Headache Flashcards
What is headache
Headache is a symptom
What are the causes of headache
some structural ie scalp, earache , pharmacological , psychological regions
What are the 5 types of headache
1) acute single headache
2) Dull headache increasing in severity
( 1 + 2 indicates smt more serious)
3) dull headache , unchanged over moths ( most common presenting complaint)
4) Triggered headache
5) Recurrent headaches
( 3 + 5 most common presenting complaint )
What are the causes of acute single headache and what are the symptoms
Febrile (fever) illness, sinusitis First attack of migraine Following a head injury Subarachnoid haemorrhage Meningitis Tumour Drugs Toxins Stroke
symptoms:
Thunderclap : headache like you’ve been hit by something
What are the causes of dull headache, increasing in severity
odeine) Contraceptive pill, HRT Neck disease Temporal arteritis (inflammation of temporal arteries) Benign intracranial hypertension Cerebral tumour Cerebral venous sinus thrombosis
what are the causes of dull headache, unchanged over months
Chronic tension headache
Depressive, atypical face pain
what are the causes of triggered headache
Coughing, straining, exertion
Coitus (sex)
Food and drink
What are the causes of recurrent headaches
Migraine
Cluster headaches
Episodic tension headache
Trigeminal or post-herpetic neuralgia
What is neuralgia
neuralgia
Intense, typically intermittent pain along the course of a nerve, especially in the head or face
what are the red flag symptoms of headache
Onset - thunderclap, acute, subacute
Meningism - Photophobia, phonophobia, stiff neck, vomiting
Systemic symptoms - fever, rash, weight loss
Neurological symptoms or facial signs - visual loss, confusion, seizures, hemiparesis, double vision, 3rd nerve palsy, Horner syndrome, papilledema
Orthostatic ( headache when upright but better lying down)
Strictly unilateral ( headache in exactly same spot every time)
Focal Signs:
Double vision
3 rd nerve palsy – oculomotor (Posterior communicating artery aneurysm can rupture and cause hemorrhage damaging oculomotor nerve)
Symptoms: Ptosis ( droopy eye muscle) and dilated pupil, down and outward gaze.
These are things that are innervated by the CNIII
Superior oblique and lateral rectus functional.
Horner syndrome – Sympathetic cervical chain of ganglia affected aka sympathetic nervous system to eye is affected causing:
eye to drop , enophthalmos , smaller pupil
what is 3rd nerve palsy
oculomotor (Posterior communicating artery aneurysm can rupture and cause hemorrhage damaging oculomotor nerve)
Whar are symptoms of CNIII palsy
Symptoms: Ptosis ( droopy eye muscle) and dilated pupil, down and outward gaze.
These are things that are innervated by the CNIII
Superior oblique and lateral rectus functional.
What is horner’s syndrome
Horner syndrome – Sympathetic cervical chain of ganglia affected aka sympathetic nervous system to eye
What are they symptoms of horner’s syndrome
eye to drop , enophthalmos , smaller pupil
what are the 6 categories of the causes of headaches
1) vascular and circulatory causes
2) Infectious
3) intercranial pressure
4) Facial pain
5) trauma
6) cervicogenic pain
What are the 7 vascular and circulatory causes of headache
1) Subarachnoid
2) aneurysm ( ie subarachnoid haemorrhage)
3) Acute intracerebral bleed
5) carotid and veterbral artery dissection
6) chronic subdural haemorrhage
7) temporal arteritis
8) cerebral venous thrombosis
What are the causes and symptoms of subarachnoid haemorrhage
thunderclap headache, sudden onset often described as “ hit on the head”
common cause: ruptured berry aneurysm
rare: arteriovenous malformations .
Can get unexplained SA haemorrhages
Symptoms → meningism: accumulation of blood within subarachnoid space irritates the meninges → stiff neck + photophobia
50% fatal bc aneurysm
what are the causes , treatments and investigation for a headache caused by aneurysm
50% fatal
Treatment:
Vasospasm to minimise bleeding.
Nimodipine & BP control
Early neurosurgical assessment to confirm bleed and establish cause as patient is at high risk of further bleeds:
CT brain, lumbar puncture (will be pink or read due to RBC and xanthochromia) and MRA, angiogram.
Note only do lumbar puncture if no visible blood on CT scan
Always do MRA, angiogram though
Treatment: fill aneurysm with platinum coils so it no longer fills with blood ( see pic on left)
What is coning?
fatal haemorrhage
falx + tentorium cerebelli: weak points → brain exhibits compliance ( aka can tolerate bleed up to a certain point without raising intracranial pressure) to accomodate large blood clot . However when volume is too large compliance is lost
What is falcine / tentorial herniation
high intracranial pressure →falcine/ tentorial herniation ( herniation causes brain to distend ( aka squeeze out of ) through foramen magnum) → compression of lower brainstem and upper cervical SC
what can an acute intracerebral bleed lead to ?
Coning
and falcine / tentorial herniation
what is paillodema
igh intracranial pressure →falcine/ tentorial herniation ( herniation causes brain to distend ( aka squeeze out of ) through foramen magnum) → compression of lower brainstem and upper cervical SC
what is the causes of carotid and vertebral artery dissection
20% of ischaemic strokes <45 years (young stroke)
Mean age: 40, carotid dissection more common > vertebral
Be due to Traumatic vs Spontaneous ( ehlers danlos)
Why does headache occur due to carotid and vertebral artery dissection
Headache can occur due to pathology in large arteries of the neck
artery dissection: tear in arterial lumen - blood accumulates within teared lumen to the extent that a false lumen appears → causes turbulent flow in true lumen as false lumen gets larger
this causes clots to occur
what is arty dissection
artery dissection: tear in arterial lumen - blood accumulates within teared lumen to the extent that a false lumen appears → causes turbulent flow in true lumen as false lumen gets larger
what causes clot formation
clot formation: turbulent flow potentiates thrombotic environment
what are the symptoms of headache caused by carotid and vertebral artery dissection
Common symptoms : headache + neck pain
occipital headache occur due to vertebral artery dissection
phantom of opera mask pain distribution: carotid artery dissection
what ehlers Danlos syndrome
predisposes individuals to a dissection.
what are the investigations and treatments for carotid and vertebral artery dissection
Investigations: MRI/MRA, doppler, angiography ( inject dye into blood vessels to see blood vessels)
Treatment: Aspirin or anticoagulation (6/12) – to minimise the risk of embolism, stroke and blood clot.
what are the causes , treatment and investigation
of headaches caused by chronic subdural haemorrhage
Disrupted cortical veins → subdural bleed.
Tendency to bleed increases in patients with anticoagulants.ie old ppl
Asymmetric herniation
Asymmetric deviation of the ventricles.
CT note : Blood is hypodense (degradation of blood – thus the age of the blood can be determined by the degree of hypodensity. Aka blood left for longer is dark and new blood is light
what is the cause s, symptoms and investigations of temporal arteritis, .?
Giant cell arteritis: granulomatous vasculitis of large/medium-sized arteries
affects external carotid artery branching
Disruption of inelastic elastic lamina
Over 55 : 3x more common in females
Polymyalgia rheumatica: proximal muscle tenderness 25% of patients
Blindness: blocking of posterior ciliary arteries
Constant unilateral headaches, scalp tenderness, and jaw claudication. ( hurts when chewing food)
Investigation Elevation of ESR and CRP ( inflammatory markers via blood test) Temporal artery inflamed and tortuous Visible on ultrasound Biopsy: inflammation and giant cells.
Treatment
Steroids ( given for a long time)
Aspirin ( stop strokes)
what are the causes of cerebral venous thrombosis ?
Like DVT of the brain
Thrombosis in the dural venous sinus or cerebral vein.
Aka blood build up because veins are blocked with raised ICP and haemorrhage
Raised ICP: unusual amount of headache
Non-territorial ischaemia – aka venous infarcts.
Haemorrhage
Causes: Thrombophilia, pregnancy, dehydration, Bechet’s
what are the infectious causes of headache
1) Herpes simplex encephalitis
2) meningitis
3) sinusitis
what are the causes and treatments of herpes simplex encephalitis
Haemorrhagic changes in the temporal lobes
Treat then diagnose (meningitis): antibiotics, blood and urine culture
what are the causes , treatments and investigations of meningitis
Viral- Coxsackie, ECHO, Mumps, EBV ( common)
Bacterial - Meningococci, Pneumococci, Haemophilus ( should be worried)
Bacterial meningitis – brain swells and decompression can occur- herniating through the foramen magnum.
CT: Cerebral oedema with effacement of ventricles and sulci & inflamed meninges.
Note vaccinated for a lot of bacterial that cause bacterial meningitis
Tuberculous
Fungal - Cryptococcus
Symptoms: Malaise, Headache, Fever!, Neck stiffness, Photophobia, Confusion, Alteration of consciousness
Note always treat then diagnose meningitis
Treatment:
Lumbar puncture: increased white cell count, decreased glucose, antigens, cytology, bacterial culture
CT or MRI scan
Blood and urine culture
Antibiotics
Note must do CT / mri b4 lumbar puncture as when there is a raised ICP and a lumbar puncture is done this can cause tentorial herniation
Fever is distinct symptom for meningitis
What are the symptoms , treatments and investigations of sinusitis
Inflammation of the paranasal sinuses.
Symptoms: 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.
Opacification of paranasal sinus
Glioblastoma multiforme (GBM): fast growing glioma developed from star-shaped glial cells (astrocytes & oligodendrocytes).
what are the 4 causes of intercranial pressure headache
1) brain tumour
2) idiopathic intracranial hypertension
3) low pressure headaches
4) Chiari malformation
5) obstructive sleep apnoea
what is a glioblastoma multiforme
type of brain tumour that has cystic components to it
what are the causes , symptoms and treatments of idiopathic intracranial hypertension
Aka pseudotumor cerebri ( not actually a tumour just looks like one on CT)
Affects often young obese women
Symptoms: Headache, visual obscurations, diplopia, tinnitus, papilloedema, +/- visual field loss, double vision + ringing in ears esp after standing after bending due to swelling of optic nerves
Can be caused by Drugs: hormones, steroids, antibiotics, vitamin E
Treatment: weight loss ( can do bariatric surgery) , diuretics, optic nerve sheath decompression, lumboperitoneal shunt, stenting of stenosed venous sinuses
Optic nerve sheath Decompression involves an incision on the medial wall of the orbit, allowing the CSF to leak out
What are the causes , investigations and treatment of low pressure headaches
CSF leak due to tear in dura
Identifiable symptom : orthostatic headaches ( aka hurts when standing up but not when lying down)
This is because pressure will drop when standing up
Causes : Traumatic post lumbar picture / spontaneous
Treatment : rehydration caffeine , blood patch ( take 20ml of blood from patient and inject it into dural space → blood is sticky and will patch the hole up
Investigation : MRI scan with contrast injection
What is a Chiari malformation
normal brain that sits very low within the skull
→ cerebellar tonsils descending through the foramen magnum; descend further when patient coughs and tugs on the meninges causing cough headache
What are teh causes , treatments and diagnosis for obstructive sleep apnoea
Characteristic body habitus, history of loud snoring and apnoeic spells
Hypoxia, Co2 retention, non-refreshing sleep, depression, impotence, poor performance at work
CO2 retention → causes vasodilation of blood vessels in the brain
Patient will get headache that reduces in pain the longer they are awake
Diagnosis Require sleep study
Treatemetn: Nocturnal NIV , surgery
what are the 2 causes of facial pain headaches
trigeminal neuralgia
atypical facial pain
what is trigeminal neuralgia
+ what are the causes , treatments and investigations
Electric shock like pain in the distribution of a sensory nerve
Triggered by innocuous stimuli ( ie chewing / wind touching face)
Any division of the trigeminal nerve can be affected.
Caused by neurovascular conflict at the point of entry of the nerve into the pons (A potential symptom of multiple sclerosis) ( aka the trigeminal nerve touches a nearby blood vessel)
Treatment: carbamazepine ( best) , lamotrigine, gabapentin
These are anticonvulsants to dampen pain
Posterior fossa decompression ( operation to separate nerve and blood vessel)
what are the causes, symptoms and treatments of atypical facial pain
Most commonly in middle-aged women who are depressed/anxious.
Daily, constant, poorly localised deep aching or burning.
Pain in Facial or jaw bones . can radiates to the neck, ear or throat.
Not lancinating
Not conforming to the strict anatomical distribution of any nerve No sensory loss
Symptoms : Pathology in teeth, temporomandibular joints, eye, nasopharynx, and sinuses must be excluded.
Unresponsive to conventional analgesics, opiates and nerve blocks; mainstay of management tricyclics
what are the causes , symptoms and treatments of post traumatic headache
Correlates with previous history of headache ( aka if you’ve had headaches before this is more likely)
Depends on the nature of the head injury - high in victims of car accidents, low in perpetrators of car accidents, low in sports injuries
Causes :
Neck injury
Scalp injury
Vasodilation – autonomic damage
Depression – often delayed.
Treatment : first explain to patient that they have head injury to prevent analgesic abuse ( aka avoid painkillers addiction)
NSAIDs ( non steroidal anti inflammatories )
Ibuprofen , naproxen
Tricyclic antidepressants
Amitriptyline
Recovery can take several years
what are the causes of cervical spondylitis
Commonest cause of new headache in older patients
Pain is Bilateral
Most commonly Occipital pain radiates forwards to the frontal region, in a steady manner.
Not associated with nausea or vomiting.
Worsened by moving the neck. ( and worst first thing in morning)
N.B: Management involves rest, deep heart, massage; anti-inflammatory analgesics (Overmanipulation may be harmful).
what is a migraine and what are the common features
Is a disorder that is inherited due to many gene mutations
Tendency to get repeated attacks, have triggers,
Features: easily hung-over, visual vertigo, motion sickness
what are the 3 types of attacks for migraines
1) pain
2) pain and focal symptoms
3) focal symptoms
what are the phases of migraines and how long do they take place
Migraines happen in Phases (over around 48 hours)
Prodrome: changes in mood, urination, fluid retention, food craving, yawning
Aura: visual, sensory (numbness/paraesthesia), weakness, speech arrest ( not always)
Headache: head and body pain, nausea, photophobia
Resolution: rest and sleep
Recovery: mood disturbed, food intolerance, feeling hungover
What is aura
and what are the +ve and -ve symptoms
Visual disturbances can develop consisting of both positive and negative visual phenomena.
Individuals also experience sensory disturbances (numbness/paraesthesia), weakness, and speech arrest.
Positive symptoms involve scintillating scotomas
Zig-zag crescent ( elemental disturbances) progressively expands towards the periphery as the electrical depression grows across the cerebral and visual cortex causing and expansion of visual image
Expanding C’s : Usually presented as a shimmering area with a circle of darkness in the middle
Star burst , bright flashes etc
Negative symptoms: blind spots and visual occlusions.
what are lifestyle issues that can cause migraines
Migraineurs have sensitive heads even in between attacks due to genetic factors
Over-react to any sort of stimulation.
Can’t ignore the world around them, it overstimulates their brains.
How do you treat an acute migraine attack
1) Painkillers : Aspirin/ibuprofen (Non-steroidals) and paracetamol and metoclopramide (anti-emetic)
Metoclopramide is a pro-kinetic agent stimulating peristalsis (gastric paresis → aka gut stops working and absorbing, in patients with migraines): reduces nausea and vomiting, soluble to aid absorption
Soluble preparations to aid absorption
2) Triptans-tablets, melts, nasal sprays, s/c injections (vasoconstrictors).
Triptans are selective 5HT-1 receptor agonists, this agonism stimulates the constriction of cranial blood vessels and inhibits the release of pro-inflammatory neuropeptides.
Synergise triptans with NSAIDS (Ibuprofen)
most effective pharmacological intervention
3) Opioids: have an analgesic abuse potential, fluctuations with opioid serum concentrations will cause headache recurrence, increasing dependency on painkillers → addiction
4) A short nap
5) TMS ( trans cranial magnetic stimulation) -interrupts complex networks that trigger and perpetuate migraine, which is caused by spreading electrical depression across the cerebral cortex.
Note treatment for migraines should be taken ASAP → don’t wait
What are triggers for migraines
dietary, environmental, hormonal, weather, dehydration, stress
what should you do to aviod triggers for migrains
Drink 2 litres water/day
Avoid caffeinated drinks
Don’t skip meals. Fresh food. Avoid ready meals & take-aways
Don’t oversleep or have late nights. Electronics downstairs.
Analgesic abuse
what are prophylactics for migraines
meds used for ppl with chronic migraines ( >14 migraines per month)
Name different prophylactics used for migraines
1) Over-the-counter preparations: feverfew, coenzyme Q10, riboflavin, magnesium, EPO, nicotinamide
2) Tricyclic antidepressants (TCAs): amitriptyline at 7pm as can make you sleepy
3) Beta-blockers - Propranolol, Atenolol ( note this drops bp , and ppl with asthma can’t take them)
4) Serotonin antagonists: pizotifen, methysergide
5) Calcium channel blockers: flunarazine, verapamil
6) Anticonvulsants: valproate ( can’t prescribe to pregnant women) , topiramate, gabapentin
7) Greater occipital nerve blocks ( inject medication here)
8) Botox: injected around the head like a crown of thorns distribution( paralyses muscles)
9) Suppress ovulation (progesterone only pill or implant/injection)
10) Erenumab: injectable monoclonal antibody disables calcitonin gene-related peptide or its receptor (CCRP)
→ Episodic migraine, chronic migraine or cluster headache.
→ Reduces frequency , length and duration of migraines
Cut number of days people had migraines from an average of 8 a month to 4- 5/month.
What is a tension type headache and how can it be treated
Caused by tight muscles around the head and neck bilaterally as though head is in a vice
Treatment :
NASAIS preferred : ibuprofen , Narien , diclofenac
Paracetamol
Tricyclic antidepressants ( if v prone )
Amitriptyline 50 - 74mg daily
SSRI’s less effective
Biofeedback and relaxation ( unproven)
what is a cluster headache ?
Symptoms?
Severe unilateral pain lasting 15-180 min untreated
Classified as a trigeminal autonomic cephalgia
Pain namely in 1st division of trigeminal nerve aka phantom of opera mask distribution
Not hemicranial ( affecting half the head) like migraines)
Symptoms : Accompanies by autonomic features → At least one of the following , ipsilaterally
Conjunctival redness/ lacrimation
Nasal congestion / rhinorrhea
Eyelid edema
Forehead and facial swelling
Miosis / ptosis
A sense of restlessness/ agitation
Pain comes back Frequently between 1 on alternate days to 8 per day
Not associated with a brain lesion on MRI
What are the treatments and polylactics for cluster headaches
Treatment: Acute Inhaled O2 ( o2 inhibits neuronal activation in the trigeminocervical complex) Subcutaneous or nasal sumatriptan Prevention Verapamil Prednisolone ( steroids) Lithium Valproate Gabapentin Topiramate Pizotifen
what are the differences between migraines and cluster headaches
1) migraine more common in women , cluster : men
2) duration of migraines are 3-12 hours whereas cluster:45 min - 3 hours
3) Migraines happen monthly , clusters happen daily
4) migraines have unusual long remissions , cluster : long remissions common
5) migraines accompanied by nausea and vomiting , cluster nausea rare
6) Migraines have pulsating hemi cranial pain . Cluster headache has steady exceptionally severe, well localised pain with is unilateral in each cluster
7) Symptoms of migraine: visual / sensory auras seen
cluster: eye waters , nose blockage , ptosis
8) migraine : patients like to lie in the dark as it make the headache better
cluster: patients pace about
see docs
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