Headache Flashcards
What is the acronym for remembering sinister caused of headache?
V: vascular I: infection V: vision threatening I: ICP raised D: dissection
What are the vascular sinister caused of a headache?
- subarachnoid haemorrhage (SAH)
- haematoma (subdural or extradural)
- cerebral venous sinus thrombosis
- cerebellar infarct
What are the infective reasons for a sinister cause of headache?
- Meningitis
2. Encephalitis
What are the vision threatening sinister reasons of a headche?
- temporal arteritis
- acute glaucoma
- cavernous sinus thrombosis
- pituitary apoplexy
- posterior leucoencephalopath
What are the raised ICP sinister causes of a headache?
- space occupying lesion (SOL; e.g. tumour, abscess, cyst)
- cerebral oedema (e.g. trauma, altitude)
- hydrocephalus
- malignant hypertension
- idiopathic intracranial hypertension
What are the dissection sinister reasons for a headache?
- Carotid dissection
How do you assess a headache?
SOCRATES
What are red flags to look for when assessing a headache?
- Decreased level of consciousness
- Sudden onset worst headache ever
- Seizure(s) or focal neurological deficit
- Absence of previous episodes
- Reduced visual acuity
- Persistent headache, worse when lying down
- Progressive, persistent headache
- Constitutional symptoms
- Past MHx
Why is decreased level of consciousness concerning with a headache?
1; SAH need exclusion
- if history of head injury could suggest subdural haematoma (fluctuating consciousness) or extradural haematoma (altered conciousness following a lucid interval)
- meningitis and encephalitis can affect consciousness
Why is sudden onset, worst headache ever worrying?
Suggest SAH with blood in CSF that is irritating the meninges
Why are seizure(s) or focal neurological deficet (e.g. limb weakness, speech difficulties) with a headache worrying?
- suggests intracranial pathology
- BUT migrainous aura can give neurological signs
Why is absence of previous episodes with a headache worrying?
- If recurrent usually less sinister
- If over 50 and new onset could be temporal arteritis
Why is reduced visual acuity with a headache worrying?
temporal arteritis is more common in older patients
What is Amaurosis fugax usually associated with?
usually due to TIA BUT rarely produce a headache
What do you ask if you are concerned about temporal arteritis?
- Jaw claudication
2. Scalp tenderness
If concerned about carotid or vertebral artery dissection what do you ask about?
minor neck trauma (yoga, chiropracter)
Why is a persistent headache worse when lying down with early morning nausea worrying/suggestive of?
- Suggests raised ICP
- Can be worse when lying down or even bending over
When is common to have headaches that are worse when standing up?
suggest reduced intracranial pressure and common after LP - not sinister
What could a progressive persistent headache sinister cause?
could be expansing SOL (e.g. tumour, abcess, cyst, haematoma)
What are some sinister constitutional symptoms with a headache?
- Weight loss
- night sweats and/or fever may suggest malignancy
- chronic infection (e.g. tb) or chronci inflammation (e.g. temporal arteritis)
What could be a sinister past medical history with a headache?
- history of malignancy that is known to metastasize to the brain (e.g. lung, breast)
- history of HIV or other immunosuppression (e.g. transplant patients) resulting in a higher risk of intracranial infection (e.g. toxoplasmosis, abcess, tb)
What investigations do you need to carry out to exclude sinister reasons?
- Basic obs
- Focal Neurological Signs
- Eye inspection
- Other special tests
What basic obs do you carry out to exclude sinister reasons for a headache?
- Altered consciousness: GCS
- Blood Pressure + pulse: check for malignant hypertension
- Temperature: fever and headache suggest intracranial infection
What would a focal limb deficit indicate?
intracranial pathology
What is 3rd nerve palsy?
- ptsosis
- mydriasis
- eye deviated down and out
What is a cause of 3rd nerve palsy?
- SAH due to ruptured aneurysm of the posterior communicating artery
- PCOM arterys are a cause of headache
What is 6th nerve palsy?
convergent squint and/or failure to abduct eye laterally
Why does 6th nerve palsy happen?
compressed either directly by a mass or indirectly by raised ICP
How do you look for 12th nerve palsy?
look for tongue deviation
When can 12th nerve palsy happen with a headache?
arise from a carotid artery dissection
What is Horner’s syndrome?
- partial ptsois
- miosis
- anhyrdosis
Why does Horner’s syndrome happen?
results from interruption of ipsilateral sympathetic pathway
What would Horner’s syndrome with a headache indicate?
- carotid artery dissection
- cavernous sinus lesion
What would exophalmos with a headache suggest?
retro-orbital process such as cavernous sinus thrombosis
What would a cloudy cornea fixed, dilated/oval pupil suggest with a headache?
acute glaucoma
What would you look for in the fundoscopy with a headache?
papilloedema
What would papilloedema suggest?
raised ICP
What would reduced visual acuity with a headache suggest?
- acute glaucoma
- temporal arteritis
What would scalp tenderness with a headache suggest?
temporal arteritis
What do you check for in meningism with a headache?
- patient has a stiff neck
- photophobia
- suggesting meningism due to infection or SAH
What sort of emergency is temporal arteritis?
opthalamological
How do you treat and diagnose temporal arteritis?
- Blood test for ESR and CRP to see if elevated which would be consistent with a systemic inflammation such as temporal arteritis
- To reduce immune mediated inflammation: high dose corticosteroids
- Then temporal artery biopsy
What are the different causes of non-sinister causes?
- Tension type headache
- Migraine
- Sinusitis
- Medication overuse headache
- TMJ dysfunction syndrome
- Trigeminal neuralgia
- Cluster headache
What questions are needed to be asked for a non-sinister headache?
- Does the patient suffer from different types of headaches
- Are there any triggering factors
- How disabling are the headaches
- Do patients get an aura before the headache?
Which type of non-sinister headache affects daily living?
- migraines
- Chronic sinusitis
- Cluster
- Trigeminal neuralgia
Which non sinister headaches are painful but not severely disabling?
- TMJ syndrome
- Medication overuse
- Sinusitis
- Tension type headache
What are common non-sinister headaches?
- Tension type
- Migraines
- Medication overuse
Which type of headache is most common 20-40 yo and 4x more likely in women?
TMJ syndrome
Which headaches are more common in women than men?
- Migraine
- Medication overuse
- Trigeminal neura;gia
- TMJ
What sort of headaches mostly affect men?
cluster
How common are cluster headaches?
occur in cluster for about 6-12 weeks every 1-2 years at exactly same time each day or night
How long do cluster headaches last?
20-30 mins
What is the pain like in cluster headaches?
- Pain focused over one eye
- Pain is intense, and severe, and contemplate suicide
- Red, watery eye, rhinorrhoea, horners syndrome, suggest by patients noticing ptosis during attacks
Where does trigeminal neuralgia affect?
unilateral
What is the pain like in trigeminal neuralgia?
- Unilateral stabbing, sharp facial pain involving one or more of divisions of trigeminal nerve
How long and often are the attacks of trigeminal neuralgia?
- Pain lasts only seconds but can be triggered by eating, laughing, talking or touching affected area
- Several or hundreds attacks a day and can develop long-lasting background pain
- Rarely during sleep
What is the common demographic for trigeminal neuralgia?
60/70 (rare)
What is the pain like in TMJ syndrome?
- Headache, and dull ache in muscles of mastication that radiates to jaw/ear
- Report hearing a click or grinding noise when they move their jaw
When is medication overuse headaches common?
w/Migraine medications and analgesics
What is the pain like in medication overuse headaches?
either migraine or tension type headache
What is the pain like in sinusitis?
- Facial pain coming on over hours to days with coryzal symptoms
- Pain is tight and exacerbated by movement
How long does sinusitis last?
last several days with time course consistent with the infection
What type of headache gives pulsatile, throbbing pain that is usually unilateral?
migraines
How long to migraines last?
- Last between 4-72 hours unless successfully treated
What type of headache gives bifrontal pain described as pressure or tightness around the head like tightening band?
tension headache
Are there any other features apart from a headache in tension headaches?
No
How long do tension headaches last and how often do they happen?
- Episodic occurring in variable frequency
- Only last a few hours and no severely disabling
- Rare cases occur daily
What are triggers for tension headaches?
stress and fatigue
What does migraine treatment involve?
Triptans
Analgesics
Antiemetics
How do you ensure it is a sinister cause and why?
CHECK:
- BP: to exclude malignant hypertension
- Head and neck examination: for muscle tenderness, stiffness or limited movement which can occasional mimic tension type headaches
- Focal neurological signs: should alter intracranial pathology
- Fundoscopy: to exclude raised intracranial pressure
