Headache Flashcards
Headache preceding subarachnoid haemorrage?
Sentinel headache.
May be due to small bleed from aneurysm
What is the concern with carotid artery dissection?
Inflammatory response to heal -> thrombus formation -> thromboembolism -> stroke.
DDx of sudden onset headache?
SAH Meningitis Intracerebral haemorrage Migraine Primary Sex Related Headache Reversible cerebral vasospasm
How is SAH distinguished from primary sex related headache?
Duration.
SAH ongoing, PSRH 15-20min before diminishing.
What are the important headaches not to miss?
SAH Meningitis/encephalitis Subdural haematoma Space occupying lesion Giant cell arteritis Glaucoma
What are the characteristics of subdural haematoma?
Slow: hours - day.
Elderley
Anticoagulants
Alcoholics
What are the features of headache due to giant cell arteritis?
Unilateral Over 50yo Visual disturbance - amaurosis fugax Jaw claudication Temporal tenderness \+/- general malaise/fatigue
An aneurysm of which is artery is most likely to cause surgical 3rd nerve palsy?
Posterior communicating artery
Will generally involve the pupil (diplopia, ptosis, pupil dilation)
What is the commonest cause of 3rd nerve palsy?
Microvascular pathology
E.g. smoking, DM, HTN
Decreased blood flow to nerve -> ischaemia.
Often pupil sparing (diplopia, ptosis)
What investigations in suspected SAH?
Non-contrast CT
Bloods: FBE, UEC, LFT; coags
Causes SAH?
Ruptured cerebral aneurysm (70%)
Ruptured AV malformation (10%)
Undiscovered (!5%)
Rare (5%): spinal av malformation, arterial dissection, tumour, bleeding diathesis).
If CT normal but SAH expected, what is follow up?
LP: look for bloodstained CSF that does not clear on 3 consecutive collection tubes.
Looking for xanthochromia (yellow staining due to breakdown of Hb 6-8 h after SAH).
What are overall management priorities in SAH?
Monitor: GCS, BP
Symptomatic: pain, nausea, vomiting, raised ICP and hydrocephalus.
Prevent re bleeding: dx and manage cause SAH.
What are the considerations in SAH analgesia?
Don’t want to impair conscious state.
Mild opiates
Paracetamol
Simple NSAIDs (although often avoided as decrease platelet clotting).
What BP parameters post SAH?
Normotension
What follow up investigations post SAH?
CT angiogram
Coag studies
What is normal ICP?
10 - 15mmHg
What is ICP directly related to?
Volume of the intracranial contents: brain, CSF, blood. (Monro-Kellie doctrine).
What are the causes of raised ICP?
Space occupying lesion: tumour, blood clot, abscess
Increased volume normal contents:
-brain e.g. cerebral oedema
-CSF e.g. hydrocephalus
-blood e.g. vasodilation due to hypercapnia from hypoventilation
What are the symptoms of raised ICP?
Headache Nausea and vomiting Drowsiness, eventual coma Papilloedema Signs of transtentorial herniation
What are the signs of transtentorial herniation?
Unilateral dilated pupil (3rd nerve palsy)
Contralateral hemiparesis (midbrain)
Hypertension/bradycardia (Cushing response)
Respiratory failure
What is raised ICP treatment?
- Elevation of head to encourage venous return
- Diuresis to reduce cerebral oedema/extracellular fluid
- Hyperventilate/avoid hypoventilation (intubate if necessary)
- Sedate/paralyse
- Remove mass
- Drain hydrocephalus
Headaches causing meningitic pain?
- SAH
- Meningitis / encephalitis
Intracerebral mass causing headache?
- Tumour/abscess
- SDH/ SDE(empyema)
What is idiopathic intracranial hypertension?
- Young women
- Usually overweight
- ?problem in CSF production / resorption
- Chronic disorder
- CNI and CNVI d/o
Important features to exclude in idiopathic intracranial hypertension?
- Exclude mass lesion
- Exclude CVST
Serious headaches to exclude?
- Meningitic: SAH, meningitis encephalitis
- Mass: tumour, SDH, SDE
- Other raised ICP
- GCA
Common non serious headaches?
- Migraine
- Tension
- Trigeminal autonomic cephalgias (inc cluster HA)
- Low CSF pressure HA
- Cough cephalalgia
- Primary orgasm HA
- Trigeminal neuralgia
Cluster HA AFx?
- Watery eye
- Conjunctival haemorrhage
- Stuffy nose
- Ptosis
Rx cluster HA?
- High flow O2
- IV Sumatriptan
- Indomethacin (NSAID)
- Verapamil (post ECG)
Most sensitive test for SAH several weeks post occurrence?
MRI
Describe pain of trigeminal neuralgia?
- Stimulus sensitivity
- Agonising stab of electric shock type pain
- Usually V2/3 (rarely V1)
Rx trigeminal neuralgia?
- Carbemazepine
- Pregabalin (less effective)
Ix for SAH
- CT
- If Hx suggestive and CT Normal then ==> LP for bilirubin + oxyhaemoglobin >12h from ictus
Why is LP deferred 12h post ictus?
Allows differentiation of old blood or new (i.e. exclude traumatic tap)
CFx of meningitis?
-Neck stiffness
-Subacute/acute HA
-Photo/phonophobia
+/-
-Fever
-Rash
-Kernig’s sign
-Confusion/dec GCS / seizures focal signs
TREAT FIRST WHILE Ix DONE
Rx meningitis?
- Benzyl penicillin + ceftriaxone
- Often + acyclovir (for herpes encephalitis)
Rx tuberculous meningitis?
- Rifampicin
- Isoniazid
- Pyrazinamide
- Ethambutol
When should steroids be added to meningitis treatment?
Add dexamethasone for:
- pneumococcal
- Meningococcal
- Tuberculous
When is brain imaging necessary?
Mandatory if: focal signs or decreased GCS, to exclude mass lesions / obstructive hydrocephalus / diffuse brain swelling
What are the parameters required pre LP?
- Imaging ok
- Plt >100
- INR
Ix on LP CSF?
- Measure pressure, cell counts, protein, glucose, blood glucose, culture
- HSV PCR
CFx of mass lesion HA?
- Worse in AM / lying down
- AM n/v
- Focal neuro signs
- Seizure
- Systemic 1’
- Prodromal sinusitis / otitis media
Ix GCA?
-ESR
-CRP
(both)
-Superficial temporal artery Bx (at least 1cm in length)
What is malignant HTN with MRI correlate termed?
Posterior reversible encephalopathy syndrome (PRES)
Dx for consideration in all pts with raised pressure HAs?
Cerebral venous sinus thrombosis
Mx cerebral venous sinus thrombosis?
Treat as for DVT with anticoagulation
Ix in CVST?
- MRV or CTV
- Ix for local infection, thrombophilia, malignancy
Acute migraine treatments?
- Aspirin / paracetamol / ibuprofen
- +/- anti emetic
- strong NSAID
- Avoid codeine
- Triptan 5HT1 agonists
- Parenteral triptan (rizatriptan, sumatriptan,)
Consideration in migraine treatments?
Overuse of opiates or triptans can cause medication overuse HA (constant HA of varying severity)
Migraine prophylaxis? Which in pregnancy?
- B-blocker (not in pregnancy)
- Pizotifen (not pregnancy)
- Amitryptylline (safest in pregnancy)
- Valproate (not pregnancy)
- Topiramate (slightly safer but only lose doses)
