Common Conditions Flashcards
What are headaches classified into?
Primary & Secondary
What are Primary Headaches?
No structural abnormalities identified, includes migraines, tension type headaches, cluster headaches
What are secondary HA’s?
Associated with various underlying primary aetiologies such as head and neck trauma, infections, substance abuse or its withdrawal
What are Red Flag indicators for Headaches?
- Sudden onset, especially if no previous history
- Severe and debilitating pain
- Progressive
- Fever
- Vomiting
- Disturbed consciousness/confusion, drowsiness
- Personality change
- worse with bending, coughing or sneezing
- maximum in morning
- wakes patient at night
- neurological and visual symptoms/signs
- seizure
- young obese female
- “new” in elderly, especially >50 yrs
- Post Head injury
What is a Cervicogenic Headache?
= Headache from neck disorders (cervical dysfunction or spondylosis)
What is the cause of a Cervicogenic Headache?
- caused by abnormalities in any structure innervated by upper two cervical nerves C2, C3
- bony structures and soft tissues of the neck can refer pain in the head and face
What is the Pathophysiology/Anatomy of Cervicogenic Headache? Why does this happen?
- convergence, whereby afferents from the upper three cervical nerve roots interact woth afferent fibres in the descending tract of the Trigeminal nerve in the region of the upper cervical spinal cord known as the Trigeminocervical Nucleus
- In the presnece of sensitization of this complex, cervical afferent input is misinterpreted an as well perceiving neck pain, a headache is also felt
Site of Cervicogenic Headache?
usually the occipital region, the pain starts in the neck, eventually spreading to the head where max pain is often located
Radiation of Cervicogenic Headaches?
possible radiation to parietal region, vertex of the skull and behind the eye, ipsilateral neck, shoulder and arm pain
Quality of Cervicogenic Headaches
moderate to non excruciating pain, usually non throbbing
Duration of Cervicogenic HA’s
pain episodes varying duration or fluctuating, continuous pain
Onset of Cervicogenic HA’s
usually present on waking and settles during the day
Aggravating factors of Cervicogenic HA’s
neck movement and/or sustained awkward position
Associated features of Cervicogenic HA’s
often a history of trauma including a MVA or blow to the head
- autonomic symptoms and signs
Physical examination of Cervicogenic HA’s
stiffness and grating of the neck, tenderness to Palp over C1, C2 and/or C3 cervical vertebra, especially on the side of the HA
What is a tension Type HA?
muscle contraction HA’s
- most common type of primary HA
75% of patients are females
What is the cause for tension type HA’s
often associated with cervical dysfunction, musculoskeletal neck problems, stress or mental tension
Pathophysiology/Anatomy of Tension HA
- muscular origin
- typically symmetrical tightness
Site of Tension HA
frontal, over the forehead and temples
Radiation of Tension HA
Occiput
Quality of Tension HA
Dull ache, tight pressure feeling, tight band around head
Frequency of Tension HA
almost daily
Duration of Tension HA
hours, can last days
Onset of Tension HA
after rising, can get worse during the day
Aggravating factors of Tension HA
stress, overwork with skipping meals
relieving factors of Tension HA
alcohol
Associated features of Tension HA
light headedness, fatigue, neck ache or stiffness, perfectionist personality, anxiety/depression
Physical examination of Tension HA
muscle tension, scalp may be tender to touch, may be positive “invisible pillow sign” (when they hold their head up after removing pillow when they are lying prone)
What is a Sinus Headache (Frontal)?
Symptomatic inflammation of the paranasal sinuses usually associated with concurrent inflammation of the nasal mucosa
usually last less than 4 weeks
Aetiology of Sinus Headache (Frontal) (cause)
- most common = viral infection
- risk factors: older age, smoking, air travel, exposure to changes in atmospheric pressure, swimming, asthma and allergies, dental disease and immunodeficiency
Pathophysiology/Anatomy of Sinus Headache (Frontal)
- viral inoculation via direct contact with the conjunctiva or nasal mucosa
- Symptoms usually develop in the first day after inoculation
- nose blowing may propel contaminated fluid from the nasal cavity into paranasal sinuses
- inflammation follows, resulting in sinonasal hypersecretion and increased vascular permeability leading to transudation of fluid into the nasal cavity and sinuses. Viruses also can exert a direct toxic effect on nasal cilia, impairing mucociliary clearance. A combination of mucosal oedema, cuopious thickened secretions, and ciliary dyskinesia results in sinus obstruction and perpetuates the disease process
Site of Sinus Headache (Frontal)
frontal or retro orbital, maxillary tooth discomfort, facial pain or pressure that is worse or localized to the sinuses when bending forward
Quality of Sinus Headache (Frontal)
facial pain, pressure or fulness in face
Frequency of Sinus Headache (Frontal)
Diurnal variation, developing in the morning, being most intense in the middle of the day, then subsiding early evening
Duration of Sinus Headache (Frontal)
< 4 weeks of purulent discharge
Aggracating factors of Sinus Headache (Frontal)
bending forward
Associated features of Sinus Headache (Frontal)
nasal congestion, rhinorrhea, tearing, fever, fatigue, cough, hyposmia or anosmia, ear pressure or fullness, halitosis, eustachian tube dysfunction, purulent discharge
Physical examination of Sinus Headache (Frontal)
tenderness, erythema or oedema over the frontal or maxillary sinuses, pain on percussion, tenderness with percussion of upper teeth, fever, oedema over the upper eyelid, ewing sign may be elicited, transillumination of the frontal or maxillary sinuses may show opacity
What are migraine HA’s?
greek - pain involving half the head
10-15% of adults
more common in females
peaks between 20-50 years
various types - classic migraine (HA, vomiting & aura), common migraine (without aura)
What is aura?
- focal neurological symptoms that initiate or accompany an attack that can last b/w 5-60 minutes
- visual disturbances (bright spots in the visual fields)
- somatosensory sensations (tingling of the lips, face or hands
- paraesis of an arm or leg
- mild aphasia and confusion
Aetiology of Migraine HA’s
- most common trigger factor is stress
- Exogenous (particularly foods, alcohol, drugs, glare bright light, emotional stress, head trauma, allergen, climatic change, excessive noise, perfume) and Endogenus (Tiredness, physical exhaustion, lack of sleep, stress, hormonal changes, family history)
Pathphysiology/Anatomy of Migraine HA’s
- thought to be vascular
- now suggests abnormality in brain function leading to a chain of events in the periphery
- neuroanatomical basis for migraine i sthe trigeminocervical nucleus
- likely to be a combination of direct factors in concert with a reduction in the normal functioning of the centrally mediated endogenous pain control pathways that normally gate pain
Site of Migraine HA’s
temporofrontal region (unilateral, can be bilat)
Radiation of Migraine HA’s
retro-orbital and occipital
Quality of Migraine HA’s
intense and throbbing
Frequency of Migraine HA’s
1 or 2 per month
Duration of Migraine HA’s
4-72hrs
Onset of Migraine HA’s
paroxysmal, often wakes with it
Offset of Migraine HA’s
spontaneous, often after sleep
Aggravating factors of Migraine HA’s
tension, activity
Relieving factors of Migraine HA’s
sleep, vomiting
Associated features with Migraine HA’s
nausea, vomiting (90%), irritability, aura (visual, sensory)
Common migraine without aura involve the following checklist
- patient needs to have at least 5 attacks fulfilling:
HA’s that last 4-72hrs and at least two of nausea and/or vomiting, photophobia and/or phonophobia
Common migraine with aura involve the following checklist
at least two attacks fulfilling:
- one or more of visual, sensory, speech, and/or language, motor, brainstem, retinal and at least two of
1. at least one aura symptom spreads
2. each aura symptom lasts 5-60min
3. at least one symptom is unilateral
4. HA follows aura within 60min
What is Meningitis?
- inflammation of the meninges usually caused by an infection
- it may be caused by a number of different microorganisms with the most types in australia being viral and bacterial
- access route - systemic or bloodstream infection or direct extension from an infected area
Bacterial Meningitis
- most due to meningococcus
- 1-3 people affected per 100,000 each year in australia
- fatality rates 6%
Viral meningitis
- causes due to human enteroviruses, herpes simplex virus type 2, as well as varicella zoster virus and the viruses that cause measles and mumps (DONT NEED TO KNOW ALL OF THESE)
- not reportable in AUS
- more common that bacterial meningitis
- usually less severe and not usually life threatening
- may resolve in ~ 1 week
Cause of bacterial meningitis
common inhabitants of the nasopharynx
- usually predisposing factor such as a prior URTI before the bacteria become blood borne
- bacteria function as irritants and induce an inflammatory response by the meninges, CSF, ventricles
- Exudate can thicken CSF and interfere with CSF flow around brain and spinal cord
Cause of Viral Meningitis
usually begins in the respiratory or gastrointestinal tract
- enters lymphatic system and travels to the blood and crosses the blood brain barrier to reach the meninges
Radiation of Meningitis
- HA’s from meningitis is usually generalised and radiates to the neck
Duration of Meningitis
HA is constant and severe and may begin abruptly
Associated Factors with Meningitis
Fever and neck stiffness
Aggravating factors of Meningitis
flexion of the neck, Kernig’s sign test
When do we refer to the hospital (Meningitis)
HA + neck stiffness + fever
What is Cervical Artery Dissection? (CAD)
A tear in the carotid and/or vertebral arteries
Aetiology of Cervical Artery Dissection
Most are spontaneous (61%), some due to trauma (30%)
A few associated with Cx manipulation
Epidemiology of Cervical Artery Dissection
2.6 persons per 100,000 (US data) - reported to occur in all age groups with a peak incidence of 34-54 yrs
Risk factor with Cervical Artery Dissection
- History of Cx trauma, inc. minor/trivial trauma
- recency of trauma: immediate > 5 days post-trauma
- HTN or other risk factors for cardiovascular disease
- past/family history of migraine
- relationship with Cx manipulation: casual/temporal?
- data inconclusive
- need informed consent
- awareness of contraindications to Cx HVLA as well as risk factors for CAD
Symptoms of Cervical Artery Dissection
- acute, sudden onset headache
- unilateral - affecting the frontal, temporal, occipital or supraorbital regions
- unilateral neck or facial pain
- pain: tunica adventitia innervated with nociceptors
- constant - ache/throbbing/sharp
- unlike anything they have experienced perviously
- horners syndrome
- cranial neuopathy
- upper or lower limb neurological symptoms (weakness, ataxia)
- pulsating tinnitus
Management of a patient with suspected CAD
immediate medical referral (ED)
What is Raised Intracranial Pressure
increased intracranial pressure in the skull that can cause a HA
Cause of Raised Intracranial Pressure
a space occupying lesion including a cerebral tumour and subdural haematoma
Symptoms of Raised Intracranial Pressure
- general HA
- usually in morning
- aggravated by abrupt changes in intracranial pressure
- later associated with vomiting and drowsiness
Site of Raised Intracranial Pressure
generalised, often occipital
Radiation of Raised Intracranial Pressure
retro-orbital
Quality of Raised Intracranial Pressure
dull, deep steady ache
Frequency of Raised Intracranial Pressure
daily
Duration of Raised Intracranial Pressure
may be hours in the morning
Onset of Raised Intracranial Pressure
worse in mornings, usually intermittent, can waken from sleep
Aggravating factors of Raised Intracranial Pressure
coughing, sneezing, straining at toilet
Relieving factors for Raised Intracranial Pressure
analgesics, sitting, standing
Associated features with Raised Intracranial Pressure
vomiting, vertigo/dizziness, drowsiness, seizures, confusion (later), neurological signs (depending on side)
HA’s caused by Medication
medication overuse HA’s in people whose HA’s developed or worsened while they are taking the following drugs for 3 months or more:
- triptans, opoids, ergots or combination analgesic medication on 10 days per month or more
- paracetamol, aspirin or a NSAID, either alone or any combination on 15 days per month or more
TMJ related HA’s
- recurrent pain in one or more regions of the head &/ face
- X-ray, MRI and/or bone scintigraphy demonstrate TMJ disorder
- Pain is precipitated by jaw movements and/or chewing of hard or tough food
- reduced range of irregular jaw opening
- noise from one or both TMJs during jaw movements
- tenderness of joint capsule of one or both TMJs
- HA resolve within 3 months after successful ttt
Types of Neck Pain
Acute (<6 weeks)
Subacute (persists for 6/52 to 6/12)
Chronic (>6months)
What is nociceptive pain?
arises from actual or threatened damage to non-neural tissue and is due to activation of nociceptors
- facet joints, IVDs, Ligaments, muscles, bones
What is Neuropathic Pain?
caused by a lesion or disease of somatosensory nervous system
What is radicular pain?
pain associated with nerve root pathology
- sharp or shooting in quality
- usually experienced in the dermatome affected
- nerve root pain
What is Radiculopathy?
a range of symptoms that can arise from nerve root pathology
- radicular pain
paraesthesia, anaesthesia, hypoesthesia - motor deficiencies, weak or loss of reflexes
Red flags for acute neck pain
- Symptoms and signs of infection
- History of trauma
- past history of malignancy
- age >50 years
- Neurological symptoms in limbs
- Cardiovascular risk factors, transient ischaemic attack
- concurrent chest pain, shortness of breath, diaphoresis
