Headache Flashcards
What is a headache?
Is a symptom
Can be due to:
- structural
- pharmacological
- psychological
What patterns of headache are there?
- Acute headache
- Dull headache increasing in severity
- Triggered headache
- Recurrent headaches
- Dull unchanging headache
What red flags are there with headaches to distinguish what is serious?
Onset : thunderclap, acute, subacute
Meningism : photophobia, phonophobia, stiff neck, vomiting
Systemic symptoms : fever, rash, weight loss
Neurological symptoms: visual loss, confusion, seizures, hemiparesis, double vision, 3rd nerve palsy, Horner syndrome
Orthostatic- better lying down
strictly unilateral
How does a subarachnoid heamorrhage headache feel?
Sudden generalised headache ‘blow to the head’
meningism - stiff neck and photophobia - blood is irratant in subarachnoid space
Most are caused by ruptured aneurysm, some from arteriovenous malformations
How to deal with a subarachnoid haemorrhage?
50% are fatal
Vasosppasm may stop the leak, use nimodipine and BP control
there is a high risk of further bleed
Can do a lumbar punction ( RBC, xancthochromia ) to double check if there is a bleed in the brain
How do we coil an aneurysm?
- Used to be clipped or wrapped by skull removed
- Nowdays it is filled with platinum coils through a cathetar from groin
Why is intracranial bleeding so bad because it raises pressure?
- Raised intracranial pressure = ICP
There is a weak point at falx and tenant, foramen magnum
if there is a bleed or tumour the brain can tolerate to a certain point without pressure raising.
After this point pressure climbs extensively
Brain will start seeping into areas of weakness : falcine / tentorial herniation
This is the MECHANISM OF CONING = brain will squeeze out and squash it, loses its blood supply and hence brain stem death
What is papilloedema and what is its clinical relevance?
Optic disk swelling due to raised ICP : can se swelling at the back of the eye
How can pathology of the large arteries of the neck cause headaches?
The layers of tissue in the vessels can split and blood can collect there causing turbulent flow ( artery dissection )
Cause of headache + neck pain
Common cause of stroke in young people
If a px gets a carotid artery dissection what is the pain pattern?
- phantom of the opera mask distrubution : eye and forehead pain
- More common than vertebral artery.
- due to trauma e.g. seatbelt snag
If a px gets a vertebral artery dissection what is the pain pattern?
Occipital headache at back of head and neck
What can ehlers danlos syndrome increase the risk of?
- large artery dissection
How to diagnose artery dissection?
- how to treat?
MRI and MRA, angiogram
US of blood vessels to see flow
treat with aspirin or anti-coagulants to stop clotting and prevent strokes
What is a subdural haemorrhage?
Due to vein ruptures ( veins are thin and suceptible )
common in elderly due to falls and anticoagulants
- if it is a chronic subdural haemorrhage the blood will look dark on CT
What is Temporal arteritis?
Common in women over 55
constant unilateral headache, scalp tenderness, jaw claudification
polymyaglia rheumatica proximal muscle tenderness
this involves posterior ciliary arteries and so can cause blindness so very important!
How to test for temporal arteritis?
Elevated ESR + CRP
temporal artery are usually inflamed and tortuous
visible on US
biopsy to see signs of inflammation + giant cells
Give high dose of steroids and aspirin
What would you see in a arteritis biopsy?
disruption of internal elastic lamina
in temporal : lots of giant cells * also called giant cell arteritis
What is a cerebral venous thrombosis?
In dural venous sinus or cerebral vein
unusual headache due to raised ICP
non-territorial ischaemia ‘venous infarcts’
Haemorrhage
Thrombophilia, pregnancy, dehydration and Behcets ( all makes blood sticky * check headaches in post partum women )
What is Meningigtism what causes it?
Viral : Coxsackie, ECHO, Mumps, EBV
- the one we worry about is Bacterial - Meningococci, Pneumococci, Haemophilus Tuberculous
Fungal - Cryptococci
Granulomstous - Sarcoid, lyme, Brucella, Syphilis
Carcinomatous
What is the presenting symptoms of meningitas?
( very similar to subarachnoid haemorrhage )
- Malaise
- Headache
- Fever!! give away
- Neck stiffness
- Photophobia
- Confusion
- Alteration of consciousness
What is Herpes Smplex Encephalitis?
Classic haemorrhagic changes in the temporal lobe
- when infection affects the matter of the brain not just CSF
How to handle a meningitis patient?
Treat first then diagnose
- Antibiotics
then take blood and urine culture, then lumbar culture to check : - increased w.b.c
- decreased glucose
- antigens
- cytology
- bacterial culture
Why do you have to do a CT or MRI before a meningitis lumbar puncture?
The brain swells in bacterial meningitis
if you put a needle in someones back it decrompresses the high pressure and brain can collapse down foramen magnum
What is Sinusitis?
Infection * wont kill you
- Malaise
- Headache
- Fever
- BLOCKED nasal passages
- loss of vocal resonance
- Anosmia
- Nasal or postnasal
- Local pain and tenderness
What is a glioblastoma multiforme?
Shows on Ct scan with swelling
A lot of pressure that causes sulcus markings missing on hemisphere under pressure
* in high pressure on Ct shows small ventricles and less sulcus markings
What is idiopathic intracranial hypertension?
Pressure may suggest tumour but if there isnt any it is Pseudotumor cerebri
Often young obese women
Visual obscuration, diplopia, tinnitus
Papilloedema +/- visual field loss
Can be caused by hormes e.g. OCP, steroids, antibiotics, vit E
What are the treatments for idiopathic intracranial hypertension?
- Weight loss!!
- Diuretics
- optic nerve sheath - decrompression
- Lumboperitoneal shunt
- Stenting of stenosed venous sinuses
What are Low pressure headaches caused by?
How can we treat this?
CSF leak due to tear in dura
Traumatic post lumbar puncture or spontaneously
Rehydration, caffeine, blood patch ( px own blood injected to fill up hole )
- orthostatic headache hallmark
How to diagnose low pressure headaches?
Intense meningeal enhancement ( very white ) when looking at MRI with contrast injection
What is Chiari Malformation?
Normal brain but it sits very LOW within the skull
- Cerebellar tonsils are so low they are descending through foramen magnum
If a px sneezes or coughs it descends more and snags on meninges and causes really bad short lived pain
How to treat Chiari Malformation?
Surgery to remodel skull to remove snagging
treat coughs and sneezes
How does obstructive sleep apnoea cause headaches?
- History of loud snoring and apnoeic spells
- Hypoxia and CO2 RETENTION = vasodilator
Causes banging headache
Symtoms of depression, impotence, poor performance at work
Require sleep study and can give CPAP ( Nocturnal NIV ) or surgery
What is a Trigeminal Neuralgia?
- electric shock like pain in the distribution of a sensory nerve
- triggered by innocuous stimuli
- due to blood vessels around nerves and sometimes flows too close so when blood vessel touches nerve it can cause pain
- first division of trigeminal does scalp and face sensation so can cause headaches
Can be a symptom of M.S
How to treat trigeminal neuralgia?
( anti convulsants )
- Carbamazepine
- Lamotrigine
- Gabapentin
- Posterior fossa decompression for really bad cases, separete nerve from blood vessel
What is atypical facial pain?
Depressed / anxious middle aged women
Deep localised aching or burning pain in cheek or jaw or down neck and ear
Treat with painkillers, opiates, nerve blocks and tricyclics
How to treat post traumatic headache?
( more common in victims of trauma e.g. not the person who caused the car accident the person in the other car * so has a psychological element )
Prevent analgesic abuse
Non-steroidal anti-inflammatories, ibuprofen / naproxen
Tricylic antidepressents - amitrypline
What is cervical spondylosis?
Commonest cause of new headache in older px:
bilateral occipital pain radiating to front Steady pain No nausea or vomiting But worsened when moving the neck
How to treat cervical spondylosis?
- rest
- deep heat
- massage
- anti inflammatory analgesics
