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Oxford Clinical Cases > Headache > Flashcards

Headache Flashcards

1
Q 
VIVID sinister causes of a headache:
First V (5)
A

Vascular: subarachnoid haemorrhage (SAH), haematoma (subdural or extra-
dural), cerebral venous sinus thrombosis, cerebellar infarct

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2
Q 
VIVID sinister causes of a headache:
First I (2)
A

Infection: meningitis, encephalitis

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3
Q 
VIVID sinister causes of a headache:
Second V (5)
A

Vision-threatening: temporal arteritis†, acute glaucoma, pituitary apoplexy, posterior leucoencephalopathy, cavernous sinus thrombosis

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4
Q 
VIVID sinister causes of a headache:
Second I (7)
A

Intracranial pressure (raised): space-occupying lesion (SOL; e.g. tumour, abscess, cyst), cerebral oedema (e.g. trauma, altitude), hydrocephalus, malig- nant hypertension

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5
Q

VIVID sinister causes of a headache:

D

A

Dissection: carotid dissection

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6
Q

What is temporal arteritis aka

A

Giant cell arteritis

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7
Q

What is giant cell arteritis

A

Temporal arteritis is another name for giant cell arteritis, a systemic vasculitis

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8
Q

What are the red flag symptoms of headache (10)

A 
Decreased consciousness
Sudden onset, worst headache ever
Seizure(s) or focal neurological deficit
Absence of previous episodes
Reduced visual acuity
Persistent headache, worse when lying down + early morning nausea
Progressive, persistent headache
Constitutional symptoms (weight loss, night sweats, and/or fever)
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9
Q

What is a decreased level of consciousness with a headache suggestive of (5)

A

SAH needs exclusion. If there is a history of head injury, it could suggest a subdural haematoma (fluctuating consciousness) or extradural haematoma (altered consciousness following a lucid interval). Meningitis and encephalitis can also affect consciousness.

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10
Q

What is a sudden onset, worst headache ever type of headache suggestive of (5)

A

Suggests SAH, with blood in the cerebrospinal fluid (CSF) irritating the meninges.

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11
Q

What is very characteristic of a SAH

A

A very severe headache of almost instantaneous onset is characteristic of SAH

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12
Q

What is a headache with seizure’s or focal neurological deficit suggestive of

A

Intracranial pathology

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13
Q

What is a headache with reduced visual acuity suggestive of (3)

A

Temporal arteritis is common in older patients. Transient blindness (amaurosis fugax) is usually due to a transient ischaemic attack (TIA), but these rarely produce a headache. In the context of headaches, loss of vision can be due to temporal arteritis, carotid artery dissection causing decreased blood flow to the retina, or acute glaucoma.

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14
Q

What is reduced visual acuity without a headache suggestive of

A

Transient blindness (amaurosis fugax) is usually due to a transient ischaemic attack (TIA)

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15
Q

What is a persistent headache that’s worse when lying down and coupled with early morning nausea suggestive of

A

Suggests raised intracranial pressure
This is worse when lying flat for prolonged times (e.g. overnight) due to the effect of gravity, but can even occur when the patient is bending over.

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16
Q

What is a headache that is worse when standing up suggestive of (1)

A

Headaches that are worse when standing up suggested reduced intracranial pressure and are common after a lumbar puncture (LP), but these are not sinister and resolve with hydration and lying down for several hours.

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17
Q

What is a progressive persistent headache suggestive of (4)

A

This could be an expanding SOL (e.g. tumour, abscess, cyst, haematoma).

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18
Q

What constitutional symptoms should you screen for in a headache (3)

A

Weight loss, night sweats, and/or fever

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19
Q

What constitutional symptoms should you screen for in a headache and what are they suggestive of (2)

A

Weight loss, night sweats, and/or fever may suggest malignancy, chronic infection (e.g. tuberculosis), or chronic inflammation (e.g. temporal arteritis).

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20
Q

What does a third nerve palsy consist of (3)

A

This consists of ptosis (droopy eyelid), mydriasis (dilated pupil), and an eye that is deviated down and out

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21
Q

Which basic obstruction should you do in someone with a headache and why (3)

A
  • Altered consciousness. Assess Mr Lennon’s Glasgow Coma Scale (GCS) score, although it is likely to already be obvious from the history taking. The significance of altered consciousness is discussed above.
  • Blood pressure and pulse. Check for malignant hypertension.
  • Temperature. Fever and headache suggests meningitis or encephalitis.
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22
Q

What can cause third nerve palsy and a headache

A

One cause is an SAH due to a ruptured aneurysm of the posterior communicating artery (PCOM). PCOM aneurysms are a cause of headache.

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23
Q

What is a sixth nerve palsy

A

Convergent squint and/or failure to abduct the eye laterally.

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24
Q

Why is the 6th nerve most likely to be compressed at some point

A

It has the longest intracranial course

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25
Q

Which nerve is the most likely to be compressed and why

A

The sixth nerve has the longest intracranial course and is therefore most likely to get compressed at some point.

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26
Q

What can cause sixth nerve palsy

A

Directly by a mass or indirectly by raised intracranial pressure

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27
Q

How can you spot twelfth nerve palsy and what can cause it

A

Look for tongue deviation. A twelfth nerve palsy can arise from a carotid artery dissection.

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28
Q

What is the triad of Horner’s syndrome

A

Triad of partial ptosis, miosis (constricted pupil), and anhydrosis (dry skin around the orbit)

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29
Q

What is the DDx if someone comes in with a headache and Horner’s syndrome (2)

A

Cavernous sinus lesion

Carotid artery dissection (ask about neck pain)

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30
Q

Examples of focal neurological signs you may spot in someone with a headache (5)

A 
Focal limb deficit
Third nerve palsy
Sixth nerve palsy
Twelfth nerve palsy
Horner's syndrome
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31
Q

How to differentiate Horner’s due to carotid dissection and cavernous sinus lesion

A

Ask about neck pain, if positive it is suggestive of carotid artery dissection

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32
Q

What are you looking for in the eye inspection of someone presenting with a headache? (4)

A
  • Exophthalmos? This may indicate a retro-orbital process such as cavernous sinus thrombosis.
  • Cloudy cornea? Fixed, dilated/oval pupil? This may suggest acute glaucoma.
  • Optic disc appearance on fundoscopy. Look for papilloedema, indicating raised intracranial pressure.
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33
Q

What does exophthalmos suggest in someone with a headache

A

A retro-orbital process such as cavernous sinus thrombosis

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34
Q

What does a cloudy cornea suggest in someone with a headache?

A

Acute glaucoma

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35
Q

What does a fixed, dilated/oval pupil suggest in someone with a headache?

A

Acute glaucoma

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36
Q

What are you looking for in the optic disc appearance on fundoscopy in someone with headache?

A

Papilloedema which indicates raised intracranial pressure

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37
Q

What other things should you be looking for in a clinical examination of someone presenting with headache apart from eye inspection and focal neurological signs? (3)

A

• Reduced visual acuity. This can suggest acute glaucoma or temporal arteritis for example.
• Scalp tenderness. Classically seen in temporal arteritis.
• Meningism. Check whether the patient has a stiff neck or photophobia, sug-
gesting meningism due to infection or SAH.

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38
Q

What does reduced visual acuity suggest in someone with a headache? (2)

A

Acute glaucoma or temporal arteritis

39
Q

What does scalp tenderness suggest in someone presenting with headache?

A

Scalp tenderness. Classically seen in temporal arteritis.

40
Q

What is meningism

A

Stick neck/photophobia suggesting meningism due to infection or SAH

41
Q

What age does temporal arteritis present?

A

> 50 years old

42
Q

What is temporal arteritis?

A

The formation of immune, inflammatory granulomas in the tunica media of medium/large-sized arteries. The inflammation (or thrombosis or spasm induced by it) can be sufficient to block the lumen of medium-sized arteries affected by this disease.

43
Q

What causes the jaw claudication in temporal arteritis specifically?

A

Inflammation of the mandibular branch of the external carotid artery causes jaw claudicaion.

44
Q

What causes the headache and scalp tenderness in temporal arteritis specifically?

A

Inflammation of the superficial temporal branch of the external carotid artery causes headache and scalp tenderness

45
Q

What causes the visual disturbances in temporal arteritis specifically?

A

Inflammation of the posterior ciliary arteries causes visual disturbances, due to ischaemia to either the retina (blurring, visual field loss) or the optic motor muscles (double vision = diplopia).

46
Q

What is the first line Ix for temporal arteritis?

A

Having taken a full history and examined the patient, one should arrange only first-line investigations that are quick to do – such as blood tests to demonstrate an elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)

47
Q

Mx for temporal arteritis?

A

High-dose corticosteroids until confirmation, then a temporal artery biopsy

48
Q

Causes of non-sinister headaches (7)

A 
Tension-type headache Migraine
Sinusitis
Medication overuse headache
Temporomandibular joint (TMJ) dysfunction syndrome (TMJ syndrome) Trigeminal neuralgia
Cluster headache
49
Q

n addition to the pain history (e.g. SOCRATES), what questions should you ask to characterize non-sinister headaches? (4)

A

• Does the patient suffer from different types of headache?
• Are there any predisposing (trigger) factors?
• How disabling are the headaches?
When does the headache come on?
• Does the patient get an ‘aura’ before the headache?

50
Q

What should you be conscious of in someone with a migraine presenting with a different type of headache?

A

Patients with migraine are also vulnerable to medication overuse headaches from the treatment for their migraine.

51
Q

What type of headaches can stress or fatigue trigger

A

Tension and migraine

52
Q

What type of headaches can certain foods trigger

A

Migraine

53
Q

What type of headaches can alcohol trigger

A

Cluster

54
Q

What can trigger a cluster headache

A

Alcohol

55
Q

What can trigger a tension type headache (2)

A

Stress or fatigue

56
Q

What can trigger a migraine

A

Stress, fatigue and certain foods (e.g. cheese and caffeine)

57
Q

What is an aura before a headache suggestive of

A

Migraine (1/3 of migraine sufferers report auras)

58
Q

What does a headache that comes on at night suggest?

A

Cluster

59
Q

How disabling is a migraine?

A

Migraines render many sufferers incapable of performing even the activities of daily living for around a day

60
Q

How disabling is a tension type headache?

A

Tension-type headaches usually allow normal activities to be continued

61
Q

How disabling is a cluster headache?

A

Cluster headaches are severely painful and disabling but often occur at night, allow- ing daytime duties to continue.

62
Q

Epidemiology of medication overuse headaches

A

5x more common in women than men

63
Q

What do medication overuse headaches resemble

A

Either migraine or tension type headaches

64
Q

Which medications commonly result in medication overuse headaches

A

Migraine medications and analgesics

65
Q

Epidemiology of TMJ syndrome

A

Individuals between 20-40

4x more prevalent in women

66
Q

What symptoms do someone with TMJ syndrome experience

A

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.

67
Q

Trigeminal neuralgia epidemiology

A

More common in women

Typical age of onset of 60-70 years

68
Q

Symptoms of trigeminal neuralgia

A

unilat- eral 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 back- ground pain

69
Q

Epidemiology of cluster headaches

A

Men predominantly

70
Q

Frequency of cluster headaches

A

The headaches occur in ‘clusters’ for about 6–12 weeks every 1–2 years, hence the name.

71
Q

Timing of cluster headaches

A

Attacks tend to occur at exactly the same time every day or night, like an alarm clock going off.

72
Q

Location of cluster headaches

A

The pain is focused over one eye

73
Q

Length of cluster headaches

A

20–30 minutes

74
Q

Associations of cluster headaches (2)

A

They will probably have a red, watery eye, rhinorrhoea, and Horner’s syndrome, suggested by a history of ptosis. These headaches are very disabling.

75
Q

Tension type headaches location

A

Bifrontal (pressure or band tightening round the head)

76
Q

Length of a tension type headache

A

Few hours

77
Q

Migraines uni or bi lateral?

A

Uni

78
Q

Migraine description

A

Throbbing/pulsatile pain

79
Q

Types of migraine (4)

A

Migraine with aura (classical migraine)
Migraine without aura (common migraine)
Aura without migraine

80
Q

Associations/other features of migraine

A

Aura

Sensitivity to light, smell, sound and even nausea

81
Q

Length of migraine

A

between 4-72 hours

82
Q

Mx of migraines (4)

A

triptans (5HT -agonists such as sumatriptan), analgesics (aspirin, paracetamol), 1
and anti-emetics (metoclopramide) have been shown to be highly effective if the patient takes them as soon as they feel a migraine coming on

83
Q

In examination of someone presenting with a history suggestive of a non-sinister cause of headache what should you examine for and why? (4)

A
  • Blood pressure, to exclude malignant hypertension.
  • Head and neck examination for muscle tenderness, stiffness, or limited move- ment – which can occasionally mimic tension-type headaches. If present, such findings may need treatment in order to relieve the headache.
  • Focal neurological signs. The presence of focal neurological signs in some- body with headache should alert you to intracranial pathology.
  • Fundoscopy, to exclude raised intracranial pressure.
84
Q

What is xanthochromia

A

yellow CSF due to bilirubin content

85
Q

Ix for suspected SAH

A

An urgent computed tom- ography (CT) head scan, looking for blood in the CSF (this appears bright on CT, for example in the Sylvian fissures). An LP looking for xanthochromia (yellow CSF due to bilirubin content) must be performed to exclude SAH if the CT is negative. Note that CT is only useful as an aid to diagnosis of SAH in the first days following a bleed – by approximately day 7 the scan will have ~50% sensitivity. LP should be delayed for 12 hours after the onset of the headache as false negative results can occur before that time. It remains reliable for up to 12 days (12 hour to 12 day rule).

86
Q

What is yellow CSF due to bilirubin content known as

A

Xanthochromia

87
Q

How long should you wait before performing a LP for SAH

A

12 hours and is accurate for 12 days

88
Q

How long is a CT sensitive for a SAH

A

In the first few days only

By day 7 it has a 50% sensitivity so you may as well flip a coin

89
Q

Mx of SAH

A

Patients are initially managed with nimodipine (a calcium-channel blocker that reduces spasm of the ruptured cerebral artery, thus preventing ischaemia, i.e. a stroke) and bed rest.
Then a cerebral angiography
Followed by insertion of a platinum coil to cause the aneurysm to clot, scar and heal

90
Q

Diagnostic indications of a LP (6)

A

Looking for:
Oligoclonal bands (e.g. multiple sclerosis)
High protein (Guillain–Barré syndrome)
Blood or bilirubin (e.g. SAH)
Pathogens (e.g. bacterial meningitis, viral encephalitis)
Malignant cells (e.g. CNS lymphoma)
Rapid improvement in gait and cognitive function after removal of 30 mL of CSF (e.g. normal pressure hydrocephalus).

91
Q

Contraindications of a LP (4)

A

Raised intracranial pressure due to an SOL, as the sudden drop in pressure can cause the brainstem to cone through the foramen magnum.
• Increased bleeding tendency (e.g. patient on warfarin, disseminated intravascular coagulation).
• Infection at prospective site of puncture.
• Cardiorespiratory compromise. Deal with this before doing any other procedure

92
Q

Risks of LP (3)

A

Headache
Nerve root pain
Infection

93
Q

Therapeutic indications of LP (2)

A

• Therapeutic LP: intrathecal drug administration (e.g. haematological malignancy in children), tempo- rary reduction in intracranial pressure (e.g. idiopathic intracranial hypertension).

94
Q

What are the main symptoms and signs of raised intracranial pressure (6)

A

Headache, often worse when lying down
Nausea, usually first thing in the morning, after lying down all night Papilloedema, a swollen optic disc when visualized by fundoscopy Visual blurring
Cushing’s reflex, a paradoxical bradycardia and raised blood pressure, often with irregular breathing Cushing’s peptic ulcer, causing epigastric pain

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