Headache Flashcards
What % of adults does a headache affect in the 18-65 year range?
50-75%
List the patterns of headache.
Acute single headache Dull headaches, increasing in severity Dull headache, unchanged over months Triggered headache Recurrent headaches
List the potential causes of an acute single headache.
Febrile illness, sinusitis First attack of migraine Following a head injury Subarachnoid haemorrhage Meningitis, tumour, drugs, toxins, stroke Thunderclap (Sudden onset) low pressure.
List the potential causes of dull headaches, increasing in severity.
Benign Overuse of medications (Codeine) Contraceptive pill, hormone replacement therapy Neck disease Temporal arteritis Benign intracranial hypertension Cerebral tumour Cerebral venous sinus thrombosis
List the potential causes of a dull headache, unchanged over months.
Chronic tension headache
Depressive, atypical facial pain
List the potential causes of a triggered headache.
Coughing, straining, exertion
Coitus
Food and drink
List the potential causes of recurrent headaches.
Migraine
Cluster headache
Episodic tension headache
Trigeminal, or post-herpetic neuralgia
List the red flags associated with headaches.
Onset - thunderclap, acute, subacute
Meningism - photophobia, phonophobia, stiff neck, vomiting
Systemic symptoms - fever, rash, weight loss
Neurological symptoms or focal signs - Visual loss, confusion, seizures, hemiparesis, double vision, 3rd nerve palsy, Horner syndrome, papilledema.
Orthostatic better lying down
Strictly unilateral
List the focal signs associated with a headache.
Double vision
3rd nerve palsy – oculomotor (Posterior communicating artery aneurysm can
rupture).
Horner syndrome – Sympathetic cervical chain of ganglia affected.
What symptoms would a patient present with if they had a 3rd nerve palsy?
Ptosis and dilated pupil, down and outward gaze.
Superior oblique and lateral rectus functional
Describe the onset and character of a headache a patient with a subarachnoid haemorrhage would develop.
Thunderclap headache with a sudden onset.
Whats a common cause of a headache due to a subarachnoid haemorrhage?
Ruptured berry aneurysm
What may somebody with meningism present with?
Stiff neck and photophobia
What type of scan reveals aneurysm manifesting as a subarachnoid haemorrhage?
Angiogram
What % of subarachnoid haemorrhages are instantly fatal?
50%
What may stop the leak in a subarachnoid haemorrhage?
Vasospasm
What will confirm the bleed and establish the cause if a patient may have a subarachnoid haemorrhage?
Early neurological assessment
CT brain, Lumbar puncture (RBC and xanthochromia) and MRA, angiogram done for further investigations
How are aneurysms treated nowadays?
Aneurysms are filled with platinum coils.
What is an acute intracerebral bleed?
Fatal haemorrhage due to coning.
Explain how coning occurs.
Elevations in intracranial pressure results in herniation (tectorial), considering the brain distends through the foramen magnum > Compression of the lower brainstem and upper cervical spinal cord.
What is a papilledema?
Optic disc swelling due to raised intracranial pressure.
Why does an artery dissection occur?
An artery dissection occurs due to a tear in the layer of the arterial lumen, this results in the accumulation of blood within the teared lumen to the extent that a false lumen appears.
A clot forms – limiting blood flow through the artery.
Turbulent flow potentiates a thrombotic environment.
Outline the presentation of a vertebral and carotid artery dissection respectively.
Headache and neck pain common.
An occipital headache is present in a vertebral artery dissection
Phantom of the opera mask distribution of pain is typical in a carotid artery dissection.
> 20% of ischaemic strokes <45 years (young stroke)
Mean age: 40, carotid > vertebral
Traumatic v Spontaneous
What syndrome predisposes individuals to a dissection?
Ehlers Danlos Syndrome
What investigations can be done to confirm a dissection of the carotid or vertebral artery?
MRI/MRA, doppler, angiography
What is the treatment for a patient with a dissection>
Aspirin or anticoagulation (6/12) to minimise the risk of embolism, stroke and blood clot.
What is a chronic subdural haemorrhage?
Cortical veins are disrupted leading to a subdural bleed. Tendency to bleed increases in patients with anti-coagulants. Asymmetric herniation.
What is temporal arteritis?
Giant cell arteritis is a granulomatous vasculitis of large and medium-sized arteries affecting branching of the external carotid artery.
Epidemiology of temporal arteritis.
Over the age of 55
3 times more common in females
List the symptoms of temporal arteritis.
Polymyalgia rheumatica – proximal muscle tenderness
Involvement of the posterior ciliary arteries causes blindness
Elevation of ESR and CRP
Temporal artery inflamed and tortuous
Visible on ultrasound
Biopsy – inflammation and giant cells.
Constant unilateral headaches, scalp tenderness, and jaw claudication.
What is cerebral venous thrombosis?
Thrombosis in dural venous sinus or cerebral vein.
Unusual amount of headache due to raised ICP
Non-territorial ischaemia “venous infarcts”
Haemorrhage
Thrombophilia, pregnancy, dehydration, Behcets
List causes of meningitis.
Viral- Coxsackie, ECHO, Mumps, EBV
Bacterial - Meningococci, Pneumococci, Haemophilus
Tuberculous
Fungal - Cryptococci
Granulomatous- Sarcoid, Lyme, Brucella, Bechet’s, Syphilis Carcinomatous
List the potential symptoms a patient with meningitis may present with.
Malaise Headache Fever Neck stiffness Photophobia Confusion Alteration of consciousness
What is herpes simplex encephalitis?
Haemorrhagic changes in the temporal lobes.
Would you treat and then diagnose bacterial meningitis?
Yes, because bacterial meningitis is fatal.
Give Abs first and then do blood and urine culture.
What signs would you look for an a lumbar puncture that would indicate meningitis?
Increased white cell count, decreases glucose
Antigens
Cytology
Bacterial culture
What scans could you do to confirm meningitis?
CTI or MRI scan
Bacterial meningitis
Cerebral oedema with effacement of ventricles and sulci & inflamed meninges. Bacterial meningitis – brain swells and decompression can occur- herniating through the foramen magnum.
What is sinusitis?
Inflammation of the paranasal sinuses.
List the symptoms of sinusitis.
Malaise, headache, fever Blocked nasal massages Loss of vocal resonance Anosmia Nasal or postnasal catarrh Local pain & tenderness
Frontal pain characteristically begins 1-2 hours after rising and clears up during the afternoon.
What is a glioblastoma multiforme?
Fast growing glioma developed from star-shaped glial cells (astrocytes & oligodendrocytes).
Who does idiopathic intracranial hypertensions often effect?
Young obese women
What are the symptoms of idiopathic intracranial hypertension?
Headache, visual obscuration, diplopia, tinnitus
Papilledema, +/- visual field loss
What drugs can cause idiopathic intracranial hypertension?
Hormones, steroids, antibiotics, Vitamin E
What are the treatment options for idiopathic intracranial hypertension?
Weight loss, diuretics, optic nerve sheath decompression, lumboperitoneal shunt, stenting of stenosed venous sinuses.
(Decompression involves an incision on the medial wall of the orbit, allowing the CSF to leak out.)
What is a low pressure headache caused by?
Cerebrospinal fluid leak due to a tear in the dura (and meningeal membranes). Traumatic post lumbar puncture or spontaneous.
How can you treat a low pressure headache?
Rehydration, Caffeine, blood patch.
What would an MRI with contrast injection reveal if a patient had a low pressure headache?
Intense meningeal enhancement
What is Chiari Malformation?
Cerebellar tonsils descending through the foramen magnum. Descend further when patient caught and tug on the meninges causing cough headache.
OSA
Characteristic body habitus, history of loud snoring and apnoeic spells.
Hypoxia and CO2 retention; non-refreshing sleep.
Depression, impotence and poor performance at work.
N.B: Requires sleep study, nocturnal non-invasive ventilation and potential surgery
What is trigeminal neuralgia?
Electric shock like pain in the distribution of a sensory nerve
Triggered by innocuous stimuli. Any division of the trigeminal can be affected. Neurovascular conflict at the point of entry of the nerve into the pons (a potential symptom of MS)
List the treatments for trigeminal neuralgia.
Carbamazepine, lamotrigine, gabapentin.
Posterior fossa decompression.
Atypical face pain
Most commonly in middle-aged women. Depression/anxious.
Daily, constant, poorly localised deep aching or burning.
Facial or jaw bonesRadiates to the neck, ear or throat.
Not lancinating
Not confirming to the strict anatomical distribution of any nerve
No sensory loss
Pathology in teeth, temporomandibular joints, eye, nasopharynx, and sinuses must be
excluded.
What is the mainstay of management for atypical face pain?
Tricyclics
Unresponsive to conventional analgesics, opiates and nerve blocks.
Post-traumatic headache
Patients admitted with head injury presented with headache; depends on the nature of the head injury (High in car accidents and low in sports injuries).
List the causes of post traumatic headache.
Neck injury
Scalp injury
Vasodilation – autonomic damage
Depression – often delayed.
What is the treatment for a post-traumatic headache?
NSAIDs & TCAs.
Cervical spondylosis
Commonest cause of new headache in older patients
- Bilateral
- Occipital pain can radiate forwards to the frontal region, in a steady manner.
- Not associated with nausea or vomiting.
- Worsened by moving the neck.
N.B: Management involves rest, deep heart, massage; anti-inflammatory analgesics (Over- manipulation may be harmful).
