Approach to headache Flashcards
What are primary headache disorders?
1) Tension headache
2) Cluster headaches
3) Migraines
What are the features of tension headaches?
- bilateral tight band like (non pulsatile) discomfort
- Associations: Insomnia, absent mindedness, early morning awakening
- Timing: (30 min) 30mins to 7 days
- Patient profile: Usually at the end of day in a stressed individual
What are the features of migrainous headaches?
- Unilateral, pulsating
- Disabling
- A/w aura (visual, sensory, motor or speech changes), nausea, vomiting, photophobia, phonophobia
- halo when looking at lights
- seen in young females with worsening during periods of stress or menstrual cycle
- ppt by intense stimuli (bright lights, strong smell, lethargy, emotional stress)
What are the features of cluster headaches?
- retro- orbital, unilateral
- associated with ipsilateral autonomic signs such as tearing, rhinorrhea, miosis and ptosis
- timing: (a few min) 15-180 mins, multiple episodes a day
- In clusters of days to weeks followed by months without symptoms
- patient profile: Man pacing up and down due to headache at night. Pt tend to be restless and move around!
What are the differentials for acute generalised (intracranial) headaches?
Tumor / other causes of ↑ ICP
- Space Occupying Lesion
- Phaeochromocytoma: Paroxysmal episodes of headaches, palpitations, tachycardia and hypertensive
- Acromegaly
- Malignant Hypertension
Infection i.e. meningitis
Trauma (Haemorrhage)
- Subarachnoid: ‘worse headache in my life’, sudden onset with pain maximal within seconds to minutes but improving after.
- Subdural: typically an elderly with head trauma and develops headaches within days (acute SDH) or weeks (chronic SDH).
- Extradural: Younger patient who suffered head trauma e.g. RTA
- Cerebrovascular accident: can occur in (a) some haemorrhagic strokes, (b) occipital strokes and (c) carotid dissection
- Cerebral venous thrombosis: usually in females with hypercoagulable state
Post Lumbar Puncture
What are the differentials for acute localised (extracranial) headaches?
AACG (Acute Angle Closure Glaucoma)
- unilateral headache +/- vomiting with severe eye pain, blurring of vision and halo around lights
- eye is red with fixed mid dilated pupil
- RAPD can be seen if optic nerve is damaged
GCA (Giant Cell Arteritis)
- Unilateral headache with jaw claudication (jaw pain with chewing), transient visual loss of visual field defect and scalp tenderness
- may have systemic symtoms of polymyalgia rheumatica (joint pain, peripheral synovitis, constitutional symptoms)
Trigeminal Neuralgia
Sinusitis, Otitis media
What are the differentials for chronic progressive headaches?
Space occupying lesion (SOL) e.g. tumours and abscess : increased ICP
Medications
Alcohol or withdrawal
What are the red flags to rule out in headaches?
- New, worst or change in character of headache
- Altered Mental State
- Focal neurological Deficits
- Seizures
- Change in vision: Acute Glaucoma / Temporal Arteritis
- Fever
- Trauma
- Chronic progressive headache - transient obscuration of vision
- pulsatile tinnitus
- nausea and vomiting
- worst in supine posture and in morning, coughing, straining
- obtundation of sensorium
- Raised ICP: early morning headache, headache worse on lying supine, coughing or straining, papilloedema
- Meningism (photophobia, neck stiffness, fever): Subarachnoid Haemorrhage OR Meningitis
- Systemic illness: weight loss, history of malignancy, immunosuppression including HIV, drugs including anticoagulants
What are symptoms would you ask patients for to rule out secondary headache?
Symptoms and signs of focal neurological deficits mass lesion?
- Weakness or loss of sensation
- CN involvement: dysarthria, dysphagia, ophthalmoplegia, amnosia
- Cortical features
Symptoms of signs of raised ICP
- Transient obscuration of vision
- Pulsatile tinnitus
- Nausea and vomiting
- Early morning headaches; worse when straining
Sinister features
- Thunderclap (onset to peak is <5min), worst headache of life – SAH
- Lucid interval (improvement, then sudden deterioration) – Epidural
- New onset nocturnal headache
- Persistent, prolonged, do not respond to treatment
- New onset older patient
Constitutional symptoms
- LOA, LOW
- Fever
- Other features of systemic disease
What is the demographic of a patient with temporal arteritis?
check for elevated ESR in elderly presenting with new onset headache
What is the demographic of a patient with acute angle closure glaucoma?
Elderly female, Chinese myopic lady w/ headache / eye pain at night
What are the investigations to perform for a patient if you suspect raised ICP?
- Fundoscopy
- Plain CT Brain: Ix for SAH / ICH, Hydrocephalus
- CT Brain, MRI Brain with contrast – to Ix for mass / abscess / meningitis / encephalitis
What are the investigations to perform for a patient if you suspect have central venous thrombosis?
MR / CT V
What are the investigations to perform for a patient if you suspect have arterial dissections?
MR / CT Angiogram
What are the investigations to perform for a patient if you suspect have meningitis?
FBC, Blood Culture,
Throat swab
CRP, ESR, PT / PTT, Renal Panel
Lumbar Puncture
- Xanthochromasia (for SAH)
- FEME, Protein, Glucose, Gram stain, C/s
- Cryptococcal Ag, Fungal Smear, Fungal C/s
- AFB Smear, AFB C/s, TB PCR
- HSV PCR, Tetraplex (for CNS infection)
- Opening and Closing Pressures
- Cytology, Flow cytometry (leptomeningeal mets / lymphoma)
What are the investigations to perform for a patient if you suspect have temporal arteritis?
ESR and Temporal Artery Biopsy
How do you differentiate between a stroke and ICH using CT brain?
Bleed is always WHITE / HYPERINTENSE. However, after 1 week –> bleed becomes isointense –> hard to tell
Stroke, at the very most, causes EDEMA which is BLACK. Better assessed via DWI
What are the features of meningitis?
- acute onset headache
- Fever, Petechial non-blanching rash (if N. Meningitidis)
- meningism (neck stiffness, photophobia, Kernig’s sign)
- signs of shock (cold clammy fingers, drowsy)
What are the features of acute glaucoma?
- acute onset headache (frontal / periorbital)
- usually seen in middle aged / elderly Asian lady
- conjunctival injection, cloudy cornea
- increased cup: disc ratio
- fixed, mid-dilated pupil; presenting at night
- painful blurring of vision/reduced visual acuity
- sees colored ‘halos’ around lights (=/= glare)
What are the features of temporal arteritis (GCA)?
- age >50, male
- pain localized to temporal or occipital region
- palpable, tender, non-pulsatile temporal artery
- scalp tenderness
- jaw claudication
- +/- loss of vision
- constitutional symptoms (fever, malaise, night sweats, fatigue, weight loss)
- polymyalgia rheumatica (proximal pain, no weakness)
What are the signs of raised intracranial pressure?
- age >50, male
- pain localized to temporal or occipital region
- transient obscuration of vision
- pulsatile tinnitus
- nausea and vomiting
- worst in supine posture and in morning, coughing, straining
What are the features of trigeminal neuralgia?
- transient obscuration of vision
- pulsatile tinnitus
- nausea and vomiting
- worst in supine posture and in morning, coughing, straining
What are the features of sinusitis?
- Pressure or dull sensation
- Bilateral, periorbital headache
- Lasts for days at a time
- a/w Nasal congestion, rhinorrhea, anosmia, tearing, fever
What are the features of phaeochromocytoma?
- Classic triad: episodic headache, sweating, tachycardia
- Other symptoms: palpitations, tremor, pallor, dyspnea, weakness
What is the diagnostic criteria of Cluster headache?
A. At least 5 attacks fulfilling criteria B-D
B. Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15-180 minutes if untreated
C. Headache is accompanied by at least one of the following:
- ipsilateral conjunctival injection and/or lacrimation
- ipsilateral nasal congestion and/or rhinorrhoea
- ipsilateral eyelid oedema
- ipsilateral forehead and facial sweating
- ipsilateral miosis and/or ptosis
- a sense of restlessness or agitation
D. Attacks have a frequency from one every other day to 8 per day
E. Not attributed to another disorder
What is the diagnostic criteria of tension headache?
A. At least 10 attacks fulfilling criteria B-D
B. Headache lasting from 30 min to 7 days
C. At least 2 of the following pain characteristics
- Pressing (non-pulsating) quality
- Mild or moderate intensity (may inhibit but doesn’t prohibit activities)
- Bilateral location
- Not aggravated by climbing stairs or similar routine physical activity
Both of the following
- No nausea or vomiting
- Photophobia and phonophobia are absent or only one is present
What is the diagnostic criteria of migraine (with aura)?
A. At least 5 attacks fulfilling criteria B
B. At least 3 of the following 4 characteristics
- One or more fully reversible aura symptoms
- At least 1 aura symptom develops gradually over >4 mins, or 2 or more symptoms occur in succession
- No aura symptoms last more than 1 hour. If more than 1 aura symptom present, accepted duration is proportionally increased
- Headache follows aura with a free interval of <1 hour but may begin before or simultaneously with the aura
What is the diagnostic criteria of migraine (without aura)?
A. At least 5 attacks fulfilling criteria B-D
B. Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)
C. Headache has at least two of the following characteristics:
- unilateral location
- pulsating quality
- moderate or severe pain intensity
- aggravation by or causing avoidance of routine physical activity (e.g. walking or climbing stairs)
D. During headache at least one of the following:
- nausea and/or vomiting
- photophobia and phonophobia
E. Not attributed to another disorder
What is the management of primary headache?
Symptomatic Mx
- Paracetamol
- NSAIDs
- Triptans: are usually more effective if they are given early in the course of the headache
- Combination of sumatriptan and naproxen
- Antiemetics
Prevention: conservative Mx
- Migraine Diary – keep a diary to assess the ppt factors, then adapt to avoid them
- Trigger avoidance eg: coffee, intense motions / anger, lack of sleep etc
- Stop smoking, reduce alcohol, decrease caffeine intake
- Encourage – good sleep hygiene, regular exercise
What are the indications of migraine prophylaxis?
- Frequent or long-lasting migraine headaches
- Migraine attacks that cause significant disability or diminished QOL despite appropriate acute Mx
- Contraindication to acute therapies
- Failure of acute therapies
- Serious adverse effects of acute therapies
- Risk of medication overuse headache
- Menstrual Migraine
What are the drugs used for migraine prophylaxis?
Beta Blockers – Propanolol, metoprolol
Antidepressants – amitriptyline
Anticonvulsants – Valproate, Topiramate
CCB: Flunarizine
CGRP Antagonists: Erenumab, Fremeneszumab, Galcanezmab
- Known as calcitonin gene related peptide
- Helpful for pt who are resistant to other medications
What is the management of raised ICP?
- Head elevation – inc venous outflow
- Permissive Hyperventilation to PCO2 of 26-30mmHg – to induce vasoC
- Kept euvolemic and normo- to hyper- osmolal
- Keep pt appropriately sedated can decrease ICP by reducing metabolic demand
- Allow permissive Hypertension – to maintain CPP of >60mmHg
- Keep normothermic – Treat Fever
- Osmotic Diuretics (Mannitol) – reduce brain volume by drawing fluids out
- Decompressive Craniotomy
