Headache Flashcards
Aetiology/RF tension headache
- Unknown- muscle contraction? Psychological stress?
- F>M
- Young
How can tension headache be divided?
Episodic - occurs on < 15 days per month
Chronic - occurs on > 15 days per month
SOCRATES tension headache
S: Generalised, Bilateral. O: Gradual or acute onset C: Dull – “tight band” R: Neck/shoulders A- insomnia, stress T: Lasts 3-4 hours E: Analgesics help S: Moderate
Ix/Mx for tension headache
CLINICAL DIAGNOSIS
Conservative: Headache diaries (avoid triggers, relaxation)
Medical: Simple analgesia (paracetamol, ibuprofen)
What must you be wary of when prescribing analgesics for headache?
Medication Overuse Headaches-
analgesics cease to provide pain relief and actually perpetuate and intensify the headaches.
Define migraine
chronic condition that causes
attacks of headaches
What is believed to be the pathophysiology of migraine?
Inflammation of the trigeminal nerve changes
the way that the brain process stimuli
So things like the pulsations of the meningeal arteries which are normally ignored by the brain are perceived as painful.
RF migraine
F>M
Younger 30-40
Migraine triggers (chocolates)
Chocolate/cheese HTN/hypothyroid Obesity Caffiene Oral contraceptive/hormone changes Lack of sleep/sleep disorder Alcohol Travel Exercise Stress
SOCRATES migraine
S: Unilateral O: Paroxysmal, comes on gradually C: Pulsating/throbbing R: neck stiffness/pain A: aura, photophobia, N+V, parasthesia T: 4 – 72h E: Physical activity/stress, noise, light; lying in a quiet, dark room S: Moderate to severe
What are the associated symptoms of migraine?
Aura: flashing lights, tingling Photophobia, phonophobia Nausea, vomiting Visual changes Tingling Numbness
INTERFERES WITH ADLs
Briefly describe the phases of migraine
PRODROME
- few hours-days
changes in mood, behaviour and sleep.
AURA
- 5-60 mins before
- visual changes, flashing lights
- pathognomonic but only present in 15-20%
MIGRAINE ATTACK -throbbing, drilling - icepick in head - N+V - sensitivity to light/sound/smell and then a postdrome which is characterised by weakness and fatigue
POSTDROME
- fatigue
- depressed/euphoric
- lack of concentration
Ix for migraine
Migraine is a CLINICAL diagnosis
Investigations only to exclude sinister causes
Mx of acute migraine
Conservative: Headache diary, avoid triggers
MEDICAL
- Paracetamol, NSAIDs
- Triptans- if above is ineffective (cause vasoconstriction of MMA + inhibit nociceptive transmission)
Prophylaxis of migraines
- Propranolol (BB)
- Topiramate (antiepileptic)
If ineffective:
- Amitriptyline (antidepressant
NOTE- only give prophylaxis if triptans ineffective
A 40-year-old man comes in with a headache. The headache started yesterday and he feels it more over one side of his head. He is also quite nauseous and the only thing that helps him is to seat in the dark. He says that he has had similar headaches in the past for which the GP advised ibuprofen and NSAIDs but these did not help him. What’s the next most appropriate step in his management?
Sumatriptan
Codeine → opioids should be avoided in migraine as they can cause dependence
Diclofenac → NSAIDs haven’t worked so need to step up
Sumatriptan
Topiramate → first-line for prevention but doesn’t manage headache acutely
Amitriptyline → second-line for prevention
Define cluster headache
A neurological disorder characterized by
recurrent, severe headaches on one side of the head, which
occur at a cyclical pattern
Epidemiology cluster headaches
M>F
20-40 yrs
Pathophysiology cluster headache
hypothalamic activation with secondary trigeminal and autonomic activation
- Hypothalamus regulates body clock
- Autonomic activation > autonomic features
- Trigeminal activation > pai
Cluster headache presentation
S: UNILATERAL, behind the eye O: Acute onset, CYCLICAL PATTERN, (same time each day, usually at night) C: intense, sharp, penetrating A: autonomic symptoms T: 15 minutes – 3 hours E: triggered by alcohol & strong smells S: Severe – Can be disabling
What is the pattern of cluster headache attacks?
come in clusters following a cyclical pattern
eg every few months will wake you up at 1am every night for a week
Describe the associated symptoms of a cluster headache
ANS symptoms:
- Watery, red eye
- Facial flushing
- Nasal congestion
O/E:
- Partial Horner’s (Ptosis, miosis)
RFs cluster headache
smoking
alcohol
Define trigeminal neuralgia
Facial pain syndrome in
the distribution a division of the trigeminal nerve.
What is thought to be the cause of trigeminal neuralgia?
Compression of the trigeminal nerve by a loop of artery or vein
what is trigeminal neuralgia associated with?
MS (plaque deposition)
HTN
What are the triggers for trigeminal neuralgia?
Things that compress the affected area:
washing your face, eating, brushing teeth
Typical trigeminal neuralgia presentation
Unilateral pain, along the trigeminal division
Paroxysmal, lasting for seconds
Stabbing, shooting
Numbness/parasthesia
Commonest causes of meningitis in neonates
E. coli
Group B Strep
Commonest causes of meningitis in children
H. influenzae
Strep. pneumoniae
Commonest cause of meningitis in young adults
Nesseria meningitidis
Commonest causes of meningitis in elderly
Strep pneumoniae,
Listeria monocytogenes
What is the typical presentation of meningitis?
Acute onset, severe headache + fever = early signs
- Meningism- headache, neck stiffness, andphotophobia
- N+V
- Seizures
- Altered Mental status
- Shock (tachycardia, hypotension)
- non-blanching rash
RF for meningitis
- Closed communities/Crowding (spread via resp droplets)
- Extremes of age <5, >65
- Infections (head/face, mastoiditis, sinusitis)
2 signs of meningitis
Kernig’s Sign - with the hips flexed, there is pain/resistance on passive knee extension - this is due to severe stiffness in the hasmstrings
Brudzinski’s Sign - flexion of the hips and knees when the neck is flexed - this is due to severe neck stiffness
Ix for meningitis
CT head-PRIMARY:
if neurological deficit or ↓ consciousness (check for raised ICP)
DIAGNOSTIC: LP + CSF analysis
2 sets of blood cultures
Compare the appearance of CSF in bacterial, viral and TB meningitis
APPEARANCE
- bacterial = turbid
- viral = clear
- TB = fibrin web
Compare the cells of CSF in bacterial, viral and TB meningitis
CELLS - bacterial = ↑ neutrophils (polymorphs) - viral = ↑ lymphocytes (mononuclear) - TB = ↑ lymphocytes (mononuclear)
Compare the glucose of CSF in bacterial, viral and TB meningitis
GLUCOSE
- bacterial = ↓
- viral = normal
- TB = ↓
Compare the protein of CSF in bacterial, viral and TB meningitis
PROTEIN
- bacterial = ↑
- viral = normal / ↑
- TB = ↑
GP management of suspected meningitis
benzylpenicillin IM
& URGENT REFERAL TO THE HOSPITAL
A+E management of suspected meningitis
Broad spectrum antibiotics
- ceftriaxone IV
- benzylpenicillin IM
- acyclovir if viral
IV dexamethasone (prevent hearing loss, cerebral oedema + improve mortality)
Complications of meningitis
Hearing loss (most common)
Sepsis
Impaired mental status
Define encephalitis
Acute onset febrile illness with behavioural, cognitive, psychiatric manifestations due to inflammation of the brain parenchyma.
aetiological causes of encephalitis
USUALLY VIRAL:
- HSV1-2
- CMV
- EBV
- HIV
- measles
NON-VIRAL
- bacterial meningitis
- TB
- malaria, listeria, Lyme disease, legionella
Epidemiology of encephalitis
Affects mostly the extremes of age
- <1
- > 65
How does encephalitis present?
Viral prodrome
Fever
Headache
ALTERED MENTAL STATE
- Memory disturbances
- Personality changes
- Psychiatric manifestations
- Impaired consciousness
Ix for encephalitis
- LP- CSF analysis for same as meningitis
- Bloods
- EEG
- CT/MRI (bitemporal oedema/hyperintense lesions)
A 19-year old medical student presents to A & E with
headache, fever, and neck stiffness. Once raised ICP is
excluded a lumbar puncture is performed and CSF
analysis reveals the following:
High polymorphs, low glucose and high protein
Given the most likely diagnosis, which is the most likely
causative organism?
Listeria monocytogenes
HIV
HSV
Neisseria meningitidis
VZV
Neisseria meningitidis
Causes of raised ICP
SOL- tumour, abscess, haemorrhage
Hydrocephalus
Symptoms of raised ICP
HEADACHE
- Bilateral
- Gradual
- throbbing/bursting
- worse in the morning
- coughing, sneezing
ASSOCIATED:
- Vomiting
- Altered GCS
- Seizures
Signs of raised ICP
- Focal neurological symptoms
- Papilloedema
Cushing’s reflex → Cushing’s triad:
- ↑SBP
- Irregular breathing
- Bradycardia
- Cheyne-stokes respiration
What reflex is a physiological response to raised ICP?
Response to ↑ICP that results in Cushing’s trial of
- ↑BP
- irregular breathing
- bradycardia
Cheyne - stokes respiration
Abnormal pattern of breathing characterised by progressively deeper and sometimes faster breathing followed by a gradual decrease that results in apnoea
Which conditions may show cheyne - stokes respiration?
HF stroke hyponatraemia TBI brain tumours
Ix for raised ICP
- URGENT CT-head
- ↑ICP is a CONTRAINDICATION to LP
- Causes brainstem herniation
Define EDH
A collection of blood in the potential space between the dura and the bone
Causes of EDH
Head trauma
- Skull fracture causing laceration of the MMA
- can also result from tears in dural venous sinus
Epidemiology of EDH
YOUNG (20-30 years old males)
How does EDH present?
- Trauma (major)
- LOC
- Lucid interval
- Increasingly severe headache, drop in GCS, signs of raised ICP
Ipsilateral pupil dilation (compression of PSNS fibre in CNIII)
Ix for EDH- what would you see?
Urgent Non-contrast CT head
MRI
Fluid collection shows LENTICULAR (lemon) shape that does not cross suture lines
Define SDH
A collection of blood between the dural and arachnoid covering of the brain.
Causes of SDH
Rupture of the bridging veins
- elderly
- alcoholics
due to brain atrophy
SDH presentation
- Gradual onset, continuous headache
- Fluctuating consciousness
- Confusion
- Personality changes
- Symptoms of ↑ ICP
How can SDHs be classified?
ACUTE: Within 72 hours (younger patients, trauma)
SUBACUTE: 3-20 days (worsening headache, elderly)
CHRONIC: After 3 weeks (headache, confusion)
RF for SDH
- Head trauma & falls (often following minor trauma up to 9 weeks before which patients have forgotten)
- Old age
- Alcoholics
- Anticoagulation
Ix for SDH- what would you see?
Urgent Non-contrast CT head
MRI
The subdural fluid collection is usually CRESCENTIC (banana) in shape and can cross suture lines.
Different histories for different categories of SDH?
ACUTE: history of trauma with head injury, patient has reduced conscious level
SUBACUTE: worsening headache 7-14 days after injury, altered mental status
CHRONIC: can present with headache, confusion, cognitive impairment, psychiatric symptoms, gait deterioaration, focal weakness, sezures
SDH conservative management + indications
CONSERVATIVE- <10mm, no midline shift, non neuro deficit
- Admit, observe and monitor
- Do a follow-up CT in 2-3 weeks.
- Prophylactic antiepileptics
- ICP monitoring if GCS < 9
- Correct coagulopathies
SDH surgical management + indications
Burr hole surgery
May leave drain in place
Most common cause of SAH
Berry (saccular) aneurysm rupture
Blood flows into the SAH, sometimes seeping into brain parenchyma and/or ventricles.
What causes symptoms in SAH?
- Sudden increase in ICP
- Toxic effects of blood on brain parenchyma and cerebral vessels
SAH symptoms
HEADACHE
- Occipital (or diffuse)
- Sudden (“Thunderclap”)
- Continuous
- Very severe, maximum intensity within MINUTES
OTHER:
- meningism
- symptoms of ↑ ICP
RF for SAH
Polycystic kidney disease
Alcohol
Smoking
HTN
CT sensitivity over time
< 12 hours- 98%
< 1 week- 50%
> 3 weeks - 0%
What would you see in lumbar puncture in SAH? When is it indicated?
- Indicated if CT is normal
- Xanthochromia & oxyhaemoglobin
- From 12 hours after symptom onset
An older man with a longstanding history of AF on anticoagulation with warfarin is brought into A & E by his carer, who is concerned about the patient's confusion at home. The carer describes frequent falls over the last several months. On examination, he has a right-sided pronator drift and is weaker on his right side. His mental status testing reveals poor concentration. What is the most likely cause of his symptoms? Stroke Subdural haemorrhage Alzheimer’s disease Encephalitis Parkinson’s disease
Subdural haemorrhage
Pronator drift is a sign of an upper motor neuron problem, and subdural is an UMN problem
Stroke → UMN (can have pronator drift but more acute presentation)
Subdural haemorrhage
Alzheimer’s disease → wouldn’t present with one-sided weakness and pronator drift
Encephalitis → has changes in behaviour and mental state but here the patient does not have any features suggestive of infection, and the anticoagulation is a stronger RF for bleeding
Parkinson’s disease → would present more with resting tremor, bradykinesia and tremor
Most common type of primary brain tumour
Most brain tumours arise from glial cells (the supportive cells of the NS)
How can primary brain tumours be classified?
Intra-axial tumours: within the brain substance
Extra-axial tumours are outside the brain parenchyma (they originate from meninges or CNS)
What is the most common type of brain tumour in children?
Medulloblastoma
CNS tumour presentation
raised ICP headache:
- Bilateral
- Gradual
- Throbbing/bursting
- Worse in the morning
- Coughing, sneezing
Others:
- FLAWS
- Focal neurological signs
- Weakness
- Difficulty walking
- Seizures
- Personality changes
RF for brain tumours
Ionising radiation
Immunosuppression (HIV)
Inherited syndromes (eg neurofibromatosis)
What in general causes the symptoms of CNS tumours?
- By direct effect: brain is infiltrated and local function impaired
- By secondary effects of raised ICP and shift of intracranial contents (papilloedema, vomiting, headache)
- By provoking generalised or partial seizures
How do frontal lobe tumours present?
personality disturbance,
apathy
impaired intellect
How do R parietal lobe tumours present?
L homonymous Hemianopia
L sided hemiparesis
Left sensory loss
How do vestibular schwannoma’s present?
progressive deafness
Ix for CNS tumours
CT (quicker)
MRI (better resolution)
CXR, CT thorax, abdo & pelvis to check for metastases
Biopsy (definitive)
A 33-year-old woman attends her six-month follow-up appointment for headache. They are migrainous in nature but whereas she used to have them every few months, over the last three months she has experienced a chronic daily headache. She takes co-codamol qds and ibuprofen
tds. What is the best medical management?
A. Stop all medication
B. Start paracetamol
C. Start sumatriptan
D. Start propranolol
E. Continue current medication
The treatment is to withdraw analgesics which initially will worsen the headache (the patient should be prepared for this) but in the long run will alleviate it.
It is not advisable for headache patients to take simple analgesia more than 2 days a week.
Once she is off the analgesia, it will be easier to discern the
effect of her migraines
