20. Headache Flashcards
DDX headache
Vascular:
Migraine
Haemorrhage (EDH,SDH, SAH, ICH)
Infective/immune:
Meningitis
Encephalitis
Abscess
Herpes zoster
Sinusitis
Trauma
SAH
SAH → hydrocephalus
EDH
SDH
Autoimmune
Temporal arteritis
Iatrogenic
Medication overuse
Post lumbar puncture
Idiopathic
Idiopathic intracranial hypertension
Tension headache
Cluster headache
Trigeminal neuralgia
Hypertension/malignant HTN
Neoplastic
Glioma
Meningioma
Pheochromocytoma
Space occupying lesion → hydrocephalus
Congenital
Hydrocephalus
History taking headache
PC: SOCRATES
hoPC: recent trauma? Recent illness? lacrimation?, headache behaviour? lacrimation?
Red flags: fever, weight loss, worse in morning, worse on coughing, worse on straining, vomiting, weakness, sensation etc. photophobia, associated non-blanching rash, vision changes? Aura? Nausea and vomiting? confusion?
MHx: history of cancer? Immunocompromised? HIV?
DHx: pain killers? Immunosuppressive drugs?
FHx:
SHx: household contacts with same issue? (carbon monoxide poisoning)
ICE:
Examination headache
Vital signs — assess blood pressure, pulse, respiration rate, temperature, and oxygen saturation levels.
General appearance and mental state — assess for signs of a serious underlying cause, including non-blanching skin rash, reduced level of consciousness, or confusion.
Extracranial structures — assess the carotid arteries, temporal arteries, sinuses, and temporomandibular joints.
The neck — assess for meningeal irritation, tenderness of cervical paraspinal muscles, range of movement, and crepitation, neck pain - acute torticollis, Neck pain - cervical radiculopathy
Fundoscopy — assess for papilloedema, pupillary asymmetry and reactivity.
Neurological examination — assess cranial and peripheral nerves including gait.
Recurrent, severe headache which is unilateral and throbbing in nature. Associated with nausea and photosensitivity. Last 4-72 hours
Behaviour: withdrawal, not moving, dark room, no noise
migraine
Typical history migraine
PC: Recurrent, severe headache which is unilateral and throbbing in nature. Associated with nausea and photosensitivity. Last 4-72 hours
Behaviour: withdrawal, not moving, dark room, no noise
DHx: COCP
SHx: alcohol, caffiene, chocolate, cheese, travel
Migraine triggers
Mneumonic CHOCOLATE
Chocolate
Hangovers
Orgasms
Cheese/Caffeine
Oral contraceptive pill
Lie-ins
Alcohol
Travel
Exercise
Migraine diagnostic criteria
A. At least 5 attacks fulfilling criteria B-D
B. Between 4-72 hours* (untreated or unsuccessfully treated)
C. Characteristics, 2 of:
1. unilateral location*
2. pulsating quality (i.e., varying with the heartbeat)
3. moderate or severe pain intensity
4. aggravation by or causing avoidance of routine physical activity (e.g., walking or climbing stairs)
D. During headache at least one of the following:
1. nausea and/or vomiting*
2. photophobia and phonophobia
E. Everything else excluded
Acute treatment of migraine
In practice:
1. combination therapy triptan + NSAID
2. Add in an anti-emetic - metoclopramide 10mg or prochlorperazine 10mg
+ use non-oral preparations of the above if vomiting is an issue
depending on severity use:
Simple analgesia
- Ibuprofen (400 mg) — if ineffective, consider increasing to 600 mg or
- Aspirin (900 mg) or
- Paracetamol (1000 mg).
Triptan
- sumatriptan (50–100 mg)
Anti-emetic
- metoclopramide 10mg or prochlorperazine 10mg
Warn pts about medication overuse headache..
criteria for getting migraine prophylaxis
‘Migraine attacks are having a significant impact on quality of life and daily function, for example they occur frequently (more than once a week on average) or are prolonged and severe despite optimal acute treatment’
Migraine prophylaxis
Women
1. Propranolol or amitriptyline
Men
1. Topiramate or amitriptyline
- Accupuncture up to 10 sessions of acupuncture over 5-8 weeks’
- riboflavin can be effective in reducing migraine frequency
How to treat pre-menstrual migraine
Frovatriptan (2.5mg twice a day) or zolmitriptan (2.5mg twice or three times a day) as mini-prophylaxis
What type of side effects can occur in children and young adults taking antiemetic metoclopramide?
EPSE (extrapyramidal side effects)
Typical history SAH
PC: Sudden onset occipital headache (‘thunderclap’ or ‘baseball bat’), severe (‘worst of my life’
Nausea and vomiting
Meningism (photophobia, neck stiffness)
Coma
Seizures
Sudden death
HoPC: head injury (traumatic SAH)
MHx: autosomal dominant polycystic kidney disease, ehlers-danlos, coarctation of aorta (all associated with intercranial aneurysm)
Sudden onset occipital headache (‘thunderclap’ or ‘baseball bat’), severe (‘worst of my life’
Nausea and vomiting
Meningism (photophobia, neck stiffness)
Coma
Seizures
Sudden death
SAH
Most common cause SAH
head injury
conditions which increase likelihood of cerebral aneurysm
adult polycystic kidney disease, Ehlers-Danlos syndrome and coarctation of the aorta
Plan ?SAH
Plan
Invetsigations
1. CT head (Acute blood (hyperdense/bright on CT) is typically distributed in the basal cisterns, sulci and in severe cases the ventricular system) convex shape
- Lumbar puncture used to confirm SAH if Ct negative, perfomed at least 12 hours after onset, xanthochromia seen
Management
1. referral to neurosurgery
risk of rebleeding so treat promptly
1. Coil by interventional radiologist
2. Vasospasm is prevented using a 21-day course of nimodipine (a calcium channel inhibitor targeting the brain vasculature)
3. Hydrocephalus is temporarily treated with an external ventricular drain (CSF diverted into a bag at the bedside) or, if required, a long-term ventriculo-peritoneal shunt
Complications of SAH
- re-bleeding
- vasospasnm
- hyponautraemia caused by SIADH
- seizures
- hydrocephalus
Typical history meningitis inc neonates
Fever
Neck stiffness
Vomiting
Headache
Photophobia
Altered consciousness
Seizures
Non-blanching rash
Neonates:
Hypotonia, poor feeding, lethargy, hypothermia and a bulging fontanelle.
Therefore lumbar puncture in all children if:
Under 1 month old and presenting with fever
1-3 months with fever and unwell
Under 1 years with unexplained fever and other features of serious illness
Examination findings meningitis
Fever
Non-blanching rash
Photophobia
Kernig’s test (Kernig’s test involves lying the patient on their back, flexing one hip and knee to 90 degrees and then slowly straightening the knee whilst keeping the hip flexed at 90 degrees. This creates a slight stretch in the meninges and where there is meningitis will produce spinal pain or resistance to this movement.)
Brudzinski test (Brudzinski’s test involves lying the patient flat on their back and gently using your hands to lift their head and neck off the bed and flex their chin to their chest. A positive test is when this causes the patient to involuntarily flex their hips and knees.)
What is Meningococcal meningitis vs Meningococcal septicaemia
Meningococcal meningitis - meningococcus bacteria (neisseria meningitidis) is infecting the meninges and CSF
Meningococcal septicaemia - meningococcal bacterial infection in the bloodstream → non blanching rash due to DIC and subcutaneous haemorrhage
plan ?meningitis
Airway
Breathing
Circulation
Disability: GCS, ; focal neurological signs; seizures; papilloedema;
Initial:
if in primary care and ?meningococcal - an urgent stat injection (IM or IV) of benzylpenicillin prior to transfer to hospital as time is so important:
< 1 year – 300mg
1-9 years – 600mg
> 10 years and adults – 1200mg
Once in hospital, decisions to treat empirically quickly vs LP depends on patient and senior clinician
Investigations:
Bloods:
full blood count
CRP
coagulation screen
blood culture
whole-blood PCR, this will be relied upon if lumbar puncture contraindicated
blood glucose
blood gas
Lumbar puncture
unless contraindicated eg if there is evidence of raised ICP as it can cause herniation of cerebrum. Signs of raised ICP: cushing’s reflex (raised BP, low HR), focal neurological signs, papilloedema, significant bulging of the fontanelle, disseminated intravascular coagulation (meningococcal septicaemia eg the rash), signs of cerebral herniation.
Blood glucose at same time as CSF so can be compared
Normal lumbar puncture result
clear appearance
glucose 70% of plasma
protein 0.3 g/l
WCC 2 per mm^3 (neuts)
Bacterial meningitis LP result
Cloudy
Glucose low (< 1/2 plasma) bacteria using up the glucose
Protein high (> 1 g/l) bacteria releasing proteins
WCC 10 - 5,000 polymorphs/mm³ the immune system releases neutrophils in response to bacteria
Viral meningitis LP result
Clear/cloudy
Glucose 60-80% of plasma glucose* viruses don’t really use glucose
Protein normal/raised viruses may release a small amount of protein
WCC 15 - 1,000 lymphocytes/mm³ the immune system releases lymphocytes in response to viruses
Tuberculous LP result
Slight cloudy, fibrin web
glucose Low (< 1/2 plasma)
Protein high >1g/l
WCC 30-300 lymphocytes/mm3
The Ziehl-Neelsen stain is only 20% sensitive in the detection of tuberculous meningitis and therefore PCR is sometimes used (sensitivity = 75%)
Bacterial meningitis 0-3 months
BELS
- Group B Streptococcus (most common cause in neonates)
- E. coli
- Listeria monocytogenes
- Strep pneumoniae
Bacterial meningitis 3 months-6 years
- Neisseria meningitidis
- Streptococcus pneumoniae
- Haemophilus influenzae
Bacterial meningitis 6-60 years
- Neisseria meningitidis
- Streptococcus pneumoniae
Bacterial meningitis >60 years
- Streptococcus pneumoniae
- Neisseria meningitidis
- Listeria monocytogenes
Meningitis in immunocompromised
listeria monocytogenes
Community meningitis initial management
Benzylpenicillin IM or IV
< 1 year – 300mg
1-9 years – 600mg
> 10 years and adults – 1200mg
Meningitis initial empirical therapy < 3 months
IV cefotaxime + amoxicillin (or ampicillin)
Meningitis initial empirical therapy 3 months-50 years
IV cefotaxime
Meningitis initial empirical therapy > 50 years
IV cefotaxime + amoxicillin (or ampicillin)
Meningitis management - listeria
IV amoxicillin (or ampicillin)
+ gentamicin
When should dexamethasone be given for meningitis?when should it be withheld?
Give if lumbar puncture reveals:
- frankly purulent CSF
-CSF white blood cell count greater than 1000/microlitre
- raised CSF white blood cell count with protein concentration greater than 1 g/litre
- bacteria on Gram stain
Withhold if:
- septic shock
- meningococcal
- septicaemia
immunocompromised
Management meningococcal meningitis
IV benzylpenicillin or cefotaxime
Post exposure prophylaxis bacterial meningitis
Ciprofloxacin single dose
This risk is highest for people that have had close prolonged contact within the 7 days prior to the onset of the illness
Typical history encephalitis
PC:
Fever
Headache
Confusion
- psychiatric symptoms
- vomiting
- seizures
- focal features
Brain scan where does encephalitis classically affect
temporal lobe
Most common pathogen encephalitis in children and adults
herpes simplex HSV-1 from cold sores
Most common pathogen encephalitis in neonates
herpes simplex type 2 (HSV-2) from genital herpes, contracted during birth.
think “been passed on 2”
Plan ?encephalitis
Initial:
Immediate IV aciclovir (covers HSV and varicella zoster)
Invetsigations:
- CSF : lymphocytosis, raised protein
- PCR for HSV
- CT medial temporal and inferior frontal changes (e.g. petechial haemorrhages) - normal in one-third of patients.
- MRI is better
- EEG pattern: lateralised periodic discharges at 2 Hz
Management CMV encephalitis
Ganciclovir
Typical history brain abscess
PC:
- dull persistant headache
- fever
- focal neurology
- features of raised ICP
Plan ?brain abscess
Invetsigation:
- CT may be useful
- diffusion weighted mri is best
- invetsigate for sepsis and ddx etc
Management:
1. surgery
a craniotomy is performed and the abscess cavity debrided
the abscess may reform because the head is closed following abscess drainage.
- IV antibiotics: IV 3rd-generation cephalosporin + metronidazole
- intracranial pressure management: e.g. dexamethasone
Typical history herpes zoster opthalmicus
vesicular rash around the eye, which may or may not involve the actual eye itself, burning sensation around eye
what is herpes zoster opthalmicus
the reactivation of the varicella-zoster virus in the area supplied by the ophthalmic division of the trigeminal nerve.
It accounts for around 10% of case of shingles.
