Headache Flashcards
What is the triad of symptoms of meningitis?
- Headache
- Nuchal stiffness (neck)
- Photophobia
What is a red, purpuric rash indicative of?
Meningococcal meningitis
=
Medical emergency!
(when accompanied by fever in children it is meningitis until proven otherwise)
What signs will a meningitis patient have on examination?
- Kernig’s sign = hamstring spasm in response to extension
- Nuchal stiffness
- Pupuric rash → does not blanch on applying pressure to it; glass test
- Signs of sepsis
- tachycardia
- increased RR
- temperature
- Signs of shock
- Decreased GCS
When would a lumbar puncture for meningitis be contraindicated?
- Coagulation defects
- Raised ICP (→coning)
- Infection at site
- Severe sepsis / rapidly evolving rash
- Respiratory or cardiac compromise
- Continuous or uncontrolled seizures
- GCS <12
What are the characteristics of a tension headache?
- S - Bilateral
- O -
- C - Pressing, tightening, non-pulsating, feeling of pressure behind the eyes
- R -
- A - neck muscles tighten
- T - 30 minutes
- E - Not aggravated by routine
- S - Mild-moderate
What are the characteristics of a migraine?
- S - Unilateral OR bilateral
- O - Brought on by stress/screens/other triggers
- C - Pulsating
-
A - Nausea +/- vomiting
- Aura as a warning (flickering lights, spots, lines, partial loss of vision, numbness in limbs), usually lasts only 20 minutes. For first experience of aura consult with neuro to check it’s not a stroke or TIA.
- T - Lasts 4-72 hours in adults
-
E - Aggravated by/ causes avoidance of AoDL
- Unusual sensitivity to light / sound
- S - Moderate - severe
What are the characteristics of a cluster headache?
- S - Unilateral, around eye / side of face
- O - Same time each day
- C - Variable: sharp, boring, burning, throbbing, tightnening
-
A - Restlessness / agitation
- Red/watery eye
- Nasal congestion / runny nose
- Swollen eyelid
- Forhead / facial sweating
- Constricted pupil and/or drooping eyelid
-
T - 15 minutes - 3 hours
- usually occur every day, in bouts lasting several weeks or months at a time (typically 4-12 weeks)
- S - Severe - very severe
How do you treat a tension headache?
- Paracetamol
- NSAIDs e.g. ibruprofen
- Aspirin sometimes also recommended
- → medication overuse headache /“painkiller headache” may occur with 10 + days continuous use - you get a headache when you stop taking the medication
How do you treat a migraine:
- Acutely
- Prophylactically
- Combination therapy with:
- an oral triptan and an NSAID,
- or an oral triptan and paracetamol
- Preventative with:
- Propanolol
- Anticonvulsant e.g. Topiramate (warning: can cause foetal malformaitons and can interfer with oral contraception)
How do you treat a cluster headache?
- NSAIDs / paracetamol are often not helpful
- Treat in hospital with:
- Oxygen
- use 100% oxygen
- at a flow rate of at least 12 litres per minute
- with a non‑rebreathing mask and a reservoir bag
- Remember to arrange home oxygen
- Triptan
- subcutaneous
- or nasal spray
When would you suspect medication overuse headache?
- headache developed or worsened while they were taking the following drugs:
- triptans, opioids, ergots or combination analgesic medications on 10 days per month or more
- paracetamol, aspirin or an NSAID, either alone or any combination, on 15 days per month or more
Name 4 primary causes of headache
- Tension
- Migraine
- Cluster
- Trigeminal Neuralgia (the only one that needs MRI to find cause)
Name 6 intracranial secondary causes of headache
- Meningitis
- Temporal arteritis
- Raised ICP
- tumour
- beinign intercranial HTN
- acute hydrocephalus
- Venous sinus thrombosis
- Intercerebral haemorrhage
- Subarachnoid haemorrhage
Name 5 extracranial secondary causes of headache
- Acute closed-angle glaucoma
- Sinusitis
- Hypertensive encephalopathy
- Pre-eclampsia
- Carotid / vertebral artery dissection
What are the 4 risk factors for meningitis?
- Extremes of age
- Living in close proximity - outbreaks can occur in student halls of residence and boarding schools
- Vaccination history (absence of)
- Immune suppression/deficiency
What is the difference between meningitis and encephalitis?
Meningitis:
- = inflammation of the meninges
- Often bacterial
- Causes photophobia, neck stiffness, rash, fever, headache
Encephalitis:
- Most common cause is herpes simplex virus (HSV).
- Inflammation of the brain
- Causes confusion or disorientation, drowsiness, seizures and changes in personality and behaviour
What are the common organisms that cause meningitis?
Bacterial:
- Strep pneumoniae
- Neisseria meningitidis (meningococcal meningitis)
- Haemophilus influenzae - type b
Viral:
- Enterovirus
- Herpes simplex
- Varicella Zoster
Fungal:
- crytococcus neoformans
What tests are especially important for meningitis?
- Blood cultures
- CSF testing
- Serology for viruses causing meningo-encephalitis
- Throat swab for Neisseria meningitides & Streptococcus pneumonie
- Urine pneumococcal antigen
What tests are important for encephalitis?
- CT or MRI brain- in encephalitis this may show oedema of the temporal lobes. It can also be used to rule out other causes of intracranial pathology.
- Electroencephalogram EEG- to show characteristic slow waves.
What are the signs and symptoms of raised ICP?
Symptoms:
- New onset headache (no prev. history of headache) in patient >50
- Worse in the morning
- Wose with coughing / bending / sneezing
- Vomiting
- +/- seizures if due to tumour
- Visual disturbances:
- transient visual obscurations; vision becomes blurred or black when there is a change of posture
- May have nerological symptoms on examination
- papilloedema
- restricted visual fields
- enlarged blind spots
- reduced GCS
Signs:
- Bradycardia
- Hypertension
- Papilloedema
How would you treat viral meningitis?
- Confirm viral over bacterial meningitis with CSF, then stop antibiotics
- Commence antiviral therapy
- Aciclovir or valaciclovir is typically given first line for HSV and varicella zoster
- Don’t forget A→E medications e.g. fluids and anti-emetics
How would you treat bacterial meningitis?
Start antibiotics without delay, adjuct once CSF results are back:
- IV 3rd generation cephlosporin e.g. cefotaxime or ceftriaxone plus vancomycin
- adjunct dexamethasone
- If 60+ add amoxycillin
- If penecillin resistance is a possibliliy add vancomycin or rifampicin
In the community, IM benzylpenicillin is used
What are the signs / history of temporal / giant cell arteritis?
History:
- Unilateral
- Throbbing pain
- Scalp tenderness
- Jaw claudication (pain on chewing)
- >55 years old
- May have visual problems
- malaise
- sweats
- proximal muscle aching
Signs:
- Ispilateral blindness
- Temporal tenderness
- Optic nerve oedema on fundoscopy
How do you treat giant cell / temporal arteritis?
Initially, give oral prednisolone:
- with visual symptoms — 60 mg as a one-off dose (they should be seen by an ophthalmologist the same day).
- without visual symptoms — 40 to 60 mg daily (minimum 0.75 mg/kg)
What are the red flag symptoms (requiring 2WW) for secondary headaches?
- Symptoms of raised ICP
- dsf
- unexplained vomiting
- new onset seizures
- new or progressive neurological deficit
- PMH of malignancy
- headaches triggered by exertion
- increase in severity or frequency despite treatment
What is “thunder-clap headache” a sign of?
Subarachnoid haemorrhage (SAH)
- May also present with a ‘sentinel’ (a mild headache preceding the severe one, seen in <10%), usually in women aged 40 to 60 years.
- Sudden onset, worst headache of life
- Immediate CT or MRI.
Describe the CSF changes
Is meningitis a notifiable disease?
Yes!
Contacts need prophylaxis e.g. rifampicin
What is the commonest type of brain tumour?
Glioblastoma multiforme (GBM), a type of glioma
What is the normal ICP?
When is it pathologically high?
Normally <15 mmHg in adults
Pathological ICP is persistent pressures >20mmHg
What are the headache red flags?
- A headache of sudden onset, reaching maximum intensity by five minutes (suggestive of subarachnoid haemorrhage)
- Fever with a worsening headache, meningeal irritation and change in mental status (viral/bacterial meningitis)
- New-onset focal neurological deficit, personality change or cognitive dysfunction (intracranial haemorrhage/ischaemic stroke/space occupying lesion)
- Decreased level of consciousness
- Head trauma (more significant if within the last three months)
- Headache which is posture dependent (e.g. worse on lying down and coughing with raised ICP).
- Headache associated with tenderness in the temporal region (unilateral or bilateral) and jaw claudication (temporal arteritis)
- Headache associated with severe eye pain/blurred vision/nausea/vomiting/red eye (acute angle closure glaucoma)
What investigations are essential if you suspect temporal / GC arteritis?
- CRP and ESR (both raised)
- FBC and LFTs
- temporal artery biopsy
- ultrasound if unavailable, but this is not diagnostic
