CNS/ HN - Headache Flashcards
Differential Diagnoses of Headache
- Migraine*
- Tension Headache*
- Temporal Arteritis and Polymyalgia Rheumatica*
- Meningitis*
- Somatisation*
- Subarachnoid Hemorrhage* - 2
- Stroke*
Probability diagnosis
Acute:
•respiratory infection
Chronic: •tension-type headache •combination headache •migraine •transformed migraine
Serious disorders not to be missed Cardiovascular: •subarachnoid haemorrhage •intracranial haemorrhage •carotid or vertebral artery dissection •temporal arteritis •cerebral venous thrombosis
Neoplasia:
•cerebral tumour
•pituitary tumour
Infection:
•meningitis (esp. fungal)
•encephalitis
•intracranial abscess
Haematoma:
extradural/subdural
Glaucoma
Benign intracranial hypertension
Pitfalls (often missed) Cervical spondylosis/dysfunction Dental disorders Refractive errors of eye Sinusitis Ophthalmic herpes zoster (pre-eruption) Exertional headache Hypoglycaemia Post-traumatic headache (e.g. post-concussion) Post-spinal procedure (e.g. epidural, lumbar puncture) Sleep apnoea
Rarities: •Paget disease •post-sexual intercourse •cluster headache •Cushing syndrome •Conn syndrome •Addison disease •dysautonomic cephalgia
Masquerades checklist Depression Diabetes Drugs (see list) Anaemia Thyroid disorder and other endocrine (as above) Spinal dysfunction (cerviogenic) UTI
Is the patient trying to tell me something?
Quite likely if there is an underlying psychogenic disorder.
Headache - Key History
Key history
A full description of the pain including a pain analysis should be obtained, especially associated symptoms. It is useful to get the patient to prepare a diary with a grid plotting the relative pain intensity with time of day. Family history, psychosocial history and drug history
Headache - Key PE
Key examination
- Use the basic tools of trade: thermometer, sphygmomanometer, pen torch, diagnostic set with ophthalmoscope and stethoscope
- Inspect the head, temporal arteries and eyes
- Areas to palpate include the temporal arteries, the facial and neck muscles, the cervical spine and sinusitis, teeth and TMJs
- Look for signs of meningeal irritation and papilloedema
- A mental state examination is advisable
- Perform a basic neurological examination
Headache - Key Investigations
Key investigations Consider: •FBE •ESR/CRP •selective radiography (e.g. skull X-ray, sinus X-ray, CT scan or MRI scan).
Headache - Diagnostic tips
Diagnostic tips
- Hypertension is an uncommon cause of headache. •‘Combination headaches’, which can last for days, have a mix of components such as tension, depression, vascular headache and drug dependence.
- A patient >55 years presenting with unaccustomed headache probably has an organic cause.
- Drugs that may cause headache: alcohol, analgesics (rebound), caffeine, antihypertensives (several), COCP, corticosteroids, NSAIDs (esp. indomethacin), vasodilators esp. nitrates, sildenafil
Migraine - Management
- Treatment focuses on two aspects:
1. Treating the acute attack
(rest in a quiet dark room, avoid reading/tv, cold packs to head, and medications)
o mild migraine:
soluble aspirin 600-900mg q4 or
PCM 500mg q4 + an antiemetic
o moderate:
ergotamine + antiemetic (metoclopramide).
o severe:
sumatriptan + antiemetic (metoclopramide or chlorpromazine)
These medications are also available in the form of combinations (mersyndol - paracetamol + codeine + doxylaminesuccinate) - If on OCP, review because it might aggravate migraine.
- For prevention:
lifestyle modification,
avoid trigger factors, and
>3 attacks/mo may give preventive medications x 6-12 months then taper and review. such as
○ beta-blockers
○ cyproheptadine
○ TCAs
calcium channel blockers
Tension Headache - Management
- Relaxation therapy - yoga or meditation
- Hobby
- LSM
- MEDS: Ibuprofen or Paracetamol
Meningitis - Management
- Refer to hospital for admission
- Secure IV lines
- Blood for Ix:
- FBE, ESR/CRP, LFT, UCE, blood culture, PCR.
- Give 1st dose of ab :
Ceftriaxone - In hospital, seen by registrar and specialist
- Septic work up
(chest x-ray+ urine MCS, CT scan +/- LP.)
TA and PMR
Investigations:
Urgent ESR - CRP with request of same day report
FBE
- Start on high dose steroid (prednisolone 60-100mg)
- once ESR is normal maintain on Low Dose steroid for 2-3 years
- Urgent referral to ophtha and vascular surgeon - Temporal biopsy to confirm diagnosis
- Additional tests: MRI and serology r/o CTD
- SE of steroids
- osteopenia, osteoporosis
- hypertension
- DM
- weight gain
- changed facies
- Cataract
- gynecomastia
- low immunity
- Do not worry, monitor you regularly
- every 6 months Dexa scan, Vitamin D and Calcium for >60
- Reading material.
- Review in 48 hours.
- Red flags: worsening of headaches and visual problems
Somatization - History
- Approach
- HOPI - SIQORAA1
- Associated Symptoms/ Ddx
- Somatisation Qs
- Pain in other sites
- Tummy symptoms –N/V, bloating, food intolerance
- Loss of libido, irregular period, erectile dysfunction
- Pseudoneuro: impair balance, paralysis, aphonia and urine retention
- Psychosocial Hx
- MAWS>if positive ask complete MSIGECAPS
- Hallucinations
- Delusions
- Suicide
- HEADS - SADMA
- Hypochondrial Qs
- Do you think you have underlying serious disease
- Are you generally an anxious person?
- Family hx of cancer
PMH - Medical or mental illness
FH - Mental illness
Somatisation - Diagnosis
Condition -
Somatisation
Pain in different parts of the body ( head, abdomen, back, joints, extremities, chest and rectum)
Painful function
(menstruation, sexual intercourse, urination)
2GI symptoms
- n/v, bloating, intolerance to several foods)
1 sexual/ repro symptoms
irreg mens, erectile dysfunction, excessive mens bleeding
1 Pseudoneuro
impaired balance, paralysis, aphonia, urinary retention
Mind Body axis
Stress = pain
Common - not uncommon
Cause - unknown
Clinical feature
Complication
Somatisation - Management
Management: • Pain Management • Lifestyle Modification • Psychologist: CBT • Family meeting with consent • Support groups • Reading materials • Review • Red flags
SAH - Diagnosis
Condition -
Subarachnoid Hemorrhage - condition where blood leaks out of the blood vessel in the subarachnoid space that is one of the linings covering the brain. This bleeding then tends to increase the pressure inside your skull, causing your symptoms. it usually occurs spontaneously or if you have recently had any injuries.
Common
not uncommon
Cause / Risk factors Aneurysm Head injury Hypertension AV malformation Bleeding do
Clinical feature worst headache of my life occipital headache vomiting neck stiffness PE - 3rd nerve compression ptosis mydriasis diplopia down and out OM papilledema Nect stiffness kernig sign positive
Complication
- medical emergency
- if left untreated can be life threatening
SAH - Management
- Admit
- Seen by specialist
- IV lines and take out blood investigations
-FBE, UEC, LFTs, Coagulation profile, Blood grouping and cross-matching - Urgent CT scan
- Medication
vomiting - metoclopromide or ondansetron
BP control - Nimodipine
decrease ICP - Mannitol
Surgery
Clipping or coiling
Stroke - Management
- Refer to hospital
- Admit
- Seen by specialist (Stroke unit team)
- Urgent CT scan
- Investigation
full blood exam, ESR, CRP, UEC, BSL, coagulation profile, ECG, 2D echo, carotid doppler +/- holter monitoring. - You will be managed accordingly to the CT scan findings.
If blood clot and w/in 3 hours = injection to dissolve the blood clot
bleeding = surgery
