Headache Flashcards
What sinister causes of headache must be ruled out?
VIVID
Vascular - SAH, subdural/extradural haematoma, cerebral venous sinus thrombosis, CVA
Infection - Meningitis, encephalitis
Vision-threatening - Temporal arteritis, acute glaucoma, pituitary apoplexy, posterior leucoencephalopathy, cavernous sinus thrombosis
Intracranial Pressure - SOL, cerebral oedema, hydrocephalus, malignant hypertension
Dissection - Carotid
What are the headache redflags?
Decreased level of consciousness
Sudden onset/worst headache ever
Seizures or neuro deficit
Absence of previous episodes
Reduced visual acuity
Worse when lying down (and coupled with early morning nausea)
Progressive and persistent
Constitutional symptoms
What will you look for in a headache clinical exam?
Altered consciousness
BP, pulse and temp
Neuro: Focal limb deficit 3rd nerve palsy 12th nerve palsy Horner's
Eye:
Exophthalmos?
Scalp tenderness?
Meningism?
On examination, Mr Lennon is not obviously photophobic as he is sitting in a well-lit environment. His
heart rate is 84 beats/min (bpm), his blood pressure is 134/81 mmHg, and his temperature 36.5°C.
Examination of his cranial nerves reveals reduced visual acuity in his right eye but not his left, which
he previously hadn’t noticed. Fundoscopy is normal. The rest of his cranial nerves are intact but you do
notice that his right scalp is tender to light touch. There are no limb signs and no neck stiff ness.
Mr Lennon is an elderly man with a 4-day history of new-onset right-sided temporal headache,
possibly jaw claudication, a right-sided decrease in visual acuity, and a tender scalp.
Most likely diagnosis?
Temporal arteritis
What are the common non-sinister causes of headache?
Tension-type headache Migraine Sinusitis Medication overuse headache TMJ dysfunction syndrome Trigeminal neuralgia Cluster headaches
Questions used to differentiate non-sinister headaches?
Trigger factors? (stress/foods/smells)
How disabling are the headaches?
Aura?
TMJ syndrome?
Most common in individuals aged 20–40, and four times
more prevalent in women. As well as headache, patients get a dull ache in the muscles of mastication that may radiate to the jaw and/or ear. Patients also often report hearing a ‘click’ or grinding noise when they move their jaw.
Trigeminal neuralgia?
A rare condition, occurring more often in women,
with a typical age of onset around 60–70 years. Patients complain of unilateral facial pain involving one or more of the divisions of the trigeminal nerve.
The pain lasts only seconds, and can be triggered by eating, laughing, talking
or touching the affected area. Although attacks last seconds, there may be
several or even hundreds a day and patients can develop a longer-lasting background pain. Patients often avoid known triggers like shaving. Interestingly,
attacks rarely occur during sleep, unlike migraine or cluster headaches.
Mrs Harrison is a 42-year-old who presents to accident and emergency (A&E) complaining of a severe headache and nausea. She has a history of migraine attacks but this time she says it is different – it came on suddenly after dinner, without warning, and felt as if someone had punched her in the back of the head. Her husband, annoyed at having to drive her to the hospital in the middle of the night,
cynically thinks she is just having ‘a bad migraine’.
Likely diagnosis?
Key investigation?
SAH
CT head
Mr McCartney is a 32-year-old salesman who is worried that he might be having repeated ‘mini-strokes’ (TIAs), like his father. He says that every couple of months he suff ers from an attack where he sees a shimmering light in the corner of his eyes and gets a ringing in his ears. This usually occurs towards the
end of the day, lasting half an hour. He is fully conscious throughout and never feels dazed or confused afterwards.
Most likely diagnosis?
Migraine aura without headache
Ringo is a 16-year-old who presents with a runny nose and headache. He has been blowing out green mucus from his nose for a few days but has come to see you because the headache, which is located above his eyes, is now very bad. His nasal septum is slightly deviated and his forehead is indeed tender to gentle tapping.
Most likely diagnosis?
Frontal sinusitis
What are the main causes of SAH?
Rupture of an arterial aneurysm, usually a ‘berry aneurysm’ at the junction between arteries of the
circle of Willis (~45%)
Trauma (~45%)
Arteriovenous malformations, rupture of haemangiomas, rupture of cerebral vein around the brainstem (~10%)
What are the differentials for intracranial tumours?
Secondary brain tumours (~90% in adults)
- Five most common site of primary are lung, kidney, breast, melanoma and colon
Primary brain tumours 50% neuroepithelial/axial - Astrocytomas - Ependymomas - Oligodendrogliomas - Medulloblastomas
Extra axial
- Meningoma
- Vestibular schwannoma
=-Pituitary adenoma, prolactinomas and craniopharyngiomas
Others
Choroid plexus papilomas, haemangiomas and pineal gland tumours
What are the main symptoms of raised ICP?
Headache Nausea Papilloedema Visual blurring Cushing's reflex (paradoxical bradycardia and raised BP, often irregular breathing) Cushing's peptic ulcer
Whate are the main causes of raised ICP?
SOL
Cerebral oedema
- Tumour or lesion
Increased BP in the CNS
- Vasodilator drugs, malignant hypertension, hypercapnic vasodilation, venous sinus thrombosis or SVC obstruction
Increased volume of CSF
- Obstruction to CSF drainage, dysfunction of arachnoid granulations, increased CSF production
