Chapter 1: Headache Flashcards
What are the sinister causes of headache?
VIVID
Vascular: subarachnoid haemorrhage (SAH), haematoma (subdural, extradural), cerebral venous sinus thrombosis, cerebellar infarct
Infection: meningitis, encephalitis
Vision threatening: temporal arteritis, acute glaucoma, cavernous sinus thrombosis, pituitary apoplexy, posterior leucoencephalopathy
Intracranial pressure (raised): space-occupying lesion (SOL; e.g. tumour, abscess, cyst), cerebral oedema (e.g. trauma, altitude), hydrocephalus, malignant hypertension, idiopathic intracranial hypertension
Dissection: carotid dissection
When taking the headache Hx, what are the ‘red flags’?
- Decreased level of consciousness
- Sudden onset, worst headache ever
- Seizure or focal neurological deficit
- Reduced visual acuity
- Persistent headache, worse when lying down
- Progressive, persistent headache
- Constitutional symptoms: weight loss, night sweats, fever suggesting malignancy, chronic infection (e.g. TB) or chronic inflammation (e.g. temporal arteritis)
- Past medical history: malignancy -> mets to brain, HIV or other immunosuppression (transplant pts) resulting in higher risk of intracranial infection (toxoplasmosis, abscess, TB)
Why are you worried about decreased level of consciousness?
SAH must be excluded!
Hx of head injury could suggest subdural haematoma (fluctuating consciousness) or extradural haematoma (altered consciousness following a lucid interval).
Meningitis and encephalitis can also affect consciousness
Why are you worried about sudden onset, worst headache ever?
SAH must be excluded! Blood in the CSF irritates the meninges.
A very severe headache of almost instantaneous onset is characteristic of SAH
‘being hit on the back of the head with a bat.’
Why are you worried about seizure or focal neurological deficit?
e.g. limb weakness, speech difficulties
Suggests intracranial pathology, but a migrainous aura can give neurological signs
Why are you worried about reduced visual acuity?
-Temporal arteritis is more common in older pts
Also ask about jaw claudication (pain in jaw with chewing) and scalp tenderness
-Carotid or vertebral artery dissection
-Transient blindness (amaurosis fugax) is usually due to TIA, but rarely with a headache
Why are you worried about persistent headache, worse when lying down?
With early morning nausea (lying down flat overnight) -> raised ICP
Can also occur when pt bend over
Headaches worse when standing up suggests reduced ICP and are common after a lumbar puncture (LP) - this is not sinister!
Why are you worried about progressive, persistent headache?
Could be an expanding SOL (e.g. tumour, abscess, cyst, haematoma)
What are you looking for in the basic observation of a pt with a headache?
- Altered consciousness, esp. GCS score
- BP and pulse for malignant hypertension
- Temperature: fever suggests intracranial infection
What focal neurological signs are you looking for in the patients with a headache?
- Focal limb deficit
- 3rd nerve palsy
- 6th nerve palsy
- 12th nerve palsy
- Horner’s syndrome
What is the sig. of focal limb deficit?
Increases the likelyhood of intracranial pathology
What is the sig. of 3rd nerve palsy?
Ptosis (droopy eyelid) + mydriasis (dilated pupil) + eye deviation (down and out)
-SAH due to a ruptured aneurysm of the posterior communicating artery (PCOM)
What is the sig. of 6th nerve palsy?
Convergent squint +- failure to abduct the eye laterally
- Nerve compression either by a mass or indirectly by increased ICP
- 6th nerve has the longest intracranial course
What is the sig. of 12th nerve palsy?
Tongue deviation
-Carotid artery dissection
What is the sig. of Horner’s syndrome?
Triad of partial ptosis + miosis (constricted pupil) + anhydrosis (dry skin around the orbit)
These result from interruption of the ipsilateral sympathetic pathway
-Suspect carotid artery dissection (ask about neck pain) or cavernous sinus lesion
What can you look for in the eye inspection?
- Exopthlamos: cavernous sinus thrombosis
- Cloudy cornea, fixed dilated /oval pupil: acute glaucoma
- Optic disc appearance on fundoscopy: papiloedema, indicating raised ICP
What does reduced visual acuity suggest in the pt with headache?
Scalp tenderness?
Stiff neck or photophobia?
- Suggests acute glaucoma or temporal arteritis
- Temporal arteritis
- Meningism due to infection or SAH
Temporal arteritis is also known as?
Giant Cell Arteritis (GCA)
Pathophysiology of temporal arteritis
-Typically appears in pts with over 50 yo
-Formation of immune, inflammatory granulomas in the tunica media of medium/large size arteries
-The inflammation or thrombosis or spasm may block the lumen of the affect arteries
-Mandibular branch of the external carotid artery -> jaw claudication
-Superficial temporal branch of the external carotid artery -> headache and scalp tenderness
-Posterior ciliary artery -> visual disturbance:
retina ischaemia -> blurring, visual field loss
optic motor muscles -> double vision (diplopia)
Why concerns you about temporal arteritis?
With visual loss in one eye the other eye is at risk without prompt treatment
- Ophthalmological emergency
- Refer to on-call ophthalmologist ASAP!
What are the first-line investigation for pt with temporal arteritis?
- ESR
- CRP
What’s the first-line management for temporal arteritis?
-High-dose corticosteroids
*More time consuming Ix done after this.
e.g. temporal artery biopsy: to confirm dx
but even the biopsy may not show the granulomas
What is the guideline for diagnosing temporal arteritis?
American College of Rheumatology guideline
3 of the following 5
-Age of onset of symptoms > 50
-New headache
-ESR > 50 mm/h
-Clinically abnormal temporal artery (tender or non-pulsatile)
-Biopsy of temporal artery showing mononuclear cell infiltration or granuloma
What are the non-sinister causes of headache?
- Tension-type headache
- Migraine
- Sinusitis
- Medication overuse headache
- Temporomandibular joint (TMJ) dysfunction syndrome (TMJ syndrome)
- Trigeminal neuralgia
- Cluster headache
