18. Headaches Flashcards
What’s a tension headache?
Normal, everyday headaches. Usually when neck and scalp contract.
This headache is generalised, dull, pressure-like. Worsened by eye strain and better with analgesics.
How would we manage a tension headache?
Headache diaries - avoid triggers
Relaxation techniques - remedy stress
Analgesia - paracetamol or ibuprofen
What are we cautious of when prescribing analgesics in headaches?
Medication-overuse headaches/rebound headaches.
Withdraw all analgesic medication to stop this.
How would a cluster headache present?
Lacrimation Rhinorrhoea Partial horner's (ptosis, miosis) Red, swollen eyes Sweating
Unilateral behind the eye, acute and sudden onset often at night. Sharp, piercing, burning worst pain ever. N&V.
Same time each day for weeks, cyclical.
How do we manage cluster headaches?
Subcutaneous sumatriptan
High-dose, high-flow oxygen
Verapamil prophylactically (CCB)
What’s a migraine?
Chronic episodic, neurological disorder that causes headaches.
How do migraines present?
Unilateral
Paroxysmal, comes on gradually and is pulsating/throbbing
Exacerbated by light and sound, activity or stress.
Associated with aura - flashing light/tingling. N&V, visual changes, numbness. ADL affected.
How would we investigate a migraine?
Investigations for most headaches are to exclude more sinister causes e.g.
ESR - giant cell arteritis
LP - haemorrhage/meningitis
MRI - exclude anything more sinister
Management of a migraine?
Conservative - diary, avoiding triggers, relaxation techniques
Acute - simple analgesia, triptans
Preventative - propanolol or topimarate. Amitryptiline
NO OPIATES - cause progression, comorbidity etc.
What is trigeminal neuralgia?
A facial pain syndrome in the distribution of the trigeminal nerve. (often mixed up with temporal ateritis)
How does trigeminal neuralgia present?
Unilateral along trigeminal division. Paroxysmal with stabbing, shooting or electric shock pain and numbness. Worse on brushing teeth, speaking, shaving, talking.
MS is risk factor
How would we manage trigeminal neuralgia?
Acute anticonvulsants
Long-term - microvascular decompression or ablation surgery
What can cause a raised intracranial pressure?
Space-occupying lesion (tumour, haemorrhage, abscess)
Hydrocephalus
Meningitis/encephalitis
Risk factors for raised ICP?
Female sex
Obesity and weight gain
Endocrine conditions
How does a raised ICP present?
Focal neurological symptoms
Papilloedema
Cheyne-strokes respiration
Cushing’s triad - increased SBP, irregular breathing, bradycardia
Bilateral headache that’s throbbing, vomiting, altered GCS, seizures, vision problems. Worsen in mornings, coughing/sneezing and lay down.
How do we investigate a raised ICP?
Urgent CT head
No LP - can cause brainstem herniation
How do we treat raised ICP?
Manage risk factors e.g. weight loss
Analgesia
Identify and treat cause
How might meningitis present?
Meningism - neck stiffness, photophobia and headache Fever N&V Seizures Malaise Altered mental state
What are kernig’s and brudzinski’s signs?
Kernig’s Sign - with the hips flexed, there is pain/resistance on passive knee extension - this is due to severe stiffness in the hamstrings
Brudzinski’s Sign - flexion of the hips and knees when the neck is flexed - this is due to severe neck stiffness
A petechial or purpuric rash can be typical with meningitis too.
How would we investigate meningitis?
Obs, vbg 2 sets of blood cultures, ideally before treatment but never delay Lumbar puncture (most important) CT head before LP if signs of raised ICP
How would bacterial CSF appear?
Turbid, increased neutrophils with low glucose and high protein
How would viral CSF appear?
Clear with increased lymphocytes
How would TB CSF appear?
Fibrin web with increased lymphocytes, decreased glucose and high protein
How would we manage meningitis?
At GP - benzylpenicillin IM and urgent hospital referral
At A&E - broad spectrum antibiotics (ceftriaxone IV, benzylpenicillin IM (or acyclovir if viral))
Targeted ABx
Consider IV dexamethasone
