Case 4 - Headaches Flashcards
What are the 2 main types of headaches?
- Primary
- Secondary
What are the 3 types of primary headaches?
- Tension
- Cluster
- Migraine
What is the site of tension headache?
Band around the forehead (bilateral)
What is the site of cluster headache?
Peri-orbital pain (unilateral)
What is the site of migraine?
Variable (unilateral/bilateral- usually unilateral)
What is the onset of tension headache?
Worsens at the end of the day with stress
What is the onset of cluster headache?
Occurs at night during sleep
What is the onset of migraine?
In bright light / Related to periods - can be variable
What is the character of tension headache?
Dull, aching, persistent, tightening, pressing
What is the character of cluster headache?
Sharp, stabbing, excruciating
What is the character of migraine?
Pulsatile/throbbing,
What is the frequency/duration of tension headache?
30 min to 7 days
3 - 4 attack/week to 1 - 2 attacks/year
What is the frequency/duration of cluster headache?
15 - 180 mins/attack
1 - 8 attacks/day for 3 - 16 weeks
1 - 2 bouts/year
What is the frequency/duration of migraine?
2 - 72 hours/attack
1 attack/year to >8 per month
What are the associated symptoms with tension headache?
- Mild photophobia
- Mild phonophobia
- Anorexia
What are the associated symptoms with cluster headache?
- Sweating
- Facial flushing
- Nasal congestion
- Ptosis
- Lacrimation
- Conjunctival injection
- Pupillary changes
What are the associated symptoms with migraine?
- Visual aura
- Phonophobia
- Photophobia
- Pallor
- Nausea/vomiting
What are the risk factors for tension headaches?
- Mental tension
- Stress
- Missing meals
- Fatigue
- Female
- Family history
What are the risk factors for cluster headaches?
- Males
- Heavy smoking
- Heavy drinking
How to treat tension headache?
Acute - analgesics (paracetamol, ibuporfen)
Prophylactic - Amitriptyline
How to treat tension headache?
Acute - analgesics (paracetamol, ibuprofen)
Prophylactic - Amitriptyline
How to treat menstrual migraines?
- Occur prior to menstruation due to fall in oestrogen levels.
- May benefit from transdermal oestrogen patches 3 days before menstruation.
What is needed for diagnosis of cluster headaches?
At least 1 autonomic pain feature:
- conjunctival injection
- Facial sweating
- Lacrimation
- Redness
- Nasal stuffiness
- Eyelid and facial swelling
How to treat mild/moderate migraines?
- NSAIDs (paracetamol, ibuprofen)
- Don’t give opiates as it increases N+V
How to treat severe attacks of migraine and cluster headaches?
- Triptans (sumatriptan)
- 5HT1 receptor agonist, leads to vasoconstriction of cranial and basilar arteries.
How to treat severe attacks of migraine and cluster headaches?
- Triptans (sumatriptan)
- 5HT1 receptor agonist, leads to vasoconstriction of cranial and basilar arteries.
What are the side effects of triptans?
- Temporary blood pressure increase
- Paraesthesia and sensation of cold in the extremities
- Dizziness, malaise, flashes
- Frequent intake (≥ 10x/month) can lead to headaches
What are the contraindications for triptans?
- Coronary artery disease (MI, stroke)
- Peripheral artery disease
- Uncontrolled hypertension
- Pregnancy and breastfeeding
What is the treatment for acute cluster headaches?
- 100% oxygen with 12L/min non rebreathe mask for 15 mins
- Arrange home and ambulatory oxygen
- Sumatriptan nasal spray or SC injections
What is the prophylactic treatment for cluster headaches?
- Verapamil - CCB
- Lithium: neurotransmitter stabiliser
- Take at onset of cluster headache.
What are the different causes of secondary headaches?
- Meningitis
- Brain tumour
- Haemorrhage
What are the different causes of primary headaches?
- Tension headaches
- Cluster headaches
- Migraines
- Giant cell arteritis
What is meningitis?
Inflammation of the meninges.
What is route of infection and the incubation time?
- Pathogens colonise in nasopharynx and then enter CNS
- Bacterial: 3-7 days
- Viral: 2-14 days
What are the symptoms of meningitis?
- Headache
- N+V
- Neck stiffness: nuchal rigidity, check for sore throat
- Fever
- Altered mental state and seizures: bacterial meningitis only
- Photophobia
- Flu like symptoms: viral
- Non blanching rash/purpura
What is the triad of symptoms in meningitis?
Headache, neck stiffness, photophobia
Which bacteria are more likely to lead to bacterial meningitis?
- Neisseria meningitidis (meningococcal meningitis)
- Streptococcus pneumoniae,
- Haemophilus influenzae type b (Hib)
How to treat TB meningitis?
- Same medications for TB
- Isoniazid, rifampin, pyrazinamide and ethambutol
Who is more likely to have fungal TB?
- Immunocompromised such as HIV
What are the risk factors for meningitis?
- Extremes of age - young children, young adults (since they live in close quarters) and elderly.
- Crowding
- Immunodeficiency and absence of vaccination
- Patients with leukaemia and lymphoma
- Asplenia
What is encephalitis?
- Encephalitis is inflammation of the brain.
- Common cause is herpes simplex virus (HSV).
- Unlike meningitis it causes confusion or disorientation, drowsiness, seizures and changes in personality and behaviour, such as feeling very agitated and aggressive.
What can be seen on examination for meningitis?
- Purpuric (non-blanching) rash: press glass against rash and it it might not disappear
- Neck stiffness: chin might not be able to touch chest
- Kernig’s sign: Inability to straighten leg when hip is flexed to 90 degrees
- Brudzinski’s Signs - Flexion of the neck will cause flexion of the hips and knees
How is lumbar puncture performed?
- L3/L4 or L4/L5
- Use iliac crest as it lines up with the spinous process of L4
- Patient in lateral recumbent position.
What are the contraindications of lumbar puncture?
- Not done if signs of raised ICP as it can cause brainstem to move down foramen magnum
- Signs of ICP = seizures, focal neurological sign, papilledema
What are the results of bacterial lumbar puncture?
Colour - Cloudy WBC - High Type of WBC - Neutrophils Glucose - Very low Protein - High
What are the results of viral lumbar puncture?
Colour - Clear WBC - High Type of WBC - Lymphocytes Glucose - Normal Protein - High
What are the results of tuberculosis and fungal lumbar puncture?
Colour - Clear (fungal), turbid (TB) WBC - High Type of WBC - Lymphocytes + neutrophils Glucose - Low Protein - Very high
What does blood in LP suggest?
- Needle used to perform the LP probably punctured a vessel
- Subarachnoid haemorrhage.
- CSF will be yellow (xanthochromia) due to breakdown of haemoglobin.
How to manage encephalitis?
- CT or MRI
- Treatment: IV antivirals
How to treat viral meningitis?
Symptomatic therpay
How to treat bacterial meningitis?
1st - Cefotaxime or ceftriaxone because they can travel through the BBB and Dexamethasone.
2nd - Add amoxicillin if the patient is over 60
3rd - Add vancomycin if penicillin resistance is a possibility
- In GP: IM benzylpenicillin
What is giant cell arteritis?
Autoimmune vasculitis that causes chronic inflammation of large and medium-sized arteries in particular the carotid arteries, its major branches and the aorta.
What are the risk factors of GCA?
- Over 50 years
- Female
What are the symptoms of GCA?
- New onset headache – throbbing, dull, unilateral, temporal
- A tender, hardened temporal artery (weak/absent pulses)
- Jaw claudication – painful when chewing
- Scalp tenderness – painful to brush hair
- Sudden Vision loss:(amaeurosis fugax)
What can be a differential to GCA?
- Polymyalgia rheumatica (PMR), an inflammatory condition that classically causes morning pain and stiffness is the neck, shoulders, and hips – the pain gets better with exercise.
What are the investigations for GCA?
- Raised ESR/CRP
- Temporal Artery Biopsy:
negative results do not rule out GCA as it happens in skip lesions
What is the treatment for GCA?
- High dose steroids: oral prednisolone to prevent loss of vision
- Refer to neurology/rheumatology/ophthalmology
What is aura?
- Neurological features which precede headache.
- Around 20-30% people experience aura.
- Visual disturbance: Scintillating scotoma
- Sensory symptoms: unilateral paraesthesia and numbness affecting the hand and arm before involving the face, lips and tongue.
What are the causes of raised ICP?
- Increase in tissue: SOLs, cerebral oedema
- Increase in CSF
- Hypertension
What are the symptoms of raised ICP?
- Headache – persisting headaches, could be worse in the morning, made worse on bending over
- Vomiting
- Focal neurology – cranial nerve palsy. CN VI – longest running nerve.
- Blurring of vision - enlarged blind spots, peripheral visual field loss.
- Bradycardia
- Hypertension
- Papilledema
- Decreased level of consciousness – change in memory, change in personality
- Respiratory depression
How to treat raised ICP?
- Mannitol: osmotic diuretic
- Hyperventilation: reducing pCO2
- Barbiturate coma
- Remove SOLs: craniotomy
What are the different causes of space occupying lesion?
- Tumours
- Infection
- Vascular: haemorrhages, AVM
- Hydrocephalus: build up of CSF due to blockage, increased production, reduced absorption
Where does epidural haemorrhage occur?
Periosteal dura and skull
Where does subdural haemorrhage occur?
Meningeal dura and subarachnoid
Where does subarachnoid haemorrhage occur?
Subarachnoid and pia matter
Which artery bleed causes epidural haemorrhage?
Middle Meningeal artery
Which artery bleed causes subdural haemorrhage?
Bridging Veins
Which artery bleed causes subarachnoid haemorrhage?
Cerebral artery
How does epidural haemorrhage present on CT?
- Convex/Lens + swelling around skull
- Doesn’t cross suture line
How does subdural haemorrhage present on CT?
- Crescent
- Crosses suture line
How does subarachnoid haemorrhage present on CT?
- Blood in the sulcus
What are the causes of epidural haemorrhage?
- Trauma to head
- Fall in elderly
- Fight
What are the causes of subdural haemorrhage?
- Fall in elderly
- Alcoholic patients
What are the risk factors of subarachnoid haemorrhage?
- Hypertension
- Polycystic kidney disease
- Arteriovenous malformations
How does epidural haemorrhage present?
Collapse at time of injury followed by lucid interval followed by sudden loss of consciousness
How does subdural haemorrhage present?
Slowly progressive deterioration in abilities after injury (days to weeks)
How does subarachnoid haemorrhage present?
Severe, sudden, thunderclasp headache
What is cerebral venous sinus thrombosis?
- Thrombi in central venous sinus causing venous congestion.
- Leads to raised ICP and its symptoms.
What is idiopathic intracranial hypertension?
- This is a diagnosis of exclusion and usually occurs in obese women in the range of 20-40 years.
What are the signs of idiopathic intracranial hypertension?
- Papilledema
- Headaches
- Signs of raised ICP
How to treat idiopathic intracranial hypertension?
Acetazolamide, diuretics and losing weight
What type of brain tumours are there?
- Primary: arise from intracranial structures
- Secondary: Metastasis from breast, stomach, prostate, thyroid
What are the different types of primary brain tumours?
- Meningioma: most common, slow growing and benign
- Commonly caused by radiation for other cancers
- Treat using dexamethasone
- Gliomas
Which childhood cancer causes a “white reflex” on ophthalmoscopy instead of a red one?
Meningioma
- What is the prophylactic treatment for migraines?
- What should be remembered with each treatment?
Propranolol – should be avoided in asthmatics
Topiramate – less likely given to women of childbearing age
What is the causes of meningitis in 0-3 months?
- Group B Streptococcus (most common cause in neonates)
- E. coli
What is the causes of meningitis in 3 months - 60 years?
- Neisseria meningitidis
- Streptococcus pneumoniae
- Haemophilus influenzae
What is the causes of meningitis in immunocompromised patients?
Listeria monocytogenes
- What is likely to develop after LP?
- How long does it last?
- How to treat it?
- Infection at site and low pressure headache
- Develops within 24-28 hours
- May last several days
- Worsens with upright position
- Manage using analgesia, fluids, caffeine
- If persists: use blood patch
