Headache Flashcards
What are the two main patterns of headache?
Acute single headache and Dull headache
Triggered and recurrent headaches
What the typical causes of an acute single headache?
Following a head injury
Subarachnoid haemorrhage,
Meningitis,
Tumour, drugs toxins, stroke
Which pattern of headaches are clinically more concerning?
Acute single headaches
What type of acute single headache is considered to be a sudden onset?
A thunderclap
What is a dull headache?
Unchanged over months
what are the main causes of a dull headache?
Usually benign 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 is a triggered headache?
A headache commonly trig-erred by coughing, straining, exertion, coitus (Sexual intercourse). food and drink
What type of headache is a migraine?
A recurrent headache
What type of headache is a cluster headache?
A recurrent headache
What type of headache is associated with atypical facial pain?
Dull headaches
Give four examples of a recurrent headache:
Migraine
Cluster headache
Episodic tension headache
Trigeminal or post-herpetic neuralgia
What three headache onsets suggest a red flag?
Thunderclap
Acute
Subacute
What are the common symptoms of meningism?
1) Photophobia
2) Phonophobia (Fear of sound)
3) Stiff neck
4) Vomiting
What are the red flags for headaches?
Onset Meningism Systemic symptoms Neurological symptoms or focal signs Orthostatic- better lying down Strictly unilateral
What are some systemic red flag symptoms of headaches?
Fever, rash and weight loss
What are some neurological red flag symptoms of headaches?
Visual loss, confusion, seizures, hemiparesis, double vision, 3rd nerve palsy, Horner Syndrome, papilloedema
Which nerve is responsible for a third nerve palsy?
Oculomotor nerve
Which cerebral artery can rupture leading to a third nerve palsy?
Posterior communicating artery aneurysm –> Haemorrhage
What are the symptoms of a third nerve palsy?
Droopy eye-lid (ptosis) Depressive- abduction (Superior oblique and lateral rectus are functional)
What is Horner syndrome?
The sympathetic innervation to the eye is affected, subsequently leading to miosis (pupillary constriction), ptosis and absence of sweating.
Which headache describes a characteristic one sided pain?
Unilateral headache
What is a possible cause of a thunderclap headache?
Subarachnoid haemorrhage
Ruptured berry aneurysm
What are the common symptoms of meningism?
Stiff neck and photophobia
What is meningism?
Meningeal irritation, post subarachnoid bleed, blood irritates the meninges within the subarachnoid space.
What clinical investigation can be used to identify an aneurysm?
Angiogram
Which calcium blocker is used for subarachnoid haemorrhages?
Nimodipine
What is the treatment for a subarachnoid haemorrhage?
Nimodipine and BP control
What physiological response attempts to prevent a subarachnoid bleed?
A vasospasm is the narrowing of the arteries caused by a persistent contraction of the blood vessels, which is known as vasoconstriction. This narrowing can reduce blood flow.
What clinical investigations are conducted to diagnose a patient with a subarachnoid bleed?
CT scan
If there are uncertainties with the diagnosis, conduct a lumbar puncture (RBC and xanthochromia)
How can an aneurysm be treated?
Inserting a platinum coil
Which cerebral structures are considered to be weak points?
The falx cerebri and the tentorium cerebelli
What phenomenon occurs with a raised intra-cranial pressure?
Coning
What is coning?
A rise in intracranial pressure forces the brain to herniate (tentorial), distoting the struture, and forcing it’s descent through the foramen magnum
What can be seen in the optic disc due to a raised intracranial pressure?
Papilloedema
Optic disc swelling
Which arterial dissection is concerned with an occipital headache?
Vertebral artery dissection
What is the pain distribution in a carotid artery dissection?
Phantom of the opera mask distribution around the eye and forehead.
What is the most common form artery dissection?
Carotid artery dissection
What is a carotid artery dissection?
Turbulent flow within the lumen of the carotid artery results in the splitting of the arterial wall, subsequently forming a false lumen, with subsequent blood accumulation within.
Causes: Trauma, tear, Ehlers Danlos syndrome
Which drugs increase the chance of an individual suffering from a carotid/vertebral dissection?
Aspirin
Anticoagulation
Which location is a chronic subdural haemorrhage headache associated with?
Frontal headache
Which blood vessels are associated with a chronic subdural haemorrhage?
Sheer cortical veins leading to a collection of blood.
Why do subdural haemorrhages appear black on a radiograph?
Hypodense blood (degradation of blood, age can be determined depending on hypodensity).
What is the common age for temporal arteritis?
Over the age of 55
In which demography is temporal arteritis most common?
Three times commoner in females
What are the presenting symptoms of temporal arteritis?
1) Constant unilateral headache
2) Scalp tenderness
3) Jaw claudication
4) 25% polymylagia rheumatica-proximal muscle tenderness.
Which arteries are involved in patients with temporal arteritis?
Posterior ciliary arteries (causes blindness)
Which inflammatory markers are involved in temporal arteritis?
C-reactive protein
ESR
What does a biopsy reveal in patients with temporal arteritis?
Inflammation and giant cells (Plethora of nuclei)
Disruption of the internal elastic lamina
What does an ultrasound reveal in temporal arteritis?
Halo’s around the temporal arteries
How can temporal arteritis be treated?
Using NSAIDs (3-4 years)
Which sinuses and veins are affected in cerebral venous thrombosis?
Thrombosis in dural venous sinus or cerebral veins.
What are the symptoms of a cerebral venous thrombosis?
Cortical vein blood clots, accumulation of blood elevates intracranial pressure.
Veins can infarct
Which patients are at risk of cerebral venous thrombosis?
Thrombophillia
Pregnancy
Dehydrated patients
Behcets
What are the common bacterial forms of meningitis?
Meningococci, Pneumococci, Haemophilus
Tuberculous
What are the common forms of a granulomatous meningitis?
Sarcoid, Lyme, Brucella, Behçet’s, Syphilis
What are the 7 main presenting symptoms of meningitis?
1) Malaise
2) Headache
3) Fever
4) Neck stiffness
5) Photophobia
6) Confusion
7) Alteration of consciousness
What type of smear is conducted in patients with suspected bacterial meningitis?
CSF smear identifies gram-positive cocci bacteria
Which cerebral lobes are classically affected in patients with herpes simplex encephalitis?
Temporal lobes, haemorrhaging changes are induced
How should patients with suspected meningitis be treated?
Antibiotics (Pathogen-specific)
Blood and urine culture
How are patients diagnosed with meningitis?
Blood culture,
Blood glucose,
Lumbar puncture: Increased white cell count, decreased glucose, antigens, cytology, bacterial cultural
Neuroimaging: CT or MRI scan (Cerebral oedema with effacement of ventricles ad sulci, inflamed meninges)
What does a CT scan indicate in a patient with bacterial meningitis?
Cerebral oedema with effacement of ventricles and sulci
Inflamed meninges
Decompression occurs with the high pressure, thus the brain herniates through the foramen magnum.
What is sinusitis?
The symptomatic inflammation of the mucosal lining of the nasal cavity.
What are the common presenting symptoms in patients with sinusitis?
Malaise, headache, fever, blocked nasal passages, loss of vocal resonance
anosmia
nasal or postnasal catarrh
Local pain and tenderness
Frontal pain starts 1-2 hours after rising and clears up during the afternoon
What does radioimaging show for patients with sinusitis?
Opacification of paranasal sinus
What is a glioblastoma multiforme?
A tumour derived from astrocytes and oligodendrocytes,
Oedema around the tumour, - swelling is hyperdense on a a CT scan.
What is idiopathic intracranial hypertension?
Idiopathic intracranial hypertension (IIH) is a disorder related to high pressure in the brain. It causes signs and symptoms of a brain tumor (pseduotumor cerebri)
What are the symptoms of an idiopathic intracranial hypertension?
Headache Visual obscurations Diplopia (Double vision) Tinnitus Papilloedema
Which drugs are commonly associated with idiopathic intracranial hypertension?
Hormones, steroids, antibiotics, vitamin E, combined oral contraceptive pills
What is the treatment for a psedotumor cerebri?
Treatment: weight loss, diuretics, optic nerve sheath decompression, lumboperitoneal shunt, stenting of stenosed venous sinuses.
What does an MRI reveal in a low pressure headache regarding the meninges?
Meningeal enhancement
What causes a low pressure headache?
CSF leak due to tear in dura
Traumatic post lumbar puncture or spontaneous
What are the common forms of treatments of low pressure headaches?
Rehydration
Caffeine
Blood patch
What is a chiari malformation?
Cerebellar tonsils descending through the foramen magnum. Descend further when patient cough and tug on the meninges causing cough headache.
What does an MRI scan show for patients with a chirari malformation?
MRI scan with a contrast injection, intense meningeal enhancement characteristic of a low pressure headache;
