Headache Flashcards
Acute single headache
Febrile illness, sinusitis First attack of migraine Following a head injury Subarachnoid haemorrhage Meningitis, tumour, drugs, toxins, stroke Thunderclap (sudden onset), low pressure
Dull headache, increasing in severity
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
Triggered headache
Coughing, straining, exertion
Coitus
Food and drink
Recurrent headaches
Migraine
Cluster headache
Episodic tension headache
Trigeminal or post-herpetic neuralgia
Dull headache, unchanged over months
Chronic tension headache
Depressive, atypical facial pain
Red Flags
Thunderclap, acute, subacute - onset
Photophobia, phonophobia, stiff neck, vomiting - meningism
Fever, rash, weight loss - systemic
Visual loss, confusion, seizures, hemiparesis, double vision, 3rd nerve palsy, Horner syndrome, papilloedema - neurological
Better lying down
Strictly unilateral
Focal Signs
Double vision
3rd nerve (oculomotor) palsy
Horner syndrome
Subarachnoid Haemorrhage
Sudden generalised headache, ‘blow to the head’.
Meningism - stiff neck and photophobia
Around 50% are instantly fatal.
High risk of a further bleed.
CT brain, Lumbar puncture (RBC and xanthochromia) and MRA, angiogram.
Aneurysm treatment
Aneurysms used to be clipped or wrapped.
Nowadays filled with platinum coils.
Acute intracerebral bleed
Fatal haemorrhage due to coning.
Raised Intracranial Pressure (ICP)
Mechanism of coning.
Papilloedema
Optic disc swelling due to raised ICP
Carotid and Vertebral Arteries
Headache can also arise due to pathology in the large arteries of the neck.
Headache and neck pain common
Mean age 40, carotid > vertebral
Carotid and Vertebral artery treatment
Aspirin or anticoagulation X 6/12
Temporal Arteritis
Over the age of 55.
Three times commoner in females.
Constant unilateral headache, scalp tenderness and jaw claudication
25% Polymyalgia Rheumatica-proximal muscle tenderness.
Elevated ESR and CRP.
Visible on ultrasound.
Biopsy shows inflammation and Giant Cells.
High dose steroids and aspirin.
Disruption of the internal elastic lamina
Cerebral Venous Thrombosis
Thrombosis in dural venous sinus or cerebral vein
Unusual amount of headache due to raised ICP
Non-territorial ischaemia “venous infarcts”
Haemorrhage
Thrombophilia, pregnancy, dehydration, Behcets
Causes of meningitis
Viral- Coxsackie, ECHO, Mumps, EBV
Bacterial - Meningococci, Pneumococci, Haemophilus, Tuberculous
Fungal - Cryptococci
Granulomatous- Sarcoid, Lyme, Brucella, Behçet’s, Syphilis
Carcinomatous
Meningitis
Malaise Headache Fever Neck stiffness Photophobia Confusion Alteration of consciousness
Herpes Simplex Encephalitis
Classic haemorrhagic changes in the temporal lobes
Meningitis treatment
Treat then diagnose
Antibiotics Blood and urine culture Lumbar puncture Increased White Cell Count, decreased glucose Antigens Cytology Bacterial Culture CT or MRI Scan
Sinusitis
Malaise, headache, fever. Blocked nasal passages. Loss of vocal resonance. Anosmia. Nasal or postnasal catarrh. Local pain and tenderness.
Frontal pain characteristically starts 1-2 hours after rising and clears up during the afternoon.
Idiopathic Intracranial Hypertension
Pseudotumor Cerebri
Often young obese women
Headache, visual obscurations, diplopia, tinnitus
Papilloedema, +/- visual field loss
Drugs: hormones, steroids, antibiotics, vitamin E
Treatment: weight loss, diuretics, optic nerve sheath decompression, lumboperitoneal shunt, stenting of stenosed venous sinuses.
Low pressure headache
CSF leak due to tear in dura
Traumatic post lumbar puncture or spontaneous
Treatment rehydration, caffeine, blood patch
Chiari Malformation
Normal brain that just sits very low within the skull
Cerebellar tonsils descending through the foramen magnum. Descend further when patient cough and tug on the meninges causing cough headache.
Obstructive sleep apnoea
Often characteristic body habitus, history of loud snoring and apnoeic spells
Hypoxia, CO2 retention, non-refreshing sleep
Depression, impotence, poor performance at work
Require sleep study
Nocturnal NIV, Surgery
Trigeminal neuralgia
Electric shock like pain in the distribution of a sensory nerve.
Often triggered by innocuous stimuli.
Any division of the trigeminal can be affected
Neurovascular conflict at the point of entry of the nerve into the pons.
Can be symptom of M.S.
Carbamazepine, lamotrigine
Atypical facial pain
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.
Not lancinating.
No sensory loss.
Pathology in teeth, temporomandibular joints, eye, nasopharynx and sinuses must be excluded.
Unresponsive to conventional analgesics, opiates and nerve blocks.
Mainstay of management tricyclics.
Post traumatic headache
High in victims of car accidents
Low in perpetrators of car accidents
Low in sports injuries
Neck injury
Scalp injury
Vasodilation ? autonomic damage
Depression - often delayed
Non-steroidal anti-inflammatories - ibuprofen, naproxen
Tricyclic antidepressants - Amitriptyline
Prevent analgesic abuse
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
Rest, deep heat, massage.
Anti-inflammatory analgesics.
Over-manipulation may be harmful
Migraine
Disorder
Tendency to repeated attacks Triggers easily hung-over visual vertigo motion sickness
3 forms - pain, focal, or both
Migraine: phases
Prodrome: Changes in mood, urination, fluid retention, food craving, yawning
Aura: Visual, sensory (numbness/paraesthesia), weakness, speech arrest
Headache: Head and body pain, nausea, photophobia
Resolution: rest and sleep
Recovery: mood disturbed, food intolerance, feeling hungover
Migraine: aura
Positive & negative symptoms together:
scintillations & blindspot
Expanding ‘C’s
Elemental visual disturbance
Migraine: treatment
Acute attack
Aspirin/ibuprofen (Non-steroidals) and paracetamol and metoclopramide (anti-emetic)
Hit the headache hard and fast
Opiates-caution! Analgesic abuse potential.
A short nap
Look for triggers and avoid them
Nasal sumatriptan (serotonin, 5HT1 agonist)
Migraine: prophylaxis
Beta-blockers - Propranolol, Atenolol
Serotonin antagonists: pizotifen, methysergide
Calcium channel blockers: flunarazine, verapamil
Tricyclic antidepressants (TCAs): amitriptyline 7pm
Erenumab
Tension type headache
Tight muscles around head and neck bilaterally, as though head is in a vice.
NSAID’s preferred:
Ibuprofen Naproxen, Diclofenac
Paracetamol
Tricyclic antidepressants - amitryptyline
Cluster headache
Severe unilateral pain lasting 15-180 minutes untreated.
Classified as a trigeminal autonomic cephalgia.
At least one of the following, ipsilaterally:
Conjunctival redness and/or lacrimation
Nasal congestion and/or rhinorrhoea
Eyelid oedema
Forehead and facial sweating
Miosis and/or ptosis
A sense of restlessness or agitation
Frequency between one on alternate days to 8 per day.
Not associated with a brain lesion on MRI
Cluster headache: treatment
Acute
Inhaled oxygen. Oxygen inhibits neuronal activation in the trigeminocervical complex
Prevention
Verapamil
Prednisolone
Lithium
Subcutaneous or nasal triptan
NO paracetamol or NSAIDs
Migraine vs Cluster headache
M - more women C - more men
M - longer C - shorter
M - monthly C - daily
M - long remissions unusual C - long remissions common
M - visual or sensory aura. C - eye waters, nose blocked, ptosis
M - lie in dark C - pace about
