Headache Flashcards
Sinister causes of headache
Vascular: SAH, sub/extradural, cerebral venous sinus thrombosis
Infection: meningitis, encephalitis
Vision threat: temporal arteritis, acute glaucoma, pituitary apoplexy, cavernous sinus thrombosis
Intracranial pressure: SOL, hydrocephalus, malignant hypertension
Dissection: carotid dissection
New onset headache
>50 yrs
Suspicious of temporal arteritis until proven otherwise
Headache
Decreased GCS
Sudden onset worst pain ever, recalls exact moment pain began
Must exclude SAH
+ Hx head injury:
Fluctuating consciousness = suggestive of subdural
Lucid interval -> fluctuating consciousness = possible extradural
Persistent headache
Worse lying down
Early AM nausea
Raised ICP
E.g. Infection/SOL
Progressive
Persistent headache
Expanding SOL possible
Headache
Constitutional sx
Malignancy
Chronic infection: TB
Chronic inflammation: temporal arteritis
Temporal arteritis: opthalmological emergency
Inflammatory granulomas form in tunica media of med/large arteries. Can block med arteries
Mandibular branch of ext carotid -> jaw claudication
Superficial temporal branch ECT carotid -> headache + tender scalp
Posterior ciliary arteries -> ischaemic retina(blurry/visual field loss) or optic motor muscles (diplopia)
CRP + ESR (temporal artery biopsy)
High dose corticosteroids
Management of suspected SAH
Urgent CT head: bright blood in sylvian fissures
LP for xanthochromia if CT -ve (12 hrs from onset to 12 days)
SAH confirmed -> neurosurgeons + nimodipine (CCB reduces spasm of ruptured cerebral artery, preventing ischaemia) + bed rest
Survive + improved Sx -> cerebral angiography - platinum coil to resolve ruptured aneurysm ISAT study
High risk of morbidity + mort: 50% die pre hosp, 17% die in hosp, 17% survive with neuro deficit, 17% survive without deficit
Main causes of SAH
Rupture of arterial aneurysm: 45% oft berry at junction betw arteries of circle of Willis
Trauma: 45%
AVMs: 10% haemangioma rupture or cerebral vein around brainstem
Intracranial tumour ddx
90% are secondary mets: most common sources of primary cancer = lung, kidney, breast, melanoma, colon
Primary tumours:
Axial/neuroepithelial-50%: astrocytomas, ependymomas, oligodendrogliomas, medulloblastomas
Extra-axial: meningioma-15%(neurofibromatosis T2), vestibular schwannoma (7th + 8th nerve palsy) pituitary adenoma, Prolactinoma, craniopharyngiomas
Performing an LP
SC ends at L1/L2
LP safe at or below L3/L4
Tuffier’s line betw post-sup-iliac-crests = L4/L5
Skin->subcutis->supraspinous lig->interspinous lig->ligamentum flavum->dura mater->arachnoid space
Indications for an LP
Diagnostic Oligoclonal bands- MS High protein- GBS Blood/BR- SAH Pathogens- bact meningitis, viral encephalitis Malignant cells- CNS lymphoma Improvement in gait/cog function after 30ml removed- normal P hydrocephalus Therapeutic Intrathecal drug admin Temporary reduction in ICP
Relative CI to LP
Raised ICP
Increased bleeding risk: warfarin, DIC, deranged clotting
Infection at prospective puncture site
Cardiorespiratory compromise
Signs of raised ICP
Early AM headaches/nausea/vom worse on lying down/straining
Impaired GCS
Papilloedema
Focal neuro signs (6th nerve palsy) visual blurring
Cushing’s reflex paradoxical bradycardia + raised bp + irreg breathing
Cushing’s peptic ulcer-> epigastric pain
If any doubt image first!!
Risks of LP
Headache: 30% due to IC hypotension, minimise by lying flat for 2 hrs, smaller calibre needle
Nerve root pain: 10% pain in lumbosacral nerve root distribution due to irritation of a nerve in cauda equina, minimise by inserting and withdrawing needle slowly
Infection at site of puncture
