Headache Flashcards
What are potential causes for acute single headaches?
Febrile illness, sinusitis First attack of migraine Following a head injury Subarachnoid haemorrhage Meningitis, tumour, drugs, toxins, stroke Thunderclap (sudden onset), low pressure FSM HHMT
What are potential causes for a dull headache that increases in severity?
Overuse of medication (e.g. codeine) Contraceptive pill, hormone replacement therapy Neck disease Temporal arteritis Benign intracranial hypertension Cerebral tumour Cerebral venous sinus thrombosis
What are causes for a dull headache that doesn’t change over months?
Chronic tension headache
Depressive, atypical facial pain
What are causes of recurrent headaches?
Migraine
Cluster headache
Episodic tension headache
Trigeminal or post-herpetic neuralgia
What are potential triggers for headaches?
Coughing, straining, exertion
Coitus
Food and drink
What are 6 red flags for headaches?
- Type of onset - thunderclap, acute, subacute
- Meningism - Photophobia, phonophobia, stiff neck, vomiting
- Systemic symptoms - fever, rash, weight loss
- Neurologic symptoms/focal signs - Visual loss, confusion, seizures, hemiparesis, double vision, 3rd nerve palsy, Horner syndrome, papilloedema
- Orthostatic - if better when lying down
- Strictly unilateral
What is oculomotor palsy and why does it occur?
Oculomotor palsy occurs when nerve is compressed or blood supply lost due to aneurysm. Supplies all muscles except lateral rectus and superior oblique. Main signs are ptosis as levator supply affected and loss of pupil reflex (dilated pupils) if dropping eyelid lifted.
What is Horner syndrome?
Sympathetic supply of eye is affected resulting in eyelid droop.
What are markers of a subarachnoid haemorrhage and what causes one?
Marked by a sudden generalised headache and meningism (photophobia + stiff neck). Most are caused by a ruptured aneurysm, a few from arteriovenous malformations and some are unexplained. Ruptured berry aneurysms common cause (usually occur in Circle of Willis).
How is a subarachnoid haemorrhage managed and treated?
50% instantly fatal but vasospasm may stop leak. High risk of further bleed.
- Neurosurgical assessment - confirm bleed + establish cause
- CT of brain + Lumbar puncture to check for RBC and xanthochromia (bilirubin in CSF which is sometimes the only sign of a SH) + MRA + angiogram
- Nimodipine and BP control - nimodipine is a calcium channel blocker and relaxes + dilates blood vessels in the brain allowing greater supply of blood and preventing brain damage.
How is an aneurysm treated?
Used to be clipped/wrapped but now filled with platinum coils.
How does coning cause an acute intracerebral bleed?
Coning refers to when the brain is squeezed out of the skull. The brain has weak points and is made of components. If there is an increase in blood volume due to blood products, brain can tolerate up to a certain limit without an increase in pressure. However, past that point, for a small increase in volume, pressure climbs quite dramatically. As pressure rises, brain starts to seep under these areas of weakness – subfalcine/tentorial herniation.
Why is coning fatal?
Brainstem contains control centres for vital respiratory activities so if that is squashes and loses blood supply, results in death.
What does papilloedema signify?
Raised intracranial pressure as can be seen at back of retina via optic disk swelling
What is carotid/vertebral artery dissection?
Carotid artery surrounded by layers of tissue but this can sometimes split and cause a pooling of blood in the split layers. Therefore turbulent flow of blood occurs leading to formation of blood clots which can lodge in different parts of the brain and also cause pain.
How are carotid and vertebral artery dissections differentiated?
Vertebral artery dissections cause pain in the occipital region of the head while carotid artery dissections cause pain in a phantom of the opera mask region of the head.
Describe epidemiology of carotid/vertebral artery dissections
Makes up for 20% of ischaemic strokes <45 years (young stroke). Mean age is 40 years and carotid more common than vertebral. Usually occurs following a trauma event to the carotid/vertebral arteries. Can however be spontaneous sometimes.
How are carotid/vertebral artery dissections investigated and treated?
Investigated through MRI/MRA, Doppler, Angiography
Treatment: Aspirin and anticoagulants to prevent formation of blood clots and therefore strokes.
Describe the epidemiology and symptoms of temporal arteritis?
3x more common in women. Mainly affects those over the age of 55. Constant unilateral headache, scalp tenderness and jaw claudication.
JUS 355
What are causes of temporal arteritis?
25% Polymyalgia Rheumatica-proximal muscle tenderness.
Involvement of the posterior ciliary arteries causes blindness.
Caused by disruption of internal elastic lamina
What are characteristics of temporal arteritis?
Elevated ESR and CRP.
Temporal artery are usually inflamed and tortuous.
Visible on ultrasound.
Biopsy shows inflammation and Giant Cells.
Treated with a high dose of steroids and aspirin
ETUBS
What is cerebral venous thrombosis and what causes it?
Thrombosis in dural venous sinus or cerebral vein. Unusual amount of headache due to raised ICP.
Caused by:
Non-territorial ischaemia “venous infarcts”
Haemorrhage
Thrombophilia, pregnancy, dehydration, Behcets
What are the viral, bacterial and fungal causes of meningitis?
Viral- Coxsackie, ECHO, Mumps, EBV
Bacterial - Meningococci, Pneumococci, Haemophilus
Tuberculous
Fungal - Cryptococci
What are other causes of meningitis?
Granulomatous- Sarcoid, Lyme, Brucella, Behçet’s, Syphilis
Carcinomatous
What are presenting symptoms of meningitis?
Malaise Headache Fever Neck stiffness Photophobia Confusion Alteration of consciousness
HNF CAMP
Subarachnoid haemorrhage can have similar symptoms but fever means meningitis
What is a hallmark sign of Herpes Simplex Encephalitis?
Classic haemorrhagic changes in the temporal lobes
How is meningitis managed?
Treat then diagnose. Do a CT/MRI before lumbar puncture or brain can herniate. Antibiotics given then blood/urine cultures done.
What can be determined from a lumbar puncture in the case of meningitis?
Increased White Cell Count, decreased glucose
Antigens
Cytology
Bacterial Culture
What is observed in bacterial meningitis?
Cerebral oedema with effacement of ventricles and sulci and inflamed meninges.
What are symptoms of sinusitis?
Malaise, headache, fever. Blocked nasal passages. Loss of vocal resonance. Anosmia. Nasal or postnasal catarrh. Local pain and tenderness.
What pain is characteristic of sinusitis?
Frontal pain characteristically starts 1-2 hours after rising and clears up during the afternoon.
What is the presentation of pseudotumour cerebri?
Often young obese women
Headache, visual obscurations, diplopia, tinnitus
Papilloedema, +/- visual field loss
TH DVP
What are treatments for pseudotumour cerebri?
Weight loss, diuretics, optic nerve sheath decompression, lumboperitoneal shunt, stenting of stenosed venous sinuses.
How is raised intracranial pressure detected through imaging?
Cerebral oedema with effacement of ventricles and sulci but no mass lesion.
What causes a low pressure headache and how is it treated?
Caused by CSF leak due to tear in dura. Traumatic post lumbar puncture or spontaneous. Treatment rehydration, caffeine, blood patch. Meningeal enhancement seen radiologically.
What is Chiari malformation?
Cerebellar tonsils descending through the foramen magnum. Descend further when patient cough and tug on the meninges causing cough headache. Is a normal brain that just sits very low in the skull.
How does obstructive sleep apnoea cause headaches?
Occurs in those with history of loud snoring and apnoeic spells. Headache due to hypoxia, CO2 retention (CO2 is a vasodilator and so dilates blood vessels in the brain leading to morning headache and non-refreshing sleep).
What are consequences and treatment of obstructive sleep apnoea?
Consequence: depression, poor performance at work, impotence
Treatment: nocturnal NIV, surgery
What is trigeminal neuralgia?
Electric shock like pain in distribution of sensory nerve, often triggered by innocuous stimuli. Any division of trigeminal can be affected - Neurovascular conflict at the point of entry of the nerve into the pons. May be a symptom of multiple sclerosis.
How is trigeminal neuralgia treated?
Carbamazepine, lamotrigine, gabapentin.
Posterior fossa decompression
Who is atypical facial pain most common in and what does it affect?
Most commonly in middle aged women. Depressed or anxious. Daily, constant, poorly localised deep aching or burning. Facial or jaw bones, but may extend to the neck, ear or throat. Pathology in teeth, temporomandibular joints, eye, nasopharynx and sinuses must be excluded.
What are 4 characteristics of atypical facial pain and a treatment method?
Not lancinating.
Not conforming to the strict anatomical distribution of any nerve.
No sensory loss.
Unresponsive to conventional analgesics, opiates and nerve blocks.
Tricyclics used as treatment.
Describe post traumatic headaches
Depends on the nature of the head injury. Multiple mechanisms: Neck injury, Scalp injury, Vasodilation may indicate autonomic damage or Depression - often delayed.
How are post-traumatic headaches managed?
Non-steroidal anti-inflammatories - ibuprofen, naproxen Tricyclic antidepressants - Amitriptyline
Can take 3-4 years to heal
What are 5 characteristics of cervical spondylosis?
Commonest cause of new headache in older patients
Usually bilateral
Occipital pain can radiate forwards to the frontal region
Steady pain
No nausea or vomiting
Worsened by moving the neck
How is cervical spondylosis managed?
Rest, deep heat, massage.
Anti-inflammatory analgesics.
Over-manipulation may be harmful.
