Headache Flashcards
What are the primary headaches?
- Tension
- Migraine
- Cluster
[No underlying primary pathological cause to headaches]
What are the secondary headaches?
- Trigeminal neuralgia
- Raised ICP- space occupying lesion- tumours/bleeds
- Haemorrhages/bleeds- subarachnoid, subdural, epi/extradural
- Giant cell/temporal arteritis
- Meningitis
- Encephalitis
What is a primary headache?
- Stand alone illness caused directly by overactivity of nerves/problems with structures in head that are pain sensitive
- Less serious than secondary headache.
What is a secondary headache?
- Headache secondary to another condition.
- More serious + can have serious complication.
Tension headache
Definition
Aetiology
Risk factors
Epidemiology
Symptoms and Signs
Investigations
Management
Associated complication to look out for?
Tension headache
Definition
Benign headache, tight band around head. Most common ‘everyday’ headache.
Aetiology
Unknown, muscle contraction?
Risk factors
Stress
Lack of sleep
Epidemiology
Young
Females
Symptoms
S- bilateral, band around head, generalised
O- gradual or acute
C- dull
R- in shoulders and neck
T- lasts three to four hours
E- analgesics relieve
S- mild/moderate
Investigations
Clinical diagnosis, normal on examination
Management
Analgesia- paracetamol/NSAIDS
Conservative: Headache diary + avoid triggers
Associated complication to look out for?
Medication overuse headache
Cluster headache
Definition
Aetiology
Risk factors
Epidemiology
Triggers
Symptoms
Signs
Investigations
Management
Cluster headache
Definition
Neurological disorder causing recurrent episodes of unilateral pain behind the eye - its reccurence follows a cyclical pattern
Aetiology
Unknown- trigeminal nerve inflammation
Epidemiology
young- twenty to forty years
male
Triggers
Alcohol
Strong smellls
Symptoms
Unilateral severe pain behind eye
Acute onset
Occurs in clusters same time of day over a period of few weeks/months, cyclical pattern
Sharp, penetratiing pain
Lasts 15 mins to 3 hours
Signs- ANS associated
Ptosis, miosis
Eye watering
Red eye
Rhinorrhoea
Nasal congestion
Face flushing
Investigations
Clinical diagnosis
Exclude severe causes
Migraine
Definition
Aetiology
Risk factors
Epidemiology
Triggers
Symptoms
Signs
Investigations
Management
Migraine
Definition
Chronic condition- attacks of severe headache
Aetiology
Unknown- inflammation and vasoconstriction- trigeminal nerve
Risk factors
Genetic- FH
Epidemiology
Young
Female 3:1
Triggers
CHOCOLATES
Chocolate
Hangovers
Orgasms
Cheese/Caffeine
Oral contraceptives/hormonal changes
Lack of sleep/Lie-ins
Alcohol
Travel
Exercise
Stress
Symptoms
S- Unilateral, temples
O- Paroxysmal, gradual onset
C- Throbbing
A- Nausea, vomiting, photophobia, phonophobia, tingling, numbness-> aura- visual/sensory/smell disturbances- flashing lights, tingling
T- 4hr - Lasts up to 72hr
E- Activity, stress, light, sound
S- Moderate to severe- interferes with current activities
Aura is pathognomic- but only present in 15%
Investigations
Clinical diagnosis
Exclude serious cause if red flags
Management
First line:
Conservative- Headache diary, avoid triggers
Second line:- Acute Medical
Analgesia- paracetamol/ NSAIDS
Triptans, Sumatriptan [intranasal]
Third line: Preventative
First: Topiramate, propanolol
Second: Amitriptylline
A 41-year-old man complains of terrible headache. It started without warning, while at work. It affects the right side of his head. He scores it ‘11/10’ in severity. He had a similar episode six months ago, experiencing very similar headaches over 2 weeks which resolved spontaneously. On observation, the right side is red and he also has ptosis on the right side. What is the diagnosis?
A. Subarachnoid haemorrhage
B. Tension headache
C. Intracerebral haemorrhage
D. Migraine
E. Cluster headache
E Cluster headache
A 40-year-old man complains of a one-year history of 1 to 3
attacks per month of disabling pain over one temple, with
nausea and sensitivity to light. He says that his headaches
can be triggered by lack of sleep and made worse by
physical exertion. He has tried ibuprofen and NSAIDs but
they don’t seem to have an effect and the headaches are
being debilitating. What’s the next most appropriate step
in his management?
A.Codeine
B.Diclofenac
C.Sumatriptan
D.Topiramate
E.Amitriptyline
C. Sumatriptan
Diagnosis: Migraine
Trigeminal neuralgia
Definition
Aetiology
Risk factors
Triggers
Symptoms
Investigations
What condition is it associated with?
Trigeminal neuralgia
Definition
Sharp facial pain in the distribution of >one division of the trigeminal nerve
Aetiology
Compression of trigeminal nerve by loop of artery or vein
Risk factors
FH?
Triggers
chewing
brushing teeth
touching face
talking
shaving
Surgery
Dental procedures?
Symptoms
S- Facial pain in trigeminal distribution, unilateral
O- sudden, lasts a few seconds, paroxysmal
C- Sharp, stabbing, shooting
E- chewing, brushing teeth, touching face, talking, shaving
S- Severe
Numbness
Investigations
n/a-clinical diagnosis
What condition is it associated with?
MS
Meningitis
Definition
Aetiology
- Different age groups?
Risk factors
Symptoms
Signs
Investigations
Management- community and hospital
Complications
Meningitis
Definition
Inflammation of the meninges
Aetiology
- Viral
- Bacterial
- Fungal
- TB
[Aseptic meningitis= negative CSF culture= usually viral]
- Different age groups?- Different bacteria
Babies: Listeria monocytogenes, Group B streptococcus, E Coli
Children: Streptococcus pneumonia, Haemophilius influenzae
Teenagers and young adults: Neisseria meningitis
Elderly: Listeria monocytogenes, Strep pneumonia
Risk factors
- Close contact with an infected person
- Crowding
- Age less than 5 or over 65
Symptoms
- Headache- acute, severe
- Photophobia
- Neck stiffness
[^known as meningism]
- Fever
- Muscle aches
- Vomiting
- Seizures
- Altered mental state
Signs
- Non blanching petechial/purpuric rash- if meningococcal meningitis [Neisseria meningitidis]
- Kernig’s sign- when hips flexed, pain when knee is extended passively [hamstring stiffness]
- Brudkinski’s sign- when neck is flxed, hip and knees flex
- Septic shock signs
Investigations
- CT head- to check if raised ICP before lumbar puncture
- Lumbar puncture- CSF analysis- DIAGNOSTIC
- Viral- clear, normal glucose, high monomorphs/lymphocytes, high/normal protein
- Bacterial- turbid, low glucose, high polymorphs/neutrophils, high protein
- TB- fibrin web strands, low glucose, high monomorphs/lymphocytes, high protein
Management- community and hospital
- Community- IM benzynpenicillin + send to A+E
- Hospital- IV ceftriazone/cefuroxime- broad spectrum. acyclovir if viral
- Consider IV dexamethasone
- Targeted antibiotic treatment once cultures
- Prophylaxis for close contacts [housemates, partner]: ciprofloxacin
Complications
- Hearing loss- common
- Sepsis/septic shock
- Altered mental state
More rare:
- Meningoencephalitis
- Seizures
- Friedrich-Waterhouse syndrome- bilateral adrenal haemorrhage due to meningoccocal meningitis
CSF results in different types of meningitis
Encephalitis
Definition
Aetiology
Risk factors
Symptoms
Signs
Investigations
Definition: Inflammation of the brain parenchyma. (Can be
FATAL)
Aetiology:
- Usually viral: HSV1-2 [herpes simplex=most common encephalitis], CMV, EBV, HIV, measles
- Non viral causes: bacterial meningitis, TB, malaria, listeria, Lyme disease, legionella
Epidemiology: Affects mostly the extremes of age
•<1 and >65
Presentation: Acute onset febrile illness with behavioural, cognitive, psychiatric manifestations.
Symptoms
- Viral prodrome
- Fever
- Headache
- ALTERED MENTAL STATE
- Memory disturbances
- Personality changes
- Psychiatric manifestations
- Impaired consciousness
Sometimes also meningism
Seizures
Focal neurology
Investigations:
- Lumbar puncture
- Bloods
- EEG
- CT/MRI (oedema/hyperintense lesions)- MRI preferred
What are the serious/red flags causes of headache?
- Meningitis
- Encephalitis
- Raised ICP- space occupying lesion, bleeds/haemorhhages etc.
Differences between meningitis and encephalitis?
Three things
- Location of infection
- Aetiology/causative organism
- Consciousness
A 19-year old medical student present with to A & E with
headache, fever, and neck stiffness. Once raised ICP is
excluded a lumbar puncture is performed and CSF
analysis reveals the following:
High polymorphs, low glucose and high protein
Given the most likely diagnosis, which is the most likely
causative organism?
A.Listeria monocytogenes
B.HIV
C.HSV
D.Neisseria meningitidis
E. VZV
D.Neisseria meningitidis
- bacterial
Which causative organisms are most likely to cause meningitis in the following age groups?
Babies/infants
Young children
Teenagers/adults
Elderly
Babies: E coli and Group B streptococcus [and Listeria monocytogenes-neonates]
Infant: Haemophilus influenza and strep pneumonia
Teenager: Neisseria meningitis
Elderly: Listeria, strep pneumonia
An older man with a longstanding history of AF on anticoagulation with warfarin is brought into A & E by his carer, who is concerned about the patient’s confusion at home. The carer describes frequent falls over the last several months. On examination, he has a right-sided pronator drift and is weaker on his right side. His mental status testing reveals poor concentration. What is the most likely cause of his symptoms?
A.Stroke
B.Subdural haemorrhage
C.Alzheimer’s disease
D.Encephalitis
E. Parkinson’s disease
Subdural haemorrhage
Subdural haemorrhage
Definition
Classification
Aetiology/pathophysiology
Epidemiology
Symptoms
Signs on examination
Investigations
Management
Subdural haemorrhage
Definition
Bleed between dura and arachnoid mater
Classification
Acute: < 3 days [young, trauma]
Subacute: 3 days to 3 weeks [elderly, worsening headache]
Chronic: >3 weeks [chronic headache, confusion]
Aetiology/pathophysiology
Rupture of the bridging [dural] veins of the brain
Often happens due to trauma
Epidemiology/Risk factors
Elderly
Alcoholics
[Brain atrophy- bridging veins more easily disrupted]
Head trauma/fall
Anticoagulation
Symptoms
Gradual onset, continuous
Headache
Fluctuating consciousness
Confusion/altered mental state/cognitive problems
Personlity changes
Signs of raised ICP
Signs on examination
Focal neurology- UMN signs
Investigations
CT head- ‘banana’ crescent shape bleed [white initially then black as blood reabsorbs, can cross suture lines]
Management
ABCDE + Neurosurgery referral
If small [<10mm] + no significant neuro dysfunction: observe
If large/significant neuro dysfunction: Burr hole/craniotomy
Headache caused by raised ICP
- Causes of raised ICP
- Symptoms of raised ICP headache
- Signs of raised ICP headache
- Investigations
- Causes of raised ICP
- Space occupying lesion- tumour, abscess, aspergillus [rare]
- Bleed/haemorhhage
- Hydrocephalus
- Features of raised ICP
- Early morning headache
- Worse on lying down
- Worse on coughing/laughing/sneezing
- Bilateral
- Gradual
- Throbbing/bursting
- Nausea/vomiting
- Seizures
- Reduced GCS
- Signs of raised ICP
- Papilloedema
- Focal neurology
- Cushing’s reflex- bradycardia, hypertension, irregular breathing
- Cheyne-stokes respiration-progressively deeper, faster breathing then apnea
- Investigations
Urgent CT head
NEVER do a lumbar puncture- leads to coning + brainstem herniation
Extradural/epidural haemorrhage
Definition
Aetiology
Epidemiology
Symptoms and signs
Investigation
Extradural/epidural haemorrhage
Definition
Bleed between skull and dura
Aetiology
Trauma [massive force]
Epidemiology
Young- 20-30 y/o
Symptoms and signs
Acute, increasingly severe headache
Rapidly decreasing consciousness/GCS
Signs of raised ICP
After lucid period
Investigation
Urgent non contrast CT head- ‘lemon’ concave shape
[blood restricted to within bony sutures of skull, joined to dura]
MRI
Subarachnoid haemorrhage
Definition
Aetiology
Risk factors
Symptoms
Signs
Investigations
Subarachnoid haemorrhage
Definition
Bleeding into the subarachnoid space
Aetiology
Rupture of saccular aneurysm
Risk factors
Trauma
Hypertension
Alcohol
Smoking
Polycystic kidney disease
Symptoms
S- Occipital, diffuse
O- very sudden
C- thunderclap
T- continuous
S- very severe, worst headache ever
Meningism- photophobia, neck stiffness
Raised ICP
Third nerve palsy beforehand- if PCA aneurysm
Signs
Meningism
Raised ICP
Investigations
CT head urgent non contrast- white area around circle of willis= within 12 hours
Lumbar puncture after 12 hr if CT normal- xanthochromia + oxyhaemoglobin/blood [straw coloured yellow CSF due to breakdown of bilirubin]
[only a little bit of CSF if raised ICP]
[Also blood tests + ECG [abnormal in half of pt] + clotting]
A 33-year-old woman attends her six-month follow-up appointment for headache. They are migrainous in nature but whereas she used to have them every few months, over the last three months she has experienced a chronic daily headache. She takes co-codamol qds and ibuprofen tds. What is the best medical management?
A. Stop all medication
B. Start paracetamol
C. Start sumatriptan
D. Start propranolol
E. Continue current medication
A. Stop all medication
Medication overuse headache
CNS tumours
Definition
Aetiology
Epidemiology
Symptoms and Signs
Investigations
CNS tumours
Definition
Primary brain/central nervous system tumours arising from any of the brain tissue types
[Primary brain tumours,secondary brain tumours=mets, mets are more common]
Risk factors
PMH/FH of cancer
Epidemiology
Increases with age- peak at 65 ish years
Some only paediatric tumours= eg medulloblastoma
Symptoms and Signs
Signs of raised ICP- headache [bilateral, gradual, throbbing, worse in morning/on coughing, sneezing
FLAWS
Focal neurology
Weakness + difficulty walking
Seizures
Personality change
- Symptoms depend on tumour type and location [see other flashcard for more]
- caused by direct effect, or by midline shift, by raised ICP, or due to provoking seizures
Investigations
CT head [quick]
MRI [better resolution]
Staging + mets: CXR, CT abdo pelvis
Biopsy= definitive- but only done if easy to access tumour
Fill in table- different types of haemorrhage/bleed
What are the red flag symptoms/signs of headache?
SNOOP
Systemic signs- FLAWS
Neurological signsOnset- sudden
Older-age >fifty
Progression- change in existing headache- frequency, quality, location
Medication overuse headache
Definition
Treatment
Avoidance
Medication overuse headache
Definition
Headache due to chronic, regular use of analgesia such as paracetamol, NSAIDs
Often happens in those suffering chronic headache [migraine, tension]
Treatment
Withdraw all analgesia
- Headache will worsen at first
- Then will get better over time
Avoidance
- If headache, don’t take simple analgesia more than two days a week
What are some of the different types/location of CNS tumour and what symptoms do they cause?
Frontal lobe tumour- personality changes, apathy, impaired intellect
Right parietal lobe tumour- Left homonymous hemianopia, left hemiparesis + sensory loss
Vestibular Schwannoma- deafness
