Approach to Acute Headache Flashcards
1
Q
Differentials - primary
A
- tension
- cluster
- migraine
- trigeminal neuralgia
2
Q
Tension
- hx
- exam
- ix
- mx
A
Hx
- Bilateral tight band
- recurrent
- occurs late in day
- association with stress
Exam
- tension and tenderness in neck and scalp muscles
Ix - clinical
Mx
- simple analgesia
- avoid triggers
- amitriptyline if required
3
Q
Cluster headache
- hx
- exam
- ix
- mx
A
Hx
- short painful attacks around one eye
- lasts between 30 mins to 3 hours
- occurs 1-8 per day for 1-3 months
- may have lacrimation and flushing
Exam
- conjunctival injection
- lacrimation
- swollen eye-lid
- ptosis during attack
Ix - clinical diagnosis
Mx
- High flow oxygen for 15 mins
- Triptan
- Verapamil may be used for prevention
4
Q
Migraine
- hx
- exam
- ix
- mx
A
Hx
- unilateral pulsating
- occurs in trigeminal nerve distribution
- lasts hours to days
- may have aura
- photophobia
Exam - may have focal neurology during aura
Ix - clinical diagnosis
Mx
- Abortive - NSAID/aspirin, triptan
- Preventative - propranolol, amitriptyline, anti-convulsants
5
Q
Trigeminal neuralgia
- hx
- exam
- ix
- mx
A
Hx
- 2 second paroxysms of stabbing pain in the unilateral Trigeminal region
- face screws up in pain
- triggers - i.e. shaving
- symptoms of underlying cause - i.e. MS, tumour, aneurysm
Exam - normal
Ix - MRI to find cause
Mx
- anticonvulsants
- treat cause i.e. nerve compression
6
Q
Differentials - secondary intracranial
A
Secondary intracranial
- meningitis
- GCA
- subarachnoid haemorrhage
- raised ICP - SOL, idiopathic intracranial hypertension, acute hydrocephalus
- venous sinus thrombosis
- intracerebral haemorrhage
- encephalitis
- cerebral abscess
- pituitary apoplexy
- subdural haemorrhage
- extradural haematoma
- spontaneous intracranial hypotension
7
Q
Meningitis
- hx
- exam
- ix
- mx
A
Hx
- photophobia, neck stiffness, fever, non-blanching rash
Exam
- photophobia, neck stiffness
- Kernig and Brudzinski’s sign +ve
- non-blanching rash
- focal neurology (20%)
Ix
- blood culture and meningococcal PCR
- LP
- throat swab
- CXR - pneumonia may be cause
Mx
- IV 3rd generation cephalosporins without delay (+amoxicillin if >65 years)
- IM benzylpenicillin if in community
- dexamethasone
- ciprofloxacin prophylaxis for close contacts
8
Q
GCA
- hx
- exam
- ix
- mx
A
Hx
- unilateral throbbing pain, scalp tenderness, jaw claudication
- > 55 years
- may have visual problems
Exam
- ipsilateral blindness
- temporal tenderness
- optic nerve oedema
Ix
- Raised ESR
- temporal artery biopsy
- doppler temporal artery - reduced flow
Mx
- high dose corticosteroids
9
Q
SAH
- hx
- exam
- ix
- mx
A
Hx
- very sudden onset and very severe
- meningism
Exam
- meningism
- reduced GCS in some
Ix
- CT head - blood within circle of Willis
- LP - if CT normal - xanthochromia
Mx
- calcium antagonists to reduce vasospasm
- coiling / clipping of aneurysm
10
Q
Raised ICP
- hx
- exam
- ix
- mx
i.e. tumour, idiopathic intracranial hypertension, acute hydrocephalus
A
Hx
- worse in morning and with coughing and bending
- vomiting and reduced GCS
- visual disturbance
- may have neuro sx and/or seizures if due to tumour
Exam
- low GCS
- papilloedema
- CN6 palsy (no abduction)
- ipsilateral mydriasis (pupil dilation)
- Cushing response (low pulse, high BP)
- Cheyene-Stoke respiration (accelerates then apnoea)
Ix
- CT head to confirm and determine cause
- ICP monitoring
Mx
- Mannitol + hyperventilation if severe
- Treat cause
11
Q
Venous sinus thrombosis
- hx
- exam
- ix
- mx
A
Hx
- may build up over few days or sudden onset
- N&V
- seizures
- hx of hypercoaguable state i.e. pregnancy
Exam
- papilloedema
- visual field defects
- cranial nerve palsies
- focal neurology
Ix
- CT / MRI venography
Mx
- Treatment dose LMWH
- Cavernous sinus thrombosis - abx (high risk infection) and hypopituitarism treatment if required
12
Q
Intracerebral haemorrhage
- hx
- exam
- ix
- mx
A
Hx
- symptoms of stroke / headache
Exam
- neuro deficits i.e. hemiplegia, homonymous hemianopia, dysphasia
Ix
- CT head
- catheter angiography to look for arteriovenous malformations and arteriopathy if young/suspected
- Further CT a 6 weeks and MRI at 3 months to look for underlying tumour
Mx
- BP control
- correct any coagulopathy
- treat cause if found - i.e. AV malformation
- if large/raised ICP/midline shift/superficial - consider craniotomy and clot evacuation, stereotactic aspiration or endoscopic evacuation
13
Q
Differentials - secondary extra cranial
A
Acute closed-angle glaucoma Sinusitis Hypertensive encephalopathy Pre-eclampsia Carotid/vertebral artery dissection
Drugs - nitrates, PPI, CCB, caffeine, analgesia overuse, hormones Drug withdrawal CO poisoning Post-traumatic Paget's disease Hypoxia Cervical spondylosis Otitis media Dental causes
14
Q
Acute closed-angle glaucoma
- hx
- exam
- ix
- mx
A
Hx
- pain around one eye
- swollen red eye
- visual blurring and halos
Exam
- reduced acuity
- conjunctival injection
- cloudy cornea
- pupil mid-dilated and irregular
Ix
- tonometry >24mmHg (>21mmHg suspicious)
Mx
- IV / PO acetazolamide
- a-agonist / B-blocker drops
- laser peripheral iridecomty
15
Q
Sinusitis
- hx
- exam
- ix
- mx
A
Hx
- facial pain exacerbated by leaning forward, coughing
- rhinorrhoea, nasal congestion
Exam
- sinus tenderness, pain on percussion of frontal/temporal sinuses
Ix - clinical
Mx
- abx if bacterial
- warm face packs
- saline nasal drops
- analgesia
