
38
Red flag for serious headaches:
thunderclap headache makes you think _____ (possible DDX)
Subarachnoid hemorrhage or VBA vertebral basilar artery dissection
39
Red flag for serious headaches:
Cognitive changes makes you think _____ (possible DDX)
Stroke, tumor, degenerative neuro disease
40
Red flag for serious headaches:
Vomiting (maybe projectile) without nausea makes you think _____ (possible DDX)
Increased intracranial pressure e.g. tumor
41
Red flag for serious headaches:
Changes in vision makes you think _____ (possible DDX)
Glaucoma, optic neuritis, VBA dissection, intracranial lesion, post traumatic HA, temporal arteritis, CVA
42
Red flag for serious headaches:
Double vision makes you think _____ (possible DDX)
Intracranial mass, idiopathic intracranial HTN, post traumatic HA, dissecting aneurysm
43
Red flag for serious headaches:
Unexplained weight loss makes you think _____ (possible DDX)
Tumor, systemic disease
44
Red flag for serious headaches:
Fever makes you think _____ (possible DDX)
CNS (serious) vs systemic
45
Red flag for serious headaches:
Horner’s syndrome makes you think _____ (possible DDX)
Tumor, carotid dissection
46
Red flag for serious headaches:
Nuchal rigidity w/ or w/o fever makes you think _____ (possible DDX)
Meningitis or subarachnoid hemorrhage
47
Red flag for serious headaches:
Valsalva makes you think _____ (possible DDX)
Tumor
48
Red flag for serious headaches:
Positive jolt test makes you think _____ (possible DDX)
Meningitis
49
Red flag for serious headaches:
HTN BP changes makes you think _____ (possible DDX)
HTN headache
50
Red flag for serious headaches:
Neurological signs makes you think _____ (possible DDX)
Tumor, stroke
51
Red flag for serious headaches:
Papilledema makes you think _____ (possible DDX)
Tumor, optic neuritis, pseudotumor
52
What are 5 quick screening questions to screen HA patient’s for serious conditions?
1. Recent onset?
2. Progression in frequency or severity?
3. Onset sudden and severe?
4. Focal neurologic signs?
5. Cognitive changes?
Full sentences:
A. Is the headache of recent onset (less than 6 months)?
B. Is there any progression in the frequency or severity of the headaches?
C. Was the onset sudden and severe?
D. Are there any clues suggesting focal neurologic signs associated with the headaches?
E. Are there any cognitive changes associated with the headaches (e.g., memory loss, confusion, personality changes)?
53
What are the 3 most common types of headaches [that a chiro will see] in order of commonality?
1. Tension-type
2. Migraine
3. Cervicogenic (CGH)
54
How common is CGH in the population at large?
1-2% or 15-20% of all chronic or recurrent HA
55
How and what is generating pain for CGH?
Suboccipitals and the convergence-projection theory.
Ventral branch of C2 nerve traverses suboccipital mm and becomes entrapped. Facet joints are innervated by medial branches of cervicogenic dorsal rami. Axons from the cranial nerve and the cervical NR converge on the Trigeminal Nerve. The Trigeminal pain pathway becomes sensitized by pain stimulus from C1-3 and the patient feels pain in the Trigeminal nerve territory.
The Trigeminal-cervical nucleus is where sensations from the 2 areas converge.
56
What movements will exacerbate the patients headache?
Neck stiffness with decreased cervical ROMs triggered by prolonged awkward position of head or by specific ROM (e.g. reading a book in bed).
Digital pressure can exacerbate or induce the same headache.
Abnormal intervertebral movement manifests during either active or passive examination of the movement.
57
What is the diagnostic criteria for CGH?
Pain precipitated or aggravated by neck movement and at least one of:
- resistance to or limitation of passive neck movements
- changes in neck muscle contour, texture, tone or response to active and passive stretching and contraction
- abnormal tenderness of neck muscles
58
Describe a CGH headache: location, quality of pain, triggers, etc.
Unilateral HA withOUT side shift. Pain starts in the neck and spreads to oculi-fronto-temporal areas. Pain triggered by neck movement, awkward posture, external pressure. Quality is moderate, non excruciating, usually non-throbbing nature.
Note: may be bilateral especially if episode is severe, but then usually one side is more intense
59
Can there be referral of pain in CGH?
Yes, associated vague non-radicular type pain in the shoulder or UE
60
Does CGH interfere with sleep? If not, what type of HA does?
CGH does NOT affect sleep.
Cluster and chronic headaches do.
61
Quality of CGH pain
Dull, dragging, boring, background pain, non-throbbing
Less severe than migraine, more sever than tension-type headache
62
Chronology and timing of CGH
Episodic with unpredictable duration (hours to days) and can evolve into chronic fluctuating HA
63
What are 4 special physical exams that are more commonly positive in CGH compared to migraine or tension-type HA?
1. Active cervical flexion
2. Jull test
3. Cranial-cervical flexion test
4. Cervical flexion rotation test
64
What are some associated Sx that can accompany CGH that overlap with migraines?
* Autonomic symptoms are infrequent and less severe than in migraines, but may include mild nausea, vomiting and ipsilateral periocular edema or flushing.
* Symptoms may also include, phonophobia or photophobia (although not both), dizziness, ipsilateral vision blurring, and difficulty swallowing mimicking a migraine. (Sjaastad 1991. Antonaci 2006)
* Rarely, include ipsilateral lacrimation, conjunctiva irritation and rhinitis (similar to some characteristics of a cluster headache).
65
How do you DDX CGH from migraines or cluster headaches when some symptoms can accompany both?
* Migraine has phonophobia or photophobia or both. And nausea, vomiting.
* Cluster headache: edema, flushing, conjunctival irritation, rhinitis, lacrimation.
If CGH has any associated sx, it will be more mild than either of these.
66
What is greater occipital neuritis (GON)?
Paroxysmal stabbing pain (burning, shock-like) radiates up the back of the head.
67
What is a good method to find and palpate greater occipital nerve?
Palpate 2 cm down and 2 cm lateral to EOP. Place thumb upward next to EOP and palpation at base of nail bed.
68
What are some causes of greater occipital neuritis?
Trauma or viral infection (including herpes zoster)
69
What is the Myogenic Theory for the cause of CGH?
1. Weakness of upper cervical flexor musculature
2. FHP
3. Lack of endurance of upper cervical flexor musculature
4. FHP and concomitant lack of isometric endurance of upper cervical flexor musculature
Basically... FHP and what cervical flexors
70
What are 4 key outcomes to measure when treating a patient with CGH, migraine and tension-type HA?
Primary: decreased frequency, duration, intensity and analgesic use
Secondary: increase cervical spine ROM, decrease soft tissue involvement (tenderness scale)
71
List the parts of the quick migraine screen from the CSPE called “ID Migraine”
Step 1: patient must report 2+ HA in 3+ months
Step 2: Sx must be severe enough that HA limits ability to work, study, enjoy life
Step 3: patient must respond YES to 2/3 Qs
- has HA limited your activities for 1+ days in the last 3 months?
- are you nauseated or sick to your stomach when you have HA?
- does light bother you when you have a HA?
72
Outline your management plan for a typical CGH case
CMT: manipulate C0-3 in 8-10 visits over 4 weeks
STM: PIR suboccipital mm
BM: address muscle imbalance—deep flexors
Ex: address postural/habitual issues, teach self-treatment option—sustained retraction with gentle overpressure for 1 minute, address upper cross syndrome, strengthen deep neck flexors, correct postural abnormalities (FHP)
73
Which of the following headaches is LEAST likely to shift sides:
Cervicogenic (CGH)
Migraine
Tension-type headache
CGH
74
List some things from the history that DDX CGH from migraine
Pain beings in neck
Vague non-radicular pain in shoulder or UE
No side shifting
Non pulsing
Absent or mild nausea, photophobia, phonophobia
75
List some things from the physical exam that DDX CGH from migraine
Decrease in cervical AROM
Reduced cervical rotation with neck in flexion
Palpation pain and loss of joint play in upper cervical joints
HA provoked by manual pressure on upper cervical spine (symptomatic side) or with continuous neck extension
Poor endurance and control of deep neck flexors
Orthopedic tests might be (+)
76
General phases of migrain
Prodrome: feeling of oncoming doom, dread, anxiety
Aura (classic only)
Head pain
Post headache “hangover”
77
Describe the quality of a migraine headache
- Usually unilateral (frontotemporal location), possibly “throbbing” or “pounding”
- Severe, often incapacitating
- Nausea, possible vomiting "sick headache"
- Photophobia, phonophobia
- Association w/ morning onset
- Usually relieved by sleep
78
How do you use the migraine mnemonic POUNDS?
```
P - Pulsatile pain
O - Hours of HA 4 hours-3 days
U - Unilateral
N - Nausea or vomiting
D - Disabling pain
```
79
What 2 headaches could overlap?
Cervicogenic and tension-type
80
What is the cause of tension-type HA (TTH) versus tension HA?
Tension HA are considered to be primarily psychological in origin.
TTH is less clear though it can be linked with pericranial tenderness (ike a headband). It’s associated with muscular stress.
81
What is the criteria to DX TTH?
1. Headache lasting 30 minutes to 7 days
2. At least 2 of the following:
- pressure/tightening (non-pulsating) quality
- mild or moderate intensity (may inhibit but does not prohibit ADLs)
- bilateral location (not commonly unilateral)
- no aggravation by walking stairs or similar routine physical activity
No nausea, no vomiting.
Either photophobia or phonophobia, or neither.
82
What physical exam findings might be positive in TTH?
Palpate their scalp through their hair to see if it is tender. When pericranial tenderness is present it may be exacerbated during HA attacks.
83
You suspect TTH so you palpate your patients head to see if there is pericranial tenderness. What will the findings tell you?
Absence of tenderness does not R/O but presence will R/I.
2 classifications of TTH: with pericranial tenderness and w/o.
84
What is the HA pattern for and upper trap MFTP?
Looks like a question mark
Starts at the Tp, hits the angle of the mandible and then goes high around the ear and ending at the temple.
DDX: migraine
85
What is the HA pattern for SCM MFTP?
Looks like wider question marks.
Sternal division: EOP and large eyebrow distribution
Clavicular division: above the eye and above the origin of the
Note: similar pattern for upper cervical referral causing cervicogenic HA
86
What is the HA pattern for suboccipital muscles?
Looks like a wide headband with concentration preauricular and posterior to the ear
87
What is the HA pattern for the splenius capitis and splenius cervicis?
Splenius capitis: yamika
Splenius cervicis: wide headband that is low over the EOP
88
What is the headache pattern for temporalis MFTP?
On temporalis and referring to mandibular or maxillary pain
89
What ar the steps for doing a quick TMD screen?
```
Jaw popping and pain with chewing
Tenderness/crepitus with TMJ palp
Jaw deviation with opening/closing
Inability to fully open mouth
Tender masseters
Tender temporalis
```
90
What is needed to make a signus headache diagnosis?
Must have 1 of the following:
- nasal discharge (from nose or down throat) or
- nasal obstruction/congestion
91
Some possible causes of forehead pain:
Rhinosinusitis, eye or nose disorder, muscle TrPs of occipital or suboccipital, Cervicogenic
92
Some possible causes of side of head pain:
Migraine, eye or ear disorder, TMJ, temporal arteritis, suboccipital muscles TrP, temporalis TrP
93
Some possible causes of occipital pain:
Myofascial, disc related pain, eyestrain, HTN, greater occipital neuralgia, CGH, TrPs of SCM
94
Some possible causes of parietal pain:
Meningitis, migraine, constipation, tumor
95
Some possible causes of face pain:
Maxillary sinusitis, trigeminal neuralgia, dental problems, tumor
96
Some possible causes of vertex pain:
Rhinosinusitis (ethmoid sinus), HTN, splenius capitis MFTP
97
Some possible causes of generally around the head pain:
TTH, T4 syndrome
98
What is the classic brain tumor headache? How commonly does it present this way?
Severe
Worse in the morning on rising
Associated with vomiting
*classic presentation occurs 17% of the time
99
Who typically gets subarachnoid hemorrhage?
40-60 yo
100
What is the onset, location, course, and frequency of subarachnoid hemorrhage?
Onset: at rest or during exertion
Location: Bilateral in 68%
Course: remains the same for hours to several days, gradually subsides over a few weeks
Frequency: Unrelenting pain
101
What percentage of ischemic strokes present with headaches?
20%
102
What are 2 risks for developing subarachnoid hemorrhage?
Smoking
| Oral contraceptives
103
What is the typical description of subarachnoid hemorrhage?
Pain comes on like a thunderclap similar to vertebrobasilar and carotid dissection
104
What is a sentinel bleed (50% of cases)?
A warning sign for a subarachnoid hemorrhage
May include facial pain or local deficits. May occur hours or days prior.
105
What are some physical findings in a patient with suspected subarachnoid hemorrhage?
```
• Patient appears ill with severe headache
• At time of physical there are often no prominent neuro findings
• Signs may take hours to days to manifest:
◦ Signs of meningeal irritation
◦ Lethargy
◦ HTN
◦ Fever up to 102˚
• Visual field defects
• Double vision
• Oculomotor paralysis
• Bilateral Babinski signs
• Hemiparesis
```
106
What clues from the history or physical suggest patients’s headache is associated with ischemic stroke or TIA?
Nausea (2/5 patients)
Vomiting (1/4)
Photophobia and phonophobia (1/4)
~7 hour headache with TIA (17-54%)
107
What imaging would you get with a subarachnoid hemorrhage?
Immediate CT
| Normal CT may be followed by spinal tap looking for blood because 10% of CTs are false negatives
108
Who normally gets cluster headaches? (2 groups)
M>F
2: 1 when 30-49 yo
3: 1 when >50 yo
109
What is a prodrome for cluster HA?
Sleep disturbance or personality change
110
What are precipitating factors for cluster headaches
Histamine, serotonin, hormonal, vascular
111
What are the 2 main sets of findings suggestive of cluster headache?
1. Excruciating
| 2. Swarms of brief headaches anywhere from 15 minutes to 3 hours. And they could have up to 8 of these per day.
112
What are some associated symptoms and bilateral/uni?
UNILATERAL
- severe headache
- meiosis, ptosis, eyelid edema
- tears
- runny nose
113
Who tends to get temporal arteritis headache?
>50 yo
72 yo mean age
W>M 3:1
114
What are the symptoms associated with this condition?
* Scalp tenderness (e.g., aggravated by hat or combing the hair).
* Jaw claudication near the TMJ after a brief period of chewing firm foods such as steak or a bagel (reported in 30% to 40% of cases); a positive LR of 4.2 (95% CI 2.8-6.2). (Smentana 2002, Lipton 1993) DDX includes TMD (pain more immediate with chewing) or poorly fitted dentures.
* Vision complaints include diplopia (+LR 3.4, 95% CI 1.3-8.6), sudden transient monocular blindness (10% of individuals), or a visual field cut.
* Polymyalgia rheumatica (PMR) symptoms (about ½ of the cases) include abrupt onset of morning stiffness involving the neck/shoulder girdle or low back/pelvic girdle with myalgia and significant tenderness in the proximal arms or thighs.
* Constitutional symptoms such as unexplained weight loss or fever (reported in 48% of cases).
115
What key examination procedures would you perform and what are the findings that would suggest temporal arteritis?
* Take temp: may run a low grade fever
* Ophthalmascopic exam could reveal pale disc
* Vision field testing for potential loss of visual field
* UE and LE joint assessment. Decreased ROM and mm may be signitficantly tender
* Palpate scalp starting at tragus and then find the temporal pulse
116
How does Polymyalgia rhuematica (PMR) present?
abrupt onset of morning stiffness involving the neck/shoulder girdle or low back/pelvic girdle with myalgia and significant tenderness in the proximal arms or thighs.
117
In what age group is temporal arteritis and PMR most common?
Temporal arteritis aka giant cell arteritis >50 yo
- 50% of temporal arteritis cases also have PMR
Polymyalgia rheumatica (PMR) mean age is 72 >60 yo
118
Why is temporal arteritis an urgent referral?
Because sometimes its associated with sudden irreversible blindness
119
What ancillary tests can be ordered for this condition (temporal arteritis) and what would be the findings?
ESR could be high, but does not rule in or out
CRP would be elevated, but low does not R/O
CBC would show anemia of chronic disease (Normocytic anemia)
Temporal artery biopsy is mandatory to establish dx
120
What are signs and symptoms of meningitis?
Painful stiff neck
Fever
Headache
121
SNOOP4 red flags for headaches
```
Systemic
Neurological
Onset sudden
Onset >50 yo
Pattern change
- progressive
- valsalva
- postural/position aggravation
- papilledema
```
