Headache Flashcards
What mnemonic can be used to remember different sinister causes of headache?
VIVID
List some conditions that come under each heading of the mnemonic.
Vascular • Subarachnoid haemorrhage • Subdural/Extradural haematoma • Cerebral venous sinus thrombosis • Cerebellar infarct Infection • Meningitis • Encephalitis Vision-threatening • Temporal arteritis • Acute glaucoma • Cavernous sinus thrombosis • Pituitary apoplexy • Posterior leucoencephalopathy ICP raised • Space-occupying lesion • Cerebral oedema • Hydrocephalus • Malignant hypertension Dissection • Carotid dissection
List some red flag symptoms of headache
Decreased level of consciousness Sudden-onset worst headache ever Seizure or focal neurological deficit Absence of previous episodes Reduced visual acuity Persistent headache – worse when lying down and early morning nausea Progressive, persistent headache Constitutional symptoms Past medical history of malignancy or immunosuppression
What cause of headache can also result in a decreased level of consciousness?
Subarachnoid haemorrhage
Subdural/extradural haematoma
Meningitis/encephalitis
What must you consider if someone complains of a sudden-onset worst headache ever?
Subarachnoid haemorrhage
What does a focal neurological deficit along with a headache suggest?
Intracranial pathology
NOTE: migrainous aura can also give neurological signs (either positive or negative)
Which cause of headache is commonly accompanied by reduced visual acuity?
Temporal arteritis
What are the four main features of temporal arteritis?
Headache
Jaw claudication
Reduced visual acuity
Scalp tenderness
What type of headache is associated with causing early morning nausea/vomiting and a headache that is worse when lying down?
Raised ICP
What is likely to cause a headache that is worse when standing up?
Reduced ICP – this is common after an LP and is not considered sinister
What does a progressive, persistent headache suggest?
Gradually expanding space-occupying lesion (e.g. tumour, abscess, cyst)
List some constitutional symptoms. What can cause such symptoms?
Fever, weight loss, night sweats
It may suggest malignancy, chronic infection or chronic inflammation
What are some red flag features of the past medical history of someone presenting with headache?
History of malignancy (headache could be caused by brain metastases)
History of immunosuppression or HIV (increased risk of intracranial infection)
What are some important features of the basic observations that may make you suspect a sinister cause of the headache?
Altered consciousness
Blood pressure and pulse (check for malignant hypertension)
Temperature (suggests infection)
Describe the appearance of 3rd nerve palsy.
The pupil is down and out
Ptosis
Mydriasis (unless it is pupil-sparing 3rd nerve palsy)
What can cause a headache that is accompanied by 3rd nerve palsy?
Subarachnoid haemorrhage
Posterior communicating artery aneurysm
Describe the appearance of 6th nerve palsy.
Inability to abduct the affected eye
The 6th cranial nerve is the most susceptible to compression due to raised ICP. Explain why.
It has the longest intracranial course of any cranial nerve and so is most susceptible to compression by raised ICP
Describe the appearance of 12th nerve palsy.
Protraction of the tongue will make it deviate towards the side of the lesion
What can cause headache that is associated with 12th nerve palsy?
Carotid artery dissection
Describe the appearance of Horner’s syndrome.
Ptosis
Miosis
Anhydrosis
What can cause headache that is associated with Horner’s syndrome?
Carotid artery dissection
List some key features of eye examination and the underlying pathology that each of them is associated with.
Exophthalmos – suggests retro-orbital pathology (e.g. cavernous sinus thrombosis)
Cloudy cornea + fixed, dilated pupil – acute glaucoma
Papilloedema – raised ICP
What age group is most commonly affected by temporal arteritis?
Over 50 yrs old
Describe the pathophysiology of temporal arteritis.
It is characterised by the formation of immune, inflammatory granulomas in the tunica media of medium/large arteries
The inflammation resulting from the immune infiltration can lead to blockage of the lumen of arteries
Describe the management of temporal arteritis.
High dose corticosteroids
List some non-sinister causes of headache.
Tension-type headache Migraine Sinusitis Medication overuse headache Temperomandibular joint syndrome Trigeminal neuralgia Cluster headache
List some important questions that help you characterise non-sinister headaches.
are there different headaches in past (distinguish)
triggers (migraine -cheese and caffeine; cluster - alcohol)
disabling
aura
Describe the features of tension-type headaches.
Very common
Often bifrontal across the forehead (tightening band around head)
Not very disabling and there are no other features (e.g. photophobia)
Stress and fatigue are common triggers
Describe the features of migraines.
Typically a unilateral,
throbbing/pulsatile pain
Often focused over one eye
1/3 of migraine sufferers experience an aura
NOTE: some patients can have aura without migraine
What is the main treatment used for migraines?
Triptans (5HT receptor agonists)
They cause cerebral artery vasoconstriction and inhibition of trigeminal nerve transmission
Describe the features of sinusitis.
Facial pain along with coryzal symptoms
It is a tight pain (similar to tension-type headaches) that is often exacerbated by movement
What types of medication are most commonly associated with causing medication overuse headaches?
Analgesics
Migraine medications
Describe the features of temperomandibular joint syndrome.
Headache + dull ache in the muscles of mastication
Some patients report clicking/grinding when they move their jaw
Describe the features of trigeminal neuralgia.
Unilateral
stabbing, sharp facial pain involving one or more divisions of the trigeminal nerve
last seconds and happens many times during day
Describe the features of cluster headaches.
clusters of about 6-12 weeks every 1-2 years
same time every day
Pain tends over one eye and is extremely severe
EYE - horner syndrome, red, watery, rhinorrhea
Which types of non-sinister headache are more common in:
Women
Men
Women Migraine TMJ syndrome Trigeminal neuralgia Men Cluster headaches
Even if a non-sinister headache is suspected, why is it important to check: Blood pressure H&N exam Focal neurological signs Fundoscopy
Blood pressure Malignant hypertension Head and neck examination Meningism Focal neurological signs Intracranial pathology Fundoscopy Raised ICP
List two investigations that can be used to help diagnose a subarachnoid haemorrhage.
CT head
Lumbar puncture – check for xanthochromia (present from 12 hours to 12 days after SAH)
What medication is regularly used in the initial management of subarachnoid haemorrhage?
Nimodipine (CCB) – this reduced spasm of the ruptured artery and prevents ischaemia
AND rest at 30-40 degrees supine
Describe the differences in the types of symptoms experienced in a TIA compared to an epileptic seizure.
TIA – negative symptoms (due to loss of function e.g. loss of vision, numbness, loss of power)
Epilepsy – positive symptoms (due to overactivation e.g. flashing lights, muscle convulsions, paraesthesia)
NOTE: migraine can produce both positive and negative symptoms
Describe how epileptic patients feel immediately after a seizure.
They experience a postictal phase where they will feel exhausted or confused
Which sinus is most commonly affected in sinusitis?
Maxillary sinus
Why is frontal sinusitis dangerous?
The bacteria can erode backwards into the brain and cause meningitis or brain abscesses
Which part of the brain do most brain tumours tend to develop in children?
Posterior cranial fossa
What is the most common type of brain tumour in children?
Medulloblastoma of the cerebellum
List three causes of subarachnoid haemorrhage.
Rupture of an arterial aneurysm (usually berry aneurysms found at the junctions of the circle of Willis)
Trauma
Arteriovenous malformations (e.g. rupture of haemangiomas or cerebral veins)
What is the most common type of brain tumour?
Metastases
Most commonly from the lung, breast, colon, melanoma and kidney
List four types of axial brain tumour.
Oligodendroglioma
Ependyomas
Astrocytomas
Medulloblastoma
List five types of extra-axial brain tumour.
Meningioma Vestibular schwannoma Pituitary adenoma Craniopharyngioma (tumour of the pituitary embryonic tissue) Prolactinoma
What condition predisposes individuals to developing meningiomas and schwannomas?
Neurofibromatosis Type II
At what vertebral level should a lumbar puncture be performed?
L3/4
Which structures are traversed during a lumbar puncture?
Skin Subcutis Supraspinous ligament Infraspinous ligament Ligamentum flavum Dura mater Arachnoid space (destination)
List some diagnostic indications for a lumbar puncture.
Multiple sclerosis (look for oligoclonal bands)
Guillain-Barre syndrome (look for high protein)
Subarachnoid haemorrhage (look for xanthochromia)
Meningitis (look for pathogens)
CNS lymphoma (look for malignant cells)
Normal pressure hydrocephalus (look for improvement in gait and cognitive function after removal of a small amount of CSF)
List some therapeutic indications for a lumbar puncture.
Intrathecal drug administration
Temporary reduction in ICP
List some relative contraindications for lumbar puncture.
Raised ICP
Increased bleeding tendency
Infection and prospective puncture site
Cardiorespiratory compromise
List some risks of lumbar puncture.
Headache
Nerve root pain
Infection at puncture site
List some signs and symptoms of raised ICP.
Headache (worse when lying down) Nausea and vomiting early in the morning Papilloedema Visual blurring Cushing’s reflex Cushing’s peptic ulcer
What is Cushing’s reflex?
A response to raised ICP characterised by:
High blood pressure
Low heart rate
Irregular breathing
Describe some mechanisms that can lead to raised ICP.
Space-occupying lesion
Cerebral oedema
Increased blood pressure in the CNS (e.g. due to malignant hypertension)
Hydrocephalus
List some mechanisms of hydrocephalus.
Obstruction of CSF drainage
Dysfunction of arachnoid granulations responsible for CSF reabsorption
Increased CSF production
Describe how the unconsciousness presents with the conditions where you get unconsciousness with a headache
SAH- immediatly with onset of the headache
Extradural - following the trauma and then lucid period
Subdural - cousciousness loss later on
What is a the name of a vision loss in a TIA?
amaurosis fugax
What question do you ask if you are worried of carotid or vertebral dissection?
minor neck trauma
- recent chiropracter
- yoga
If someone presents with a headache and it is due to temporal arteritis what is your investigation of choice?
ESR and CRP
Biopsy - but since interrupted in nature could biopsy bit that is normal
What is the criteria for diagnosing temporal arteritis?
older than 50
New headache
ESR higher than 50mm
Clinically abnormal temporal artery (tender and pulsatile)
Biopsy of Temporal artery show mononuclear infiltration or granuloma
Someone has symptoms of SAH-
What do ask in the history?
Investigation?
What do ask in the history? - neck stiffeness
Investigation? CT head (blood in the sylvian fissure),
IF negative - then lumbar puncture to look for xanthochromia 12 HOURS later
for how many days can the CT scan detect blood in a SAH?
12 days
