Headache Flashcards
What are the sinister causes of headache
VIVID
Vascular - SAH, Haematoma, cerebellar infarct, CVST
Infection - meningitis/encephalitis
Vision-threatening - temporal arteritis, glaucoma, apoplexy
Intracranial pressure - SOL, cerebral oedema, hydrocephalus
Dissection - carotid dissection
What are the red flags that should be enquired about with a PC of headache
- Decreased level of consciousness - ?SAH. Head injury may indicate subdural haematoma (fluctuating consciousness) or extradural haematoma (altered consciousness after a lucid interval). Meningitis and encephalitis also affect consciousness.
- Sudden onset (worst headache ever) - SAH? . Blood in CSF irritating meninges.
- Seizures / focal neurological deficit - limb weakness/speech difficulties - suggests intracranial pathology. Migrainous aura may also give signs.
- Absence of previous episodes - recurrent episodes less sinister. >50 may suggest temporal arteritis.
- Reduced visual acuity - transient blindness usually due to TIA.
- Persistent headache that is worse when lying down. Suggests raised intracranial pressure.
- Progressive, persistent headache suggests expanding SOL
8.
What are some giveaway signs of temporal arteritis?
Jaw claudication and scalp tenderness
What should you ask about if concerned about carotid or vertebral artery dissection?
Minor neck trauma
What does a focal limb deficit suggest?
That a intracranial pathology is more likely
What are the effects of a 3rd nerve palsy and what is a cause of this?
CN3 palsy - ptosis, mydriasis, eye deviates down and out.
A cause of a CN3 palsy is due to a ruptured aneurysm of PCOM. PCOM aneurysms can cause headache
What are the effects of a 6th nerve palsy and what is a cause of this
Convergent squint and/or failure to laterally abduct eye.
CN6 palsy may be due to direct compression by a mass or indirectly due to raised ICP.
CN6 has longest intracranial course - most likely to get compressed
What are the effects of a 12th nerve palsy and what is a cause of this
Look for tongue deviation
CN12 palsy can arise from carotid artery dissection.
What are the effects of Horners syndrome and what can cause Horners syndrome
Triad of effects: partial ptosis, miosis, anhydrosis.
Horners syndrome is caused by interruption of ipsilateral sympathetic pathway. Can be caused by carotid artery dissection or cavernous sinus lesion.
What may exophthalmos indicate?
Cavernous sinus thrombosis
What might be a sign of a cloudy cornea
Acute glaucoma
What sign on a fundoscopy may indicate raised intracranial pressure
Papilloedema
What might reduced visual acuity suggest
Acute glaucoma or temporal arteritis
What is scalp tenderness a classical sign of?
Temporal arteritis
What might meningism (stiff neck/photophobia) be a sign of?
The meningism could be a sign of infection or SAH
How does temporal arteritis cause: jaw claudication, headache and scalp tenderness, visual disturbances?
Jaw claudication - mandibular branch of external carotid gets inflamed
Headache and scalp tenderness - superficial temporal branch of external carotid inflamed
Visual disturbances - due to inflammation of posterior ciliary arteries, which causes inflammation to retina or optic motor muscles
Why is temporal arteritis considered an ophthalmological emergency?
Can cause visual loss in the OTHER eye without prompt treatment. The visual loss prior to treatment is unlikely to be restored.
How would you investigate and manage temporal arteritis?
Do bloods to check for increased CRP and ESR.
Managed by using high dose corticosteroids.
Once initial management is underway, can do a temporal artery biopsy (which may/not show granulomas)
What are the causes of non-sinister headache?
- Tension type headache
- Migraine
- Sinusitis
- Medication overuse headache
- TMJ dysfunction syndrome
- Trigeminal neuralgia
- Cluster headache
Stress and fatigue are known trigger factors for which 2 types of non-sinister headache?
Tension headaches and migraines
Alcohol may trigger cluster headaches
Differentiate how disabling the different types of headache are
Migraines = sufferers may be incapable of AODL for a day.
Cluster headaches = severely painful and disabling but often occur at night so daytime activities can continue
Tension type = allow normal activities to be continued
What might an “aura” (i.e. visual phenomena but sometimes focal neurological deficits) indicate?
Migraine
Describe tension type headaches
Very Common, often bifrontal pain.
Episodic, recur with variable frequency
Pain is like a pressure or tightness around the head like a band
Typically lasts no more than a few hours (but may become disabling if frequent recurrence)
Stress and fatigue known triggers
Describe migraines
Common, but less common than tension type headache
More common in women than men
Typically unilateral
May present with aura in 1/3 of patients
Throbbing/pulsatile pain
Sensitivity to light, sound and maybe smell
Nausea may be a feature
Migraines last between 4 to 72 hours unless treated successfully
If there is AURA WITHOUT MIGRAINE- could be differential for a TIA or epilepsy
Describe sinusitis
Facial pain with a few hours to days onset.
Tight pain that is worsened by movement
Headaches last several days and are moderately severe though not disabling
Describe medication overdose headache
5x more common in women than men
Often resembles migraine or tension type headaches
Describe TMJ syndrome
F>M, 20-40 y/o
Headache and dull ache in muscles of mastication, may radiate to jaw and ear
May also hear a “click”/grinding when moving jaw
Describe trigeminal neuralgia
Rare condition - age 60-70 years, F>M.
Unilateral stabbing, sharp facial pain - involves 1/more trigeminal nerve branches
Pain only lasts a few seconds, with many triggers.
Rarely attacks occur in sleep
Describe cluster headaches
Mainly affects men.
Headaches occur in “clusters” for 6-12 weeks every 1-2 years.
Headaches onset come same time every day or night.
Pain focussed over one eye
Intense pain which causes patient to wake up - and is very severe until it diminishes 20-30 mins later
Red watery eye, rhinorrhoea, Horners syndrome.
Very disabling
How can migraines be treated
Triptans (e.g. sumatriptan), analgesics and antiemetics
All non-sinister causes of headache are diagnosed on history. What examinations should be done and what should be looked for?
BP - to exclude malignant hypertension
Head and neck exam - tension type headaches may present with muscle tenderness, stiffness or limited movement
Focal neurological signs - indicates intracranial pathology
Fundoscopy - to exclude raised intracranial pressure
If patient describes sudden onset acute pain as if someone hit them in the head with a baseball bat, this indicates SAH. What should be done next?
Urgent CT head - look for blood in CSF
If a CT scan has been missed in the first 6 hours, then what should be done?
LP and look for xanthochromia - yellow CSF due to bilirubin content from breakdown of subarachnoid blood
If a SAH is confirmed, what is the treatment?
Nimodipine (CCB) and bed rest at 30-45 degree.
Then cerebral angiography to find bleed source. Coil the source to clot/heal the aneurysm
TIAs and strokes result in “negative” (loss of function signs) - e.g. loss of vision, numbness, loss of power in muscles.
What may cause positive (gain-of-function) signs?
Epilepsy
Migraine can produce both negative and positive signs
Epilepsy is usually followed by a phase where patient is exhausted and sometimes confused
Sinusitis usually affects the maxillary sinuses, which resolves spontaneously. But why can FRONTAL sinusitis be dangerous?
Bacteria can erode backwards into the brain which can cause meningitis or a brain abscess.
So suspected frontal sinusitis go to ENT and Geta. CT head.
Give Abx and astral lavage if frontal sinusitis confirmed.
Children with tumours often present with pain where and what accompanying symptom?
Pain in occipital lobe as tumours often found in posterior fossa
Most common type of tumour is medulloblastoma in cerebellum
So must do an urgent head MRI scan.
If tumour present, dexamethasone used to reduce brain inflammation and surgery done.
What are the main causes of SAH?
- Rupture of an arterial aneurysm (usually berry aneurysm at junction in circle of Willis)
- Trauma
- Arteriovenous malformations
Most intracranial tumours are?
Metastatic tumours - common sources include lung, kidney, breast, melanoma and colon
L4 can be used for lumbar puncture. How to find this anatomically?
Line between both PSIS is Tuffiers line - which marks L4/5 space.
NB children SC ends slightly lower than adults, but L4 is fine
First give is the ligament flavum
Second give is the dura mater
