Headache Flashcards
Is a headache a symptom or a sign
A symptom
What are some reasons people get headaches?
Structural, pharmacological and psychological
What diagnosis could result after an acute single headache?
Febrile illness, sinusitis First attack of migraine Following a head injury Subarachnoid haemorrhage Meningitis, tumour, drugs, toxins, stroke Thunderclap (sudden onset), low pressure
What diagnosis could result after an dull headache that increases in severity?
Usually benign Overuse of medication (e.g. codeine) Contraceptive pill, hormone replacement therapy Neck disease Temporal arteritis Benign intracranial hypertension Cerebral tumour Cerebral venous sinus thrombosis
What diagnosis could result after an dull headache that is unchanged?
Chronic tension headache
Depressive
What diagnosis could result after recurrent headaches?
Migraine
Cluster headache
Episodic tension headache
Trigeminal or post-herpetic neuralgia
What diagnosis could result after triggered headaches?
Coughing, straining, exertion
Coitus
Food and drink
What are some red flags in headaches?
Acute onset Meningism Systemic symptoms (fever/rash) Neurological symptoms If its better lying down (orthostatic) Strictly unilateral
What are some red flag neurological syptoms?
Visual loss, confusion, seizures, hemiparesis, double vision, 3rd nerve palsy, Horner syndrome, papilloedema
When do patients get double vision?
If any eye muscle isnt working (or any associated nerve
What is 3rd nerve palsy? How does it present
When the patient has a droopy eyelid or a dilated pupil and eye points out
What is Horner syndrome? How does it present
When the sympathetic supply to the eye is affected. Eye is slightly droppy, inopthalmos
How does headache occur with subarachnoid haemorrhage?
Sudden and generalised
They have meningism (stiff neck and dont like light)
How are subarachnoid haemorrhages caused?
Aneurysm ruptre
How fatal are subarachnoid haemorrhages?
50% are fatal
How are subarachnoid haemorrhages treated?
Nimodipine and BP control.
Early neurosurgical assessment to confirm the bleed and establish the cause.
CT brain, lumbar puncture and MRA, angiogram.
How are aneurysms treated?
They used to be clipped or coiled, now they are filled with platinum coils
What is an acute intracerebral bleed? Why does it happen?
A fatal haemorrhage due to coning
What is herniation and coning?
When vol in the brain increases and starts to increase intracranial pressure so that the brain starts to be squeezed out of the skull and starts weeping
What is papilloedema?
When pressure in the brain rises and you can see the retina being pushed outwards
What is a carotid or vertebral artery dissection? How can it cause a stroke?
When the blood vessel tears and the false lumen becomes large causing turbulent flow in the actual lumen. This can cause clotting and stroke so aspirin or anticoag is given
What is temporal arteritis? How does it present?
Constant unilateral headache, scalp tenderness and jaw claudication
How is temporal arteritis diagnosed?
Elevated ESR and CRP
Temporal artery are inflamed and tortuous visible on ultrasound
How is temporal arteritis treated?
High dose steroids and aspirin
What is cerebral venous thrombosis?
Thrombosis in dural venous sinus or cerebral vein causing raised ICP
What are risk factors for cerebral venous thrombosis?
Thrombophilia, pregnancy, dehydration
What are presenting symptoms of meningitis?
Malaise Headache Fever Neck stiffness Photophobia Confusion Alteration of consciousness
What cause of meningitis is most concering?
Bacteria (low now due to vaccination)
What is herpes simplex encephalitis?
Classic haemorrhagic changes in the temporal lobes
Is meningitis treated or diagnosed first?
Treat
How are meningitis patients treated?
Antibiotics
How is meningitis diagnosed?
Blood and urine culture
Lumbar puncture
Increased White Cell Count, decreased glucose, Antigens, Cytology, Bacterial Culture
CT or MRI Scan
How does sinusitis present?
Malaise, headache, fever. Blocked nasal passages. Loss of vocal resonance. Anosmia. Nasal or postnasal catarrh. Local pain and tenderness.
How does headache present in sinusitis?
With frontal pain 1-2 hrs after waking up and clears in the afternoon
What are brain tumors called?
Glioblastoma
What is Idiopathic Intracranial Hypertension? How does it present?
Looks like they have a tumor but they dont
Presents with Headache, visual obscurations, diplopia, tinnitus
Papilloedema, +/- visual field loss
Headache, visual obscurations, diplopia, tinnitus
Papilloedema, +/- visual field loss
How is Idiopathic Intracranial Hypertension treated?
Drugs: hormones, steroids, antibiotics, vitamin E
Treatment: weight loss, diuretics, optic nerve sheath decompression, lumboperitoneal shunt, stenting of stenosed venous sinuses.
What can indicate ICP in a MRI?
Ventricles arent visible as they are squashed
What pressures can cause headaches?
Usually high but also low
How does low pressure headache occour?
CSF leak due to tear in dura, pressure falls when they get up
How is low pressure headache treated?
rehydration, caffeine, blood patch
How does low pressure headache show up on a scan?
There is meningeal enhancement
What is Chiari malformation?
The brain is normal but it sits very low in the skull
What happens to cerebellar tonsils in chiari malformation?
They go through the foramen magnum
What is the sign of chiari malformation?
Coughing headache as when the patient coughs the cerebellar tonsils snag on the meninges
What is obstructive sleep apnoea?
Headache with history of loud snoring and apnoeic spells
Why do those with obstructive sleep apnoea have headache?
They have co2 retention
What can obstructive sleep apnoea cause?
Trouble with sleep, depression, always falling asleep, poor performance at work
What is trigeminal neuralgia?
Electric shock like pain in the distribution of a sensory nerve, have a headache
How is trigeminal neuralgia treated?
Carbamazepine, lamotrigine, gabapentin.
Posterior fossa decompression.
How is pain in trigeminal neuralgia triggered?
By anything sensory eg touching the face, wind, chewing
What is atypical facial pain?
Daily, constant, poorly localised deep aching or burning
How is atypical face pain treated?
Painkillers, opiates, nerve blocks, tricylics
What is post traumatic headache?
Headache after physical trauma, depends on the nature of the injury eg victim of a car accident is more likely than person who caused it. Has many causes
How are post traumatic headaches treated?
Non-steroidal anti-inflammatories - ibuprofen, naproxen
Tricyclic antidepressants - Amitriptyline
Explain to them that they can overcome this
What is cervical spondylosis?
Narrowing of joint space in spine causing discs to be worn
How does cervical spondylosis present?
Usually bilateral Occipital pain can radiate forwards to the frontal region Steady pain No nausea or vomiting Worsened by moving the neck
How is cervical spondylosis treated?
Rest, deep heat, massage.
Anti-inflammatory analgesics
What are the main primary headaches?
Migraine, cluster and tension
How many attacks occur in someone who experiences migraines?
1-8 monthly
How long can a migraine last?
48 hrs
What are the main symptoms of a migraine?
Vertigo, motion sickness, headache, aura
What is aura in relation to migraines?
Visual symptoms eg seeing expanding ‘C’s, scintillations, blind spot
What is prodrome?
The first phase of a migraine where there are changes in mood, urination, food cravings and yawning
What are the treatments for migraine?
Aspirin/ibuprofen/paracetamol Triptans Opiates Naps Avoid triggers
How do migraines start?
Spontaneously or brought on via triggers eg light, dehydration, caffeine, skipping meals
Describe the pain in a tension type headache
Tight muscles around the head and neck
How are tension type headaches treated?
NSAIDs
Paracetamol
Tricyclic antidepressants
SSRIs (but less effective)
Describe the pain in a cluster headache
Severe unilateral pain
How long do cluster headaches last
15-180 mins
What symptoms does a cluster headache present with
At least one of the following ipsilaterally
Conjunctival redness and/or lacrimation
Nasal congestion and/or rhinorrhea
Eyelid oedema
How often do cluster headaches occur
One or alternate days up to 8 a day
Describe how migraines and cluster headaches differ in terms of duration
Migraine: 3-12 hrs
Cluster headache: 45 mins-3hrs
Describe how migraines and cluster headaches differ in terms of frequency
Migraine: 1-8 attacks monthly
Cluster: 1-3 attacks daily
Describe how migraines and cluster headaches differ in terms of remission
Migraine: Long remissions unusual
Cluster: Long remissions common
Describe how migraines and cluster headaches differ in terms of nausea
Migraine: nausea and vom frequent
Cluster: nausea rare
Describe how migraines and cluster headaches differ in terms of pain
Migraine: Pulsating hemicranial pain
Cluster: Steady, exceptionally severe, well localised, unilateral
With which type of headaches are auras seen as a symptom?
Migraines
