Headache Flashcards
Classifications of headaches
1. Hemorrhagic Caused by a bleed in the cranium 2. Inflammatory Vasculitis of the vessels in the cranium 3. Dissection Dissection of the carotid/vertebral arteries 4. Stroke Ischaemic 2. Hemorrhagic – intracranial bleed
What are risk factors and causes of intracranial
hemorrhage?
- Causes
- PRIMARY – Trauma
- SECONDARY – rupture of cerebral aneurysm/vascular malformation
- Risk factors
- Recent trauma
- Coagulopathy – clotting disorders
- Anticoagulant use – antiplatelets, anticoagulant medications
- Advanced age (>65 years)
What does each type of bleed present as in terms of a headache? (intracranial haemorrhage)
- Extradural – Severe headache with lucid interval
- Subdural – constant/fluctuating headache, gradually deteriorating
- Subarachnoid – “thunderclap” headache (sudden onset 10/10) radiating to occiput (back) of head
What are other associated symptoms of headache?
- Nausea and vomiting
- Lowered Glasgow Coma Score
- This is a score out of 15 with 3 components
- Eye response, Verbal response and Motor response
- Intracranial bleeds can cause lowered score in all 3
- Altered mental status – confusion, loss of consciousness
- Bladder and bowel incontinence
- Weakness and sensory changes
- Fluid leaking out of nose/ears
What is dangerous about it and gives it the label of ‘acute’?
- Neurological deficits with variable recovery rate
- Coma
- Can then lead onto stroke from pressure compressing on arteries
- Brain herniation
- When the pressure forces the brain out of the normal compartments
- Most dangerous is out of the foramen magnum
- This cuts off the blood supply to the brain stem from compression, leading to death from loss of basic life functions (breathing etc)
Investigations
- CT scan
What is vasculitis?
• Usually - autoimmune inflammation of the blood vessels in the brain
• Giant Cell arteritis
• Autoimmune inflammation of the large/medium sized arteries
• Commonly associated with polymyalgia rheumatica, an autoimmune disease
that causes weakness and pain in the proximal limbs
• Causes and risk factors
• Polymyalgia rheumatica, age >50 years, female sex, northern European ancestry
How does giant cell arteritis (GCA) present clinically?
- Headache – non-specific
- But Associated with tenderness/pain of the scalp “pain on brushing hair”
- Therefore, new onset headache + scalp tenderness = GCA?
- Aching and stiffness worse after rest in limbs neck
- Sign of GCA itself/underlying polymyalgia rheumatica
- Less common symptoms
- Loss of vision
- Tongue and jaw pain – unilateral, painful when eating/chewing
- Abnormal fundoscopy (eye)
What is the danger of vasculitis and why is it ‘acute’?
• Irreversible blindness
• 17x risk of developing thoracic aortic aneurysms, 2.4x risk to develop
abdominal aortic aneurysms
• Incidence of aortic aneurysm after GCA diagnosis up to 30%
Investigations (in either case start treatment first, High dose glucocorticoids)
- Vascular ultrasound
- Blood tests – CRP, ESR (inflammatory markers)
- Temporal artery biopsy
What is a dissection and where can they occur?
• Blood going into intramural (within
the wall) space
• Can either clot = blockage or rupture
= hemorrhage
- Carotid artery
- Vertebral artery
How does a dissection present clinically?
- Causes
- Trauma
- Spontaneous
- Predisposing factors – connective tissue disease, hypertension
- Presentation
- Headache + scalp, eye, neck pain
- Horner syndrome – unilateral eye with droopy lid + small pupil
- Weakness and numbness on one side of body
- Trouble speaking/understanding speech
- Other neurological deficits – impaired blood flow to brain
Why is a dissection acute and dangerous?
• Consequences of reduced blood flow to brain
• Reversible (TIA)/ irreversible neurological deficit
• Vision loss
• If clot detaches, it becomes a embolus that can travel to the brain =
stroke
• All the consequences of stroke
Investigations
- Ultrasound scan
What is a stroke?
• When a clot that formed somewhere else (dissection, AF) embolises and
travels to the brain where it gets stuck
- Types of stroke
- Hemorrhagic (15%) – refer to the first category
- Ischaemic (85%) what we are talking about here
Clinical presentation of ischaemic stroke?
- Causes and risk factors
- Atrial fibrillation (AF), hx of cardiovascular disease (HTN, cholesterol)
- Clinical presentation
- Headache (non-specific)
- FAST (Facial drooping, Arm weakness, Speech difficulty, Time to call 999)
- Gaze deviation
- Sensory changes – numbness
- Nausea and vomiting
- Decreased level of consciousness
Why is a stroke acute and dangerous?
- May transition into hemorrhagic stroke
- Death
- Time sensitive
- Thrombolysis window – 4.5 hours after onset of symptoms
- Missing the window – risk of permanent neurological deficit
Diagnosis
- CT to differentiate between ischaemic and hemorrhagic! (treatments are opposites
- ECG for underlying AF
What is the treatment for migraines?
Acute treatment (to take during the attack): Triptan (oral, nasal) +/- Paracetamol/NSAIDs (Aspirin 900mg) Antiemetics (metoclopramide, prochlorperazine)
Prophylaxis (regularly, months- years): Prevent attacks, reduce severity. Topiramate (hormonal contraceptives/pregnancy) Beta blocker: Propranolol TCAs: Amitriptyline Riboflavin may be effective. Acupuncture
