Headache Flashcards
List 8 important DDx for headache
Tension-type
Migraine
SAH
Meningitis/encephalitis
Subdural haematoma
Space-occupying lesion
GCA
Glaucoma
Describe the characteristics of a tension-type headache
Bilateral “band-like” pressure
Gradual onset
Common, associated with stress
Describe the characteristics of migraine
Unilateral
Gradual onset
May be associated with nausea and accompanying or preceding visual or sensory aura
Describe the characteristics of headache due to SAH
Severe
Sudden onset
“Warning headache” beforehand
+ive FHx
Describe the characteristics of headache due to meningitis/encephalitis
May be associated with fever, neck stiffness or photophobia
List the typical clinical vignette seen in subdural haematoma
Age
Alcoholics
Anticoagulants
Describe the characteristics of headache due to a space-occupying lesion
Morning headaches
May be associated with new-onset seizures and other neurological deficits
What clinical features also accompany GCA?
Unilateral headache
Visual disturbances
Jaw and tongue claudication
Describe the characteristics of headache due to GCA
Unilateral
Usually in over 50s
May be accompanied by visual disturbance and jaw and tongue claudication
Describe the characteristics of headache due to glaucoma
Unilateral with visual disturbance
How does SAH present clinically?
Sudden onset, severe headache (not previously experienced, sometimes with preceding sentinel headache)
Reduced conscious state with decline (30% present deeply comatose or with sudden death)
Meningism (headache, neck stiffness, photophobia, fever, vomiting), due to blood in the subarachnoid space
Focal neurological signs
What are the possible mechanisms of focal neurological signs in SAH and what signs are commonly seen?
Intracerebral component of bleeding may cause frontal or temporal haematoma and related signs
Local pressure effects of aneurysm (particularly of PCommA) may cause 3rd nerve palsy
Cerebral vasospasm may cause symptoms and signs 2-7 days post-initial presentation
List 5 DDx for severe, sudden onset headache
Meningitis
Intracerebral haematoma (HTNive or amyloid haematoma, trauma)
Migraine or cluster headache
Headache with orgasm
Reversible cerebral vasospasm
What are the 3 most common causes of SAH? List 5 rarer causes
Most common: ruptured cerebral aneurysm, undiscovered/unknown or ruptured AV malformation
Rarer: spinal AV malformation, arterial dissection, tumour, bleeding diathesis
What should be done if a normal CT is produced in a case of suspected SAH? What are the expected findings?
LP
Bloodstained CSF that does not clear on 3 consecutive collection tubes, and xanthochromia
What is xanthochromia?
Yellow staining due to breakdown of Hb which occurs 6-8 hours post-SAH
How can the risk of rebleeding of cerebral aneurysms be reduced?
Dx and Mx of cause of SAH
Maintain normotension
Avoid pain, straining, coughing, vomiting, agitation
Surgical clipping of aneurysm neck or endovascular coiling
How common is re-bleeding of a cerebral aneurysm?
50% of patients within 6 weeks, 25% within 2 weeks
How is cerebral aneurysm diagnosed and treated?
Diagnosis: cerebral CT angiogram, formal catheter angiography, DSA
Treatment: surgical clipping of aneurysm neck, endovascular coiling
How does endovascular coiling work?
Platinum wires are placed in the aneurysm angiographically via a catheter to induce thrombosis
What is normal ICP?
10-15 mmHg
What is the Monro-Kellie doctrine?
ICP is directly related to the volume of the intracranial contents
What are the 2 main causes of raised ICP?
Space-occupying lesion
Increased volume of normal intracranial contents (brain, CSF, blood)
List 3 specific causes of raised ICP related to increased volume of normal intracranial contents
Brain: cerebral oedema
CSF: hydrocephalus
Blood: vasodilation due to hypercapnia from hypoventilation
List 6 symptoms of raised ICP
Headache
N+V
Drowsiness, eventual coma
Papilloedema
Cushing response
Signs of transtentorial herniation
List 3 signs of transtentorial herniation and their underlying mechanism
Unilateral dilated pupil (3rd nerve palsy)
Contralateral hemiparesis (midbrain compression)
Respiratory failure (respiratory centre compression)
What are the 3 elements of the Cushing response?
Bradycardia
HTN
Disordered breathing
How is raised ICP treated? (6 important steps)
ELEVATE head to encourage venous return
URINATE (diuresis) to reduce cerebral oedema/ECF
HYPERVENTILATE/avoid hypoventilation (intubation may be necessary)
SEDATE or paralyse
EXCAVATE (remove) mass
EVACUATE (drain) hydrocephalus (e.g. with external ventricular drain)
Mr Styles, 45 year old accountant, presents with a severe headache that came on suddenly while showering in the morning, associated with photophobia, nausea and 2 episodes of vomiting; describes it as “like being kicked in the back of the head”
PHx: 25 pack year smoking, HTN, similar but much less severe headache 2 weeks prior (treated as “migraine”)
Rx: perindopril 5mg mane
FHx: mother alive, father died age 52 “in his sleep”
SHx: accountant, high stress job, 2 children aged 10 and 15, wife manages the home
DDx?
Tension-type
Migraine, cluster headache
SAH
Meningitis/encephalitis
Subdural haematoma
Intracerebral haematoma
Space-occupying lesion
GCA
Glaucoma
Other causes of sudden onset headache: headache with orgasm, reversible cerebral vasospasm
What demographic most commonly gets migraines?
More common in women
Often have a FHx
What features on Hx might make you suspicious of a migraine (besides characteristics of the headache)?
Often FHx
Often PHx
Mr Styles, 45 year old accountant, presents with a severe headache that came on suddenly while showering in the morning
What further information will you seek from physical examination?
Vitals
GCS
Examine for associated features e.g. photophobia and neck stiffness
Full neurological examination including cranial nerve examination
Mr Styles, 45 year old accountant, presents with a severe headache that came on suddenly while showering in the morning
O/E: looks unwell, distressed, vomit bag on bed, BP 180/110, GCS 13 (eyes open to voice, got date wrong), photophobic, neck stiffness, L pupil > R and poorly reactive to light, remainder of brief cranial nerve and peripheral examination normal
What is the most likely Dx and why?
Ix?
Mx?
Hx and physical examination point to SAH, most likely from a ruptured cerebral aneurysm on the ICA/PCommA
Ix: basic bloods (likely normal), CXR (expect normal), CT brain (hyperdense blood in the subarachnoid space, enlarged ventricles)
Mx: monitor and treat symptoms and complications of SAH (pain, N+V, raised ICP, hydrocephalus), prevent rebleeding (Dx and Mx cause of SAH)
Mr Styles, 45 year old accountant, presents with a severe headache that came on suddenly while showering in the morning
Dx: SAH
What sort of analgesia is safe for Mr Styles?
What might be the complications of analgesia?
What observations/monitoring does Mr Styles need?
Complications: respiratory depression
Obs: vitals with particular attention paid to BP
What BP parameters should be ordered in the case of SAH?
??
Mr Styles presents with SAH
Mr Styles deteriorates immediately after his CT angiogram: his headache is worse, he comes increasingly drowsy and confused, his GCS drops to 8 (does not open his eyes, only verba response is grunts and moans, localises to pain)
CT angiogram shows that the ventricles have enlarged due to worsening hydrocephalus
Explain the mechanisms of raised ICP in Mr Styles and in general
Mechanism of raised ICP relates to the Monro-Kellie doctrine; ICP is directly related to the volume of the intracranial contents so anything that increases the volume (in this case blood and CSF) also increases the ICP
