Headache Flashcards
What are some examples of primary headaches?
-Analgesia-associated headache
-Migraine
-Cluster headache
What are some examples of secondary headaches?
-Sub-arachnoid haemorrhage
-AV malformation
-Trauma
-Dissections
-Giant cell arteritis
-Space-occupying lesion eg malignancy
-Infection (meningitis, encephalitis, brain abscess)
-CO poisoning
-Metabolic (pre-eclampsia, hypercapnia)
-CSF leak (eg post LP / epidural)
What should you ask about in a headache history?
-SITE - unilateral or bilateral? frontal? occipital?
-ASSOCIATED FEATURES - rhinorrhoea? lacrimation? meningism?
What examinations should you do?
-Neuro exam
-Assess gait
-ENT / dental / fundoscopy
NB Kernig’s sign = inability to straighten leg when hip is flexed at 90 degrees –> meningitis
What investigations would you consider for someone presenting with headaches?
-Headache diary
-Bloods - inflammatory markers (GCA)
-CT head - look for signs of raised ICP
-LP - meningitis, xanthochromia post-subarachnoid haemorrhage)
What are the key features of migraines?
-Often precipitated by an aura (focal neuro signs eg scotoma, pins and needles, olfactory changes, slurred speech)
-Can get photophobia but it is often less marked than in meningitis
-Can get associated N+V
-Unilateral
-Several triggers - menstruation, chocolate, caffeine, cheese
-Can last up to 72h
-F>M
-Treat prophylactically with topiramate / amitriptyline (propranolol in WCA)
-Treat headaches with sumatriptan
What are the key features of cluster headaches?
-Unilateral
-Tends to centre around ocular area
-Complete recovery achieved between episodes (30-90 min), 1-2 episodes a day
-Often associated with autonomic symptoms eg rhinorrhoea, watery eyes, redness
-Respond well to O2 and triptans
-M>F
What are the key features of a headache caused by a subarachnoid haemorrhage?
-Thunderclap, sudden onset, occipital, worst ever headache
-Peaking in intensity within 1-5 mins
-Vomiting, syncope, seizures
-Can be preceded by small minor bleeds
-CT head
-LP to assess for xanthochromia (at least 12h post onset)
What are the key features of a headache caused by a tumour?
-NB most will have no headache
-Some present with raised ICP
-Worst in morning, associated with vomiting
-Often subacute, worsening and unlike anything previously experienced
What are the key features of a headache caused by GCA?
-Most common in women >50
-Sharp, severe pain and tenderness over temporal artery (patients often first notice when brushing hair)
-TMJ pain when chewing
-Associated with polymyalgia rheumatica (aching, morning stiffness)
-Visual disturbances due to ischaemic optic neuropathy
How would you investigate and manage GCA?
INVESTIGATION
-Raised inflammatory markers
-Temporal artery biopsy shows skip lesions
-Fundoscopy shows disc Ischaemia, splinter haemorrhages, papilloedema
MANAGEMENT
-Immediate high dose prednisolone
-Refer urgently to ophthalmology as visual damage can be reversible
What findings from an LP indicate meningitis?
-Appearance = cloudy and turbid
-Opening pressure = elevated >25cm water
-WBC = elevated >100 cell/microL
-Glucose level = low
-Protein level = elevated
How does meningitis present (early vs late)?
EARLY = headache, leg pains, cold peripheries, abnormal skin colour
LATE = meningism (neck stiffness, photophobia), reduced GCS, seizures, petechial non-blanching rash, focal CNS signs
What can cause meningitis?
INFECTIVE
-Bacterial (life-threatening, most common in babies and children)
–Strep pneumoniae
–Neisseria meningitides (can result in bacterial meningitis or meningococcal septicaemia
-Viral
–H. influenzae
-Fungal (rare)
NON-INFECTIVE
-Some cancers
-Autoimmune disorders
-Injury
-Drugs
How should you manage meningitis?
-Start abx immediately if patient in shock / deteriorating / high suspicion
-IM / IV ben-pen if suspicious
-IV ceftriaxone without delay (+ amoxicillin if <3 months or >50yrs)
-IV dexamethasone (>3months)
-Supportive care ie fluids
-Prophylaxis for household contacts eg ciprofloxacin
