Headache Flashcards
VIVID sinister causes of a headache: First V (5)
Vascular: subarachnoid haemorrhage (SAH), haematoma (subdural or extra-
dural), cerebral venous sinus thrombosis, cerebellar infarct
VIVID sinister causes of a headache: First I (2)
Infection: meningitis, encephalitis
VIVID sinister causes of a headache: Second V (5)
Vision-threatening: temporal arteritis†, acute glaucoma, pituitary apoplexy, posterior leucoencephalopathy, cavernous sinus thrombosis
VIVID sinister causes of a headache: Second I (7)
Intracranial pressure (raised): space-occupying lesion (SOL; e.g. tumour, abscess, cyst), cerebral oedema (e.g. trauma, altitude), hydrocephalus, malig- nant hypertension
VIVID sinister causes of a headache:
D
Dissection: carotid dissection
What is temporal arteritis aka
Giant cell arteritis
What is giant cell arteritis
Temporal arteritis is another name for giant cell arteritis, a systemic vasculitis
What are the red flag symptoms of headache (10)
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)
What is a decreased level of consciousness with a headache suggestive of (5)
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.
What is a sudden onset, worst headache ever type of headache suggestive of (5)
Suggests SAH, with blood in the cerebrospinal fluid (CSF) irritating the meninges.
What is very characteristic of a SAH
A very severe headache of almost instantaneous onset is characteristic of SAH
What is a headache with seizure’s or focal neurological deficit suggestive of
Intracranial pathology
What is a headache with reduced visual acuity suggestive of (3)
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.
What is reduced visual acuity without a headache suggestive of
Transient blindness (amaurosis fugax) is usually due to a transient ischaemic attack (TIA)
What is a persistent headache that’s worse when lying down and coupled with early morning nausea suggestive of
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.
What is a headache that is worse when standing up suggestive of (1)
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.
What is a progressive persistent headache suggestive of (4)
This could be an expanding SOL (e.g. tumour, abscess, cyst, haematoma).
What constitutional symptoms should you screen for in a headache (3)
Weight loss, night sweats, and/or fever
What constitutional symptoms should you screen for in a headache and what are they suggestive of (2)
Weight loss, night sweats, and/or fever may suggest malignancy, chronic infection (e.g. tuberculosis), or chronic inflammation (e.g. temporal arteritis).
What does a third nerve palsy consist of (3)
This consists of ptosis (droopy eyelid), mydriasis (dilated pupil), and an eye that is deviated down and out
Which basic obstruction should you do in someone with a headache and why (3)
- 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.
What can cause third nerve palsy and a headache
One cause is an SAH due to a ruptured aneurysm of the posterior communicating artery (PCOM). PCOM aneurysms are a cause of headache.
What is a sixth nerve palsy
Convergent squint and/or failure to abduct the eye laterally.
Why is the 6th nerve most likely to be compressed at some point
It has the longest intracranial course
Which nerve is the most likely to be compressed and why
The sixth nerve has the longest intracranial course and is therefore most likely to get compressed at some point.
What can cause sixth nerve palsy
Directly by a mass or indirectly by raised intracranial pressure
How can you spot twelfth nerve palsy and what can cause it
Look for tongue deviation. A twelfth nerve palsy can arise from a carotid artery dissection.
What is the triad of Horner’s syndrome
Triad of partial ptosis, miosis (constricted pupil), and anhydrosis (dry skin around the orbit)
What is the DDx if someone comes in with a headache and Horner’s syndrome (2)
Cavernous sinus lesion
Carotid artery dissection (ask about neck pain)
Examples of focal neurological signs you may spot in someone with a headache (5)
Focal limb deficit Third nerve palsy Sixth nerve palsy Twelfth nerve palsy Horner's syndrome
How to differentiate Horner’s due to carotid dissection and cavernous sinus lesion
Ask about neck pain, if positive it is suggestive of carotid artery dissection
What are you looking for in the eye inspection of someone presenting with a headache? (4)
- 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.
What does exophthalmos suggest in someone with a headache
A retro-orbital process such as cavernous sinus thrombosis
What does a cloudy cornea suggest in someone with a headache?
Acute glaucoma
What does a fixed, dilated/oval pupil suggest in someone with a headache?
Acute glaucoma
What are you looking for in the optic disc appearance on fundoscopy in someone with headache?
Papilloedema which indicates raised intracranial pressure
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)
• 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.
What does reduced visual acuity suggest in someone with a headache? (2)
Acute glaucoma or temporal arteritis
What does scalp tenderness suggest in someone presenting with headache?
Scalp tenderness. Classically seen in temporal arteritis.
What is meningism
Stick neck/photophobia suggesting meningism due to infection or SAH
What age does temporal arteritis present?
> 50 years old
What is temporal arteritis?
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.
What causes the jaw claudication in temporal arteritis specifically?
Inflammation of the mandibular branch of the external carotid artery causes jaw claudicaion.
What causes the headache and scalp tenderness in temporal arteritis specifically?
Inflammation of the superficial temporal branch of the external carotid artery causes headache and scalp tenderness
What causes the visual disturbances in temporal arteritis specifically?
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).
What is the first line Ix for temporal arteritis?
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)
Mx for temporal arteritis?
High-dose corticosteroids until confirmation, then a temporal artery biopsy
Causes of non-sinister headaches (7)
Tension-type headache Migraine Sinusitis Medication overuse headache Temporomandibular joint (TMJ) dysfunction syndrome (TMJ syndrome) Trigeminal neuralgia Cluster headache
n addition to the pain history (e.g. SOCRATES), what questions should you ask to characterize non-sinister headaches? (4)
• 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?
What should you be conscious of in someone with a migraine presenting with a different type of headache?
Patients with migraine are also vulnerable to medication overuse headaches from the treatment for their migraine.
What type of headaches can stress or fatigue trigger
Tension and migraine
What type of headaches can certain foods trigger
Migraine
What type of headaches can alcohol trigger
Cluster
What can trigger a cluster headache
Alcohol
What can trigger a tension type headache (2)
Stress or fatigue
What can trigger a migraine
Stress, fatigue and certain foods (e.g. cheese and caffeine)
What is an aura before a headache suggestive of
Migraine (1/3 of migraine sufferers report auras)
What does a headache that comes on at night suggest?
Cluster
How disabling is a migraine?
Migraines render many sufferers incapable of performing even the activities of daily living for around a day
How disabling is a tension type headache?
Tension-type headaches usually allow normal activities to be continued
How disabling is a cluster headache?
Cluster headaches are severely painful and disabling but often occur at night, allow- ing daytime duties to continue.
Epidemiology of medication overuse headaches
5x more common in women than men
What do medication overuse headaches resemble
Either migraine or tension type headaches
Which medications commonly result in medication overuse headaches
Migraine medications and analgesics
Epidemiology of TMJ syndrome
Individuals between 20-40
4x more prevalent in women
What symptoms do someone with TMJ syndrome experience
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 epidemiology
More common in women
Typical age of onset of 60-70 years
Symptoms of trigeminal neuralgia
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
Epidemiology of cluster headaches
Men predominantly
Frequency of cluster headaches
The headaches occur in ‘clusters’ for about 6–12 weeks every 1–2 years, hence the name.
Timing of cluster headaches
Attacks tend to occur at exactly the same time every day or night, like an alarm clock going off.
Location of cluster headaches
The pain is focused over one eye
Length of cluster headaches
20–30 minutes
Associations of cluster headaches (2)
They will probably have a red, watery eye, rhinorrhoea, and Horner’s syndrome, suggested by a history of ptosis. These headaches are very disabling.
Tension type headaches location
Bifrontal (pressure or band tightening round the head)
Length of a tension type headache
Few hours
Migraines uni or bi lateral?
Uni
Migraine description
Throbbing/pulsatile pain
Types of migraine (4)
Migraine with aura (classical migraine)
Migraine without aura (common migraine)
Aura without migraine
Associations/other features of migraine
Aura
Sensitivity to light, smell, sound and even nausea
Length of migraine
between 4-72 hours
Mx of migraines (4)
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
In examination of someone presenting with a history suggestive of a non-sinister cause of headache what should you examine for and why? (4)
- 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.
What is xanthochromia
yellow CSF due to bilirubin content
Ix for suspected SAH
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).
What is yellow CSF due to bilirubin content known as
Xanthochromia
How long should you wait before performing a LP for SAH
12 hours and is accurate for 12 days
How long is a CT sensitive for a SAH
In the first few days only
By day 7 it has a 50% sensitivity so you may as well flip a coin
Mx of SAH
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
Diagnostic indications of a LP (6)
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).
Contraindications of a LP (4)
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
Risks of LP (3)
Headache
Nerve root pain
Infection
Therapeutic indications of LP (2)
• Therapeutic LP: intrathecal drug administration (e.g. haematological malignancy in children), tempo- rary reduction in intracranial pressure (e.g. idiopathic intracranial hypertension).
What are the main symptoms and signs of raised intracranial pressure (6)
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
