HEADACHE Flashcards
What are the main categories of causes for headaches?
Structural
Pharmacological
Psychological e.g. stress
What are the patterns and causes associated with an acute single headache?
Febrile illness, sinusitis First attack of migraine Following head injury Subarachnoid haemorrhage Meningitis, tumours, drugs, toxins, stroke Thunderclap
What are the patterns associated with a dull headache, increasing in severity?
Usually benign Overuse of medication Contraceptive pill, HRT Neck disease Temporal arteritis Benign intracranial hypertension Cerebral tumour Cerebral venous sinus thrombosis
What types of headaches can be recurrent?
Migraine
Cluster headache
Episodic tension headache
Trigeminal/post-herpetic neuralgia
What can cause a dull headache, unchanged over months?
Chronic tension headache
Depressive, atypical facial pain
What triggers can cause headaches?
Coughing
Straining
Coitus
Food and drink e.g. wine
What are the red flags of headaches?
Thunderclap, acute, subacute onset
Photophobia, phonophobia, stiff neck, vomiting (associated with meningism)
Fever, rash, weight loss
Visual loss, confusion, seizures, hemiparesis, 3rd nerve palsy, Horner syndrome, papilloedema
Orthostatic (better lying down)
Unilateral (pain in same spot all the time)
What causes double vision?
Oculomotor muscle(s)/nerve(s) not working
What is 3rd nerve palsy?
Disruption of 3rd CN (oculomotor) causing ptosis and the eye to point outwards since no innervation to most of the muscles behind eye
What can a rupture of the posterior communicating artery sometimes cause?
3rd nerve palsy
What is Horner syndrome and its symptoms?
Sympathetic supply to eye is affected causing droopy eye, enopthalmos and a smaller pupil
What type of headache would a subarachnoid haemorrhage cause?
Sudden generalised headache (thunderclap)
Meningism
Why could a subarachnoid haemorrhage cause meningism?
Blood is flowing around subarachnoid space and irritating the meninges
What are the 3 causes of subarachnoid haemorrhage?
Ruptured aneurysm (main cause)
Arteriovenous malformations
Ideopathic
What percentage of subarachnoid heamorrhages are instantly fatal?
50%
What is a vasopasm?
When the smooth muscle of a blood vessel spasms to prevent leaking
What are the exams you can do to confirm and investigate a subarachnoid haemorrhage?
CT scan
Lumbar puncture (when you can’t see blood on CT as CSF will be slightly pink due to blood)
MRA
Angiogram to see location of aneurysm
How are aneurysms fixed?
Now filled with platinum coils via catheter causing aneurysm to sclerose and seal itself
Used to be clipped or wrapped
Describe the mechanism of coning
Tumour/bleed present in brain causing raised intracranial pressure (ICP). The brain has a certain amount of compliance but after that herniation of the brain occurs
List 3 different brain herniations
Subfalcine herniation
Tentorial herniation
Herniation through foramen magnum
What does a herniation through the foramen magnum cause?
Squashing and loss of blood supply leading to brainstem death and death
What is a cause of an acute intracerebral bleed?
Coning
What is papilloedema?
Optic disc swelling due to raised ICP
How can pathology in the larger arteries of the neck cause headache?
Basilar artery dissection: occipital headache
Carotid artery dissection: pain in phantom of opera mask distribution around eye and forehead
What is an artery dissection?
Tear in the wall of artery causing blood to pool in split and turbulent flow in the lumen
Dissection in which neck artery is more common?
Carotid > vertebral/basilar
What is the treatment for a dissection?
Aspirin
Anticoagulant as turbulent flow can cause sticky blood leading to clotting which can dislodge and cause stroke
What diagnostics can be done if a dissection is suspected?
MRI/MRA
Doppler
Angiography
In which age population do chronic subdural haemorrhages occur in often?
Elderly due to falls and veins are easily traumatised due to thin walls.
Also elderly are often on anticoagulants
How can you tell the age of a haemorrhage on a CT scan?
In older haemorrhage, hypotense blood darker as it has begun to degrade
What are the symptoms of temporal arteritis?
Constant unilateral headache
Scalp tenderness
Jaw claudication
If posterior ciliary muscles involved causes blindness
Elevated ESR and CRP (inflammation)
Temple artery usually inflamed and tortuous
Visible on ultrasound
What drugs can be used to treat temporal arteritis and for how long?
High dose steroids (anti-inflammatory) and aspirin (prevent stroke) for 3-4 years until disease runs its course
What should you see in a biopsy of temporal arteritis?
Disruption of internal elastic lamina (hallmark of vasculitis)
Giant cells
Inflammation
What is cerebral venous thrombosis (CVT)?
Similar to DVT but in brain
Thrombosis in dural venous sinus or cerebral vein meaning blood can’t leave
What are the symptoms of cerebral venous thrombosis?
Increased amount of headache due to raised ICP
Haemorrhage
Non-territorial ischaemia
Sticky blood causing e.g. thrombophilia
List the different possible causes of meningitis
Viral Bacterial Fungal Granulomatous Carcinomatous (seeding of cancer cells in meninges causing a meningeal reaction)
What are the symptoms of meningitis?
Fever Malaise Headache Neck stiffness Photophobia Confusion Alteration of consciousness
Which lobes are usually seen affected by herpes simplex encephalitis?
Temporal lobes
What is the important rule when managing a patient with meningitis?
Treat then diagnose as meningitis can kill
How can meningitis be diagnosed/investigated
Blood and urine culture
Lumbar puncture: increased WBC, decreased glucose, antigens, cytology, bacterial culture
CT/MRI scan
Why should you do CT/MRI scan before a lumbar puncture in a patient with meningitis?
You need to assess how much ICP with the scan. If you LP’d without knowing, brain could hurtle through foramen magnum due to pressure change
What would a CT scan of a patient with bacterial meningitis look like?
Cerebral oedema with effacement of ventricles and sulci and inflamed meninges
What are the symptoms of sinusitis?
Malaise, headache, fever Blocked nasal passages Loss of vocal resonance Anosmia Nasal or postnasal catarrh Local pain and tenderness
Frontal pain usually 1-2 hours after waking up but the clears up during afternoon
What would a CT scan of a patient with sinusitis show?
Opacification of sinuses as full of infection
What is a pseudotumor?
Might think patient has tumour due to rise in ICP but none seen in CT.
Completely idiopathic
What are the symptoms of pseudotumor cerebri?
Headache Visual obscurations Diplopia Tinnitus Papilloedema +/- visual field loss
What demographic is pseudotumor cerebri most commonly seen in?
Young obese women
What are the treatments for pseudotumor cerebri?
weight loss, diuretics, optic nerve sheath decompression, lumboperitoneal shunt, stenting of stenosed venous sinuses
What is a hallmark of a low pressure headache?
Orthostatic symptoms because when standing CSF leaks causing pressure drop thus headache
What occurs in a low pressure headache and its causes?
CSF leak due to tear in dura
Due to traumatic post lumbar puncture or spontaneous
What is the treatment for low pressure headaches?
Rehydration, caffeine, blood patch (inject blood into epidural space as it acts like a natural glue to patch up tear)
How are low pressure headaches diagnosed?
MRI scan with contrast injection of gadolinium
What is Chiari malformation?
Normal brain which sits very low in the skull
The cerebellar tonsils descend through the foramen magnum
What type of headache does a chiari malformation cause and why?
Cough headache because cerebellar tonsils descend further into foramen magnum when patient coughs which tugs on the meninges
What is trigeminal neuralgia?
Electric shock like pain in the distribution of the trigeminal nerve and is often triggered by innocuous stimuli. Due to neurovascular conflict at point of entry of the trigeminal nerve into the pons
Can be symptom of MS
What are the treatments for trigeminal neuralgia?
Anticonvulsants which dampen pain e.g. carbamazepine, lamotrigine
Posterior fossa decompression
Describe the features of atypical facial pain
Daily, constant, poorly localised deep aching/burning
Facial/jaw bones, sometimes neck, ear or throat
No sensory loss and other pathologies must be excluded
Unresponsive to conventional analgesics, opiates and nerve blocks
Which population is atypical facial pain most common in?
Middle aged women
What is a post traumatic headache and its mechanisms?
A headache which appears after head injury
Multiple mechanisms: Neck injury Scalp injury Vasodilation due to autonomic damage Depression
What treatment can be given to patients with post traumatic headaches?
Non-steroidal anti-inflammatories - ibuprofen
Tricyclic antidepressants
These drugs are the least addictive
What are the symptoms cervical spondylosis?
Usually bilateral
Occipital pain can radiate to frontal region
Steady pain
No nausea/vomiting
Worsened by moving the neck
Worse during morning but gets better after stretch
How can cervical spondylosis be managed?
Rest, deep heat, massage
Anti-inflammatory analgesics
Over-manipulation may be harmful
What is the most common cause of new headaches in older patients and why?
Cervical spondylosis due to arthritis wearing out joints
What are some of the features of a migraine?
Tendency go repeated attacks Triggers Easily hung-over Visual vertigo Motion sickness
What are the 5 phases of a migraine?
Prodrome - mood to changes, urination, fluid retention…
Aura - visual, sensory, weakness, speech arrest
Headache - nausea, photophobia
Resolution - rest and sleep
Recovery - mood disturbed, food intolerance, hung-over
What are some visual changes seen in aura of a migraine?
Positive and negative symptoms together:
- scintillations
- blindspot
- expanding Cs
Describe the expanding Cs seen in the aura of a migraine and why they occur
Cs which grow and grow whilst moving out to periphery until they disappear
Occurs because migraines caused by spreading electrical depression across cerebral and visual cortex
What treatments can be given to a patient suffering from an acute migraine attack?
Non-steroidal painkillers e.g. ibuprofen, aspirin
Antiemetics e.g. metoclopramide
Triptans (headache painkillers) + NSAIDS
Transcranial magnetic stimulation (TMS) interrupts complex network that causes the migraine
Treat as early as possible
Look for triggers and avoid them
What is erenumab?
Injectable drug against migraines.
Reduces frequency of migraines
Monoclonal antibody which disables calcitonin gene related peptide or its receptor (CGRP mAbs)
What are tension type headaches?
Headaches caused by tight muscles around head and neck
What drugs can be given for tension type headaches?
NSAIDs e.g. ibuprofen
Paracetamol
Tricyclic antidepressants e.g. amitriptyline
What are cluster headaches?
Severe unilateral pain lasting 15-180 minutes
Acute headache and then more and more (cluster)
What are cluster headaches classified as?
Trigeminal autonomic cephalgia as the pain mainly in 1st division of trigeminal nerve
What are the symptoms of a cluster headache?
At least one of the following, ipsilaterally:
- Conjunctival redness/inflammation
- Nasal congestion/rhinorrhoea
- Eyelid oedema
Facial sweating
Miosis/ptosis
Restlessness/agitation
Frequency from 1 on alternate days to 8 per day
How do you treat the acute headache of a cluster headache?
Inhaled oxygen to inhibit neuronal activation in trigeminocervical complex
S/C or nasal Sumatriptan
How do you prevent future headaches (the cluster)?
Steroids e.g. prednisolone, verapamil
Anti-epileptics/seizures e.g. valproate, gabapentin, topiramate
Pizotifen
Highlight the differences between migraine and cluster headaches
Distribution:
Migraine - 33% men, 67% women
Cluster - 90% men, 10% women
Duration:
Migraine - 3-12 hours
Cluster - 45min - 3 hours
Frequency:
Migraine - 1-8 monthly
Cluster - 1-3 daily
Remission:
Migraine - not usually long
Cluster - usually long
Nausea:
Migraine - frequent
Cluster - rare
Pain:
Migraine - pulsating hemicranial
Cluster - steady, unilateral in each cluster, well localised
Symptoms:
Migraine - visual/sensory auras
Cluster - eye waters, nose blocked, ptosis…
Actvity:
Migraine - patients lies in dark
Cluster - patients pace about
