Case 4 - Headache Flashcards
What are primary and secondary headaches?
Primary headaches have no underlying pathology causing them
Secondary headaches are due to underlying pathology e.g. SOL
What is the pathophysiology of headaches?
Due to ion channel pathology
There is depolarisation at the occipital end of the cell
This then undergoes cortical spreading depression, which is a wave of depolarisation
There’s then sustained suppression of neuronal activity
The cortical spreading depression correlates to migraine symptoms and changes in blood flow
What are the signs and symptoms of a tension-type headache?
Bilateral Pressing/tight pain Mild-moderate No effect on ADL No aura No other symptoms Lasts 30 mins to continuously
What are the signs and symptoms of a migraine?
Uni- or bilateral
Pounding headache, pulsatile
Moderate-severe
May affect ADL/causes avoidance of activities
May get photophobia, sensitivity to loud noises, N and V etc
Aura may be present with or without headache - visual disturbances, change in smell or taste etc.
Lasts 4-72 hours
What are the signs and symptoms of a cluster headache?
Usually unilateral Variable quality Severe Restless/agitated Usually watery/red eye, nose dripping, puffy eye, sweating on the ipsilateral side as the headache No aura 15-180 mins
What could be migraine triggers?
Certain foods - cheese, chocolate, red wine etc
Menstruation - due to drop in oestrogen
Environmental - bright lights, smokey rooms etc.
OCP
Long flights and jet lag
Relaxing after stress
What questions should you ask in the history?
Onset Does posture affect the pain? Sensory/power loss? Are you prone to headaches? Is this the same as previous episodes? Any trigger? Smoking/caffeine use Use of painkillers?
What defines a chronic vs. episodic headache?
Chronic:
- Tension-type and migraines = 15+ days a month for 3+ months
- Cluster = between 1 every other day - 8x a day with a remission period of less than 1 month in a 12 motnh period
Episodic:
- Tension-type and migraines = <15 days a month
- Cluster = remission >1 month
What examinations should you perform?
Basic neuro exam
Fundoscopy - looking for papilloedema and optic disc hemorrhage in raised ICP
CN exam to test for focal neurological deficit:
-Visual fields = large blind spot and peripheral field loss is raised ICP
-Eye movements = CNVI palsy due to raised ICP
Plantar reflex
Gait
Purpuric rash
Pronator drift
When should you consider investigations for a headache?
When there are any of the following:
- Worsening headache with fever
- Symptoms of GCA
- Different character of headache than previously
- Thunderclap onset - max intensity at 5 mins after sudden onset
- Signs of raised ICP - triggered by cough, sneeze or valsalva
- Orthostatic headache
- New onset cognitive dysfunction
- Change in personality
- Accompanied by a reduction in consciousness
- Trauma <3 months ago
What is aura?
Can last 5 mins to 60 mins and can precede and overlap a headache
Can be visual disturbances (scintillating scotoma) or other
But, 20-30% of migraine sufferers don’t get aura
Fully reversible
What are emergency headache symptoms?
Thunderclap onset
Acute onset with neuro signs
Raised ICP with head trauma
New onset headache in 3rd trimester/post-partum
What are red flags for GCA?
New onset headache in someone>50 Tender to the touch Non-pulsatile temporal artery Other CN palsies Linked with polymyalgia rheumatica Responds to steroids (60 mg pred)
Check ESR and CRP
May need temporal artery biopsy
What are 2WW symptoms in a headache?
Features of raised ICP - Orthostatic hypotension, worse on bending over
Headache and new onset seizures
New/progressive focal neurological deficit
History of malignancy
Vomiting without other cause
How do you treat a medication overuse headache?
Stop the offending medication for 2 months- triuptans, OCP, opioids
How do you treat a migraine/tension-type/cluster headache?
Try acute treatment
Consider triptans
Contra - heart conditions and interact with SSRIs
Should take one dose, if after 2 hours the headache has not resolved, do not take another dose
Only take a 2nd dose for a separate episode as rebound headache is a common SE
Can’t drive/operate heavy machinery on sumatriptan - makes you drowsy
Propanolol
Anti-epileptic = topiramate
Amitriptylline in tension-type
Try 3 prophylatics at max dose for 3 months each before reffering on
Can consider migraine prophylaxis in:
- ADL affected
- 2+ attacks a month
- Migraines that don’t respond to treatment
- Frequent/long/uncomfortable auras
What is acute treatment of a headache?
Try NSAIDs
Anti-emetics e.g. metocloperamide, domperidone
What are signs and symptoms of meningitis?
Classic triad of neck stiffness, photophobia and headache
May be accompanied by a fever if infective
Purpuric rash in meningococcal meningitis
What are differentials for meningitis?
Encephalitis (most common cause is HSV - seizures, drowsiness, change in personality/behaviour)
Non-infective causes of ,meningitis e.g. blood
Subdural empyema
What should you examine for in meningitis?
Kernig's sign Neck stiffness Fundoscopy Full neuro exam Purpuric rash
What are causes of meningitis?
Bacterial - Strep. pneumoniae, Neisseria meningitidis, H. influnzae
Viral - Enterovirus, EBV, HSV
Fungal - cryptococcus neoformans
What investigations you can perform for meningitis?
Lumbar puncture - WCC, protein, glucose, opening pressure, PCR, culture
Blood cultures
Throat swab
Urine culture
What investigations you can perform for meningitis?
Lumbar puncture - WCC, protein, glucose, opening pressure, PCR, lactate Blood cultures FBC, U and Es, LFTs, clotting CRP Throat swab Urine antigen for pneumococci
What would normal CSF be on an LP?
Clear, colourless
>2/3 blood glucose
0-5 WCC
0.15-0.4 protein
What would a bacterial infection be on an LP?
Turbid
Low glucose
High protein
500- 10 000 polymorphs
What would TB be on an LP?
Turbid, straw coloured, viscous
Slightly low glucose
V High protein
<500 lymphocytes
What would a viral infection be on an LP?
Clear
Normal glucose
Slightly high protein
< 1000 lymphocytes
What would a fungal infection be on an LP?
Viscous, clear
Slightly low glucose
V high protein
<500 lymphocytes/polymorphs
What is the treatment for meningitis?
If there is clinical suspicion, treat
Use appropriate agent for the type of infection
Some strains have risk of transmission, so give rifampicin to close contacts
Ceftrioxone and Dexamethosone
Add amoxicillin for older patients
What are the causes of a raised ICP?
Tumour: -Primary -Metastasis Infective: -Brain abscess, granuloma, parasitic Vascular: -Hameorrhage -AVM -Brian infarction/swelling Hydrocephalus: -Overproduction of CSF -Non-communicating ie. blockage to CSF flow -Communicating i.e. problem with CSF absorption
What are gliomas?
And what is their management?
Tumours of teh glial cells - supporting cells of the brain
Grade 1-4, with 4 being the most malignant
1- Pilocytic Astrocytoma
2-Low grade astrocytoma
3-Anaplastic astrocytoma
4-Glioblastoma multiforme
Manage with surgery if possible
Dexamethosone for raised ICP
Steroids
Radio/chemotherapy
What are meningiomas?
And what is their management?
Tumours of the arachnoid cap cells
Slow growing, but can become large
Benign
Manage with surgery if possible
Radiosurgery
What is a vestibular schwannoma?
And what is their management?
Tumour of the nearve sheath of the vestibular system
Slow-growing
Benign
Ipsilateral hearing loss and tinnitus
Surgery is high risk
Radiosurgery
Can recur
What is an extradural haematoma?
Forms oval shape
Due to the arteries bleeding
Presents with LOC, may regain consciousness
Lucid interval is when conscious, but the patient deteriorates as the haematoma develops
What is a subdural haematoma?
Has a crescent shape
Due to venous bleed, so can be from a very minor fall/injury
May have fluctuating consciousness
What is the treatment for raised ICP?
Sit patient upright so that gravity acts on the CSF flow
Avid hypotension
Sedate to decrease metabolic demands
Keep normal CO2 - can vasodilate
Insert shunts to drain CSF
Mannitol
Hyperventilation
Barbiturates to decrease metabolic demands
Craniectomy can relieve pressure temporarily
Surgical treatment of secondary cause
What are symptoms of a SOL?
Due to raised ICP:
- Vomiting
- Blurred vision
- Reduced consciousness
- Headache, worse on bending down
Generally unwell
Hormonal effects
Motor weakness
Sensory changes
What are the signs of a SOL?
Papilloedema HTN Bradycardia Focal neurological signs - lobe dependent Seizures
What are red flag symptoms in a headache?
Headache increasing despite treatment
Orthostatic headache
Headache on exertion
Headache lasting more than 8 weeks
