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)
