Headache Flashcards
What causes headache?
Thought to do with temporary changes in the chemicals, nerve, and blood vessels in the brain
- Cortical spreading depression propagated thru electrophysiological depolarization from the occipital pole has been correlated with both migraneous symptoms + changes in vascular blood flow
- Ion channel pathology
What structures can be involved in a headache?
- Trigeminovascular system -> cluster headache
- Meninges -> meningitis
- CSF containing structures -> increased intracranial pressure
- Muscle -> tension headache
- Nerves
What processes can lead to a headache?
- Neurogenic inflammation -> migraine
- Inflammation -> vascular arteritis
- Infection -> meningitis
- Pressure -> intracranial hypertension/hypotension
- Obstruction -> space occupying lesion
What is the difference between primary and secondary headaches? Give examples of each
1º headaches: No underlying disease mechanism
- Migraine, cluster headache
2º headaches: Underlying disease mechanism
- SOL, intracranial HTN, vasculitis/arteritis
Outline the important components of a headache history
PC: SOCRATES for headache pain
- focus on characteristic, onset of pain, and aggregating/relieving factors
PMH: Previous headache, other illnesses which may cause headache
Drug Hx: OCP, Codeine (if taken regularly - drug-induced headache)
Fam Hx: Migraines run in families
Social Hx: Smoking, caffeine, job, impact on daily life
What are red flags for headache?
- Thunderclap headache = SAH
- Unilateral + eye pain = cluster; acute glaucoma
- Unilateral + ipsilateral symptoms = migraine; tumour; vasculitis
- Cough-initiated headache + worse in morning/bending forward = increased ICP; venous thrombosis
- Persistent + scalp-tenderness + > 50y = giant cell arteritis
- With fever + neck stiffness = meningitis
- Change in pattern of headache
- Decreased level of consciousness
What are 2 other important questions to ask someone when taking a headache history?
- Recent foreign travel (?malaria)
2. Chance of pregnancy (?pre-eclampsia; especially if hyperproteinuria + hypertension)
What are important signs that should not be missed on physical examination of someone complaining of headache?
- Papilloedema = Increased intracranial pressure
- Peripheral field loss, enlarged blind spots = increased ICP
- 6th nerve palsy (failure to abduct eye) = increased ICP; giant cell arteritis
- Ataxia + headache = lesion in post. cranial fossa (cerebellum)
- Oral hairy leukoplakia = immunodeficiency (EBV)
- Purpuric rash + sepsis = meningococcal septicemia
- Livedo reticularis with headache = lupus (increased risk of venous clots + vasculitis)
Name 3 common investigations performed for those with headache?
- CT
- MRI
- CSF monometer (measures P in brain from LP)
What would xanthachromic CSF indicate?
Indicates presence of bilirubin in the CSF
Diagnosis = subarachnoid hemorrhage
If CSF has cells (i.e. neutrophils) in it what does this indicate?
Bacterial infection (i.e. meningitis)
If on histological examination blood vessels have lots of inflammatory infiltrates + ESR levels are raised what does this suggest?
Giant cell arteritis
What is the treatment for giant cell arteritis? What can occur without treatment?
High dose steroids should be prescribed immediately (prednisolone)
Danger of blindness if not prescribed immediately
What is the treatment for hydrocephalus?
Placement of a shunt commonly in the R lateral ventricle and draining excess fluid into the abdominal cavity where it is absorbed
Name 5 drugs used for migraine prophylaxis
- Propranolol (beta blocker) - first line
- Amitriptyline (anti-depressant) - first line
- Topimarate/sodium valproate (anti-seizure medication; teratogenic!) - second line
- Verapamil/Amlodipine (Ca2+ channel blockers) - second line
- Pizotifen (5HT-2a + 2c antagonist, antihistamine, anticholinergic)
What are the common symptoms of a migraine?
- Throbbing pain lasting hours - 3 days
- Can be unilateral or bilateral
- Sensitivity to stimuli (light, sound, smells)
- Nausea
- Aggrevated by physical activity (prefers to lie in dark room)
- Aura if present evolves slowly (in contrast to stroke) and lasts minutes-60min
What is the acute treatment for migraines?
- Aspirin 900mg
- NSAID taken with metoclopramide/domperidone
- Triptan (i.e. sumatriptan) -> agonists of 5HT-1b + 1d receptors. Should be taken < 10d per month
** Do NOT prescribe opioids for migraine!!
What are other potential treatments for migraine (if acute treatments don’t work)?
- Botulinum toxin injections (every 12wks around scalp/neck)
- Anti-CGRP monoclonal antibodies (erenumab) -> not licensed in UK yet!
- Acupuncture
What are the symptoms of a cluster headache?
- More common in men
- Severe pain lasting 30-120min
- Unilateral, side-locked
- Striking circadian rhythm clustering in periods of few weeks
- Autonomic features (associated with trigeminal nerve distribution) = tearing, red conjunctiva, ptosis, mitosis, nasal stuffiness
What is the treatment for cluster headaches?
- Sumatriptan injection 6mg s.c. (contraindicated for IHD, stroke)
- High-flow O2 thru non-rebreathe mask
- High-dose verapamil (Ca2+ antagonist) - up to 960mg/day
- Prednisolone 60mg for 1wk can abort attacks
- Indomethacin (NSAID) for paroxysmal hemicranias
What are the symptoms of a tension-type headache?
- Bandlike ache, mostly featureless
- Can have mild photo/phonophobia
- No nausea
What is the treatment for tension-type headaches?
- Low dose amitryptiline
- Low dose NSAIDs
- Relaxation
What are the features of analgesic-overuse headache?
- Can be migrainous or tension-type
Triptan intake: >10 days/mo for ≥ 3mo
Simple analgesia intake: > 15 days/mo for ≥ 3mo
What is the treatment for analgesic-overuse headaches?
Gradually decrease analgesic use (eventually stop)
What are the features of raised intracranial pressure?
- Mild headache
- Diurnal variation (worse in morning)
- Mild nausea
- Neurological symptoms (weakness, cerebellar features - ataxia)
- Papilloedema
What are 3 causes of raised ICP?
- Tumours
- Abscess
- CSF blockage
What are the features of meningitis?
- Fever
- Photophobia
- Neck stiffness
- Altered consciousness
- Purpuric/petechial rash (non-blanching)
What is the most common treatment for meningitis?
- Ceftriaxone/cefotaxime
- Benzyl penicillin
- Most are viral
What are the features of temporal arteritis?
- > 50y old
- Features of polymyalgia (tightness in muscles in morning)
- Jaw claudication (b/c arteries are narrowed)
- Tender temporal arteries
- Raised ESR
What are the features of cerebral venous thrombosis?
- Often female, on OCP/HRT
- Severe headache
- Often seizures
- May be bilateral
- Raised ICP, bilateral papilloedema
- Diagnose with MRI/magnetic resonance venography
What are the features of low ICP?
- Headache on standing, eased with lying down
- Can occur spontaneously
- i.e. after a lumbar puncture -> spontaneous leak of CSF
What is the treatment for low ICP due to lumbar puncture?
Blood patch
- Take blood from arm and inject into base of lumbar puncture site to seal hole and prevent pressure from decreasing again
What are the risk factors for early morning headaches?
- Obese
- History of snoring
- COPD
- Headache in morning
Diagnosis = sleep apnea with CO2 retention
What 4 conditions has cortical spreading depression been seen in, other than migraine?
- Cerebrovascular accident (stroke)
- Epilepsy
- Subarachnoid hemorrhage
- Traumatic brain injury
What are some recognised trigger factors for migraine?
- Cheese
- Relaxing after stress
- Jet lag
- Flickering lights on a tv
- Menstruation
- Contraceptive pill
Which area in the brain is thought to be involved in the production of the migraine headache?
Trigeminal nucleus caudalis (TNC)
What is the mechanism of action of triptans?
Strong agonistic activity at the serotonin receptor. Shown to induce vasoconstriction, mediated by an action on 5-HT 1b receptors in arterial smooth muscle
Vasoconstriction of vasodilated arterioles was thought to be the most likely mechanism of action for triptans in the treatment of acute migraine, in keeping with the theory of vasoconstriction and vasodilatation originally described by Graham & Wolff.
Which medical conditions are contraindications to treatment with triptans?
- Transient ischemic attacks (TIAs)
2. Ischemic heart disease
What treatment regimen should be followed for migraine if the patient initially doesn’t respond to triptan treatment?
Triptan + NSAID (i.e. sumatriptan + naproxen)
OR
Repeat dosage of triptan (2h after initial dose)
What are the 4 criteria for consideration of preventative treatment?
- Quality of life severely affected
- 2+ attacks/month
- Migraine attacks don’t respond to acute treatment
- Frequent/long/uncomfortable auras
What is the most common bacterial, viral, and fungal cause of sepsis/septic shock?
Bacterial = staphylococci
Viral = Herpes viridae
Fungal = Candida
What is the most common bacterial, viral, and fungal cause of meningitis?
Bacterial = streptococcus pneumonia
Viral = Enterovirus
Fungal = Cryptococcus neoformans
What is the most common causative agent of neonatal meningitis?
E coli
What is the most common bacterial, viral, and parasitic cause of encephalitis?
Bacterial = Listeria monocytogenes
Viral = Herpes simplex, EBV, CMV, Varicella zoster, adenovirus
Parasitic = Neagleria Fowleri
What is the most common bacterial and fungal cause of brain abscess?
Bacterial = staph aureus
Fungal = Candida species
What is the most common bacterial cause of spondylodiscitis?
Staph aureus
What are the differential diagnoses of meningitis?
- Encephalitis: Most common cause is HSV. Encephalitis is inflammation of the brain and unlike meninigitis it causes confusion or disorientation, drowsiness, seizures and changes in personality and behaviour, such as feeling very agitated.
- Non-infectious causes (blood, trauma, drugs) of meningeal irritation
- Subdural empyema: collection of pus in subdural space
What are risk factors for meningitis?
- Extremes of age
- Living in close proximity (outbreaks can occur in student halls of residence and boarding schools)
- Vaccination history (absence of)
- Immune suppression/deficiency
What are the signs of encephalitis?
- Cognitive changes
- Mood changes
- Drowsiness