Headache Flashcards
What is headache?
Symptom
Half to three quarters of adults aged 18–65 years in the world have hadheadachein the last year and, among those individuals, 30% or more have reportedmigraine
What categories can cause headaches?
Structural
Pharmacological e.g. blood dilators dilate vessels in brain
Psychological e.g. stress
What do we divide headaches into?
Acute single headache
Dull headache, increasing in severity
Dull headache, unchanged over moths
Recurrent headaches
Triggered headaches
What can cause acute single headaches?
Febrile illness, sinusitis First attack of migraine Following a head injury Subarachnoid haemorrhage Meningitis, tumour, drugs, toxins, stroke Thunderclap (sudden onset), low pressure
What can cause a 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 can cause a dull headache that is unchanged over months?
Chronic tension headache
Depressive, atypical facial pain
What can cause a triggered headache?
Coughing, straining, exertion
Coitus
Food and drink
What can cause recurrent headaches?
Migraine
Cluster headache
Episodic tension headache
Trigeminal or post-herpetic neuralgia
What are red flags for headahces? (onset)
Thunderclap
Acute
Subacute
Strictly unilateral
What are red flags for headaches? (Meningism)
- photophobia
- phonophobia
- stiff neck
- vomiting
What are red flags for headaches? (systemic symptoms)
Fever, rash, weight loss
Orthostatic - better lying down
What are red flags for headaches? (neurological symptoms or focal signs)
Visual loss, confusion, seizures, hemiparesis, double vision, 3rd nerve palsy, Horner syndrome, papilloedema
What is Horner syndrome?
Sympathetic supply to the eye is affected
Eye is droopy
Pupil is slightly smaller
What are the features of subarachnoid haemorrhage?
Sudden generalised headache
‘blow to the head’.
Meningism - stiff neck and photophobia
Most are caused by a ruptured aneurysm, a few from arteriovenous malformations.
50% instantly fatal
How do you diagnose subarachnoid haemorrhage?
Nimodipine and BP control.
High risk of a further bleed
.
Early neurosurgical assessment will confirm the bleed
and establish the cause.
CT brain, Lumbar puncture (will be pink) (RBC and xanthochromia) and MRA, angiogram.
Blood is white on CT
How do you treat subarachnoid haemorrhage?
Nimodipine
Aneurysms used to be clipped or wrapped.
Nowadays filled with platinum coils.
What is coning?
Causes raised intracranial pressure
Weak points in the brain
tumour or mass grows when volume becomes significant
Brain no longer compliant after a point and seeps into weak points
Causes herniation
Brainstem death
What is papilloedema?
Papilloedema
Optic disc swelling due to raised ICP
Why is neck pain common in headaches?
Headache can also arise due to pathology in the large arteries of the neck.
What often causes stroke in young people?
Carotid & vertebral artery dissection
20% of ischaemic strokes <45 years (young stroke)
What imaging do you use to diagnose dissections?
MRI/MRA, Doppler, Angiography
How do you try prevent stroke?
Aspirin or anticoagulation X 6/12
What is SDH?
Chronic Subdural haemorrhage
Why are SDH common in older people?
They fall
Often on blood thinners
> 65 years
How do SDH’s show on CT?
Dark patches
What is temporal arteritis?
Constant unilateral headache, scalp tenderness and jaw claudication
25% of those with Polymyalgia Rheumatica-proximal muscle tenderness. Shoulder and pelvic pain worse in the morning.
Involvement of the posterior ciliary arteries causes blindness (amaurosis fugax)
Who gets temporal arteritis?
Over the age of 55.
Three times commoner in females.
Polymyalgia rheumatica
How do you diagnose temporal arteritis?
Elevated ESR and CRP
Temporal artery are usually inflamed and tortuous.
Visible on ultrasound
Temporal artery biopsy shows inflammation and Giant Cells - definitive test
^ should not delay treated
How do you treat temporal arteritis?
High dose steroids and aspirin.
Oral prednisolone immediately
What are the main features of cerebral venous thrombosis?
Thrombosis in dural venous sinus or cerebral vein
Unusual amount of headache due to raised ICP
Non-territorial ischaemia “venous infarcts”
Haemorrhage
What causes cerebral venous thrombosis (like risk factors)?
Thrombophilia, pregnancy, dehydration, Behcets
What can cause meningitis?
Infections:
Viral- Coxsackie, ECHO, Mumps, EBV
Bacterial - Meningococci, Pneumococci, Haemophilus
Tuberculous
Fungal - Cryptococci
Granulomatous- Sarcoid, Lyme, Brucella, Behçet’s, Syphilis
Carcinomatous
What are the presenting symptoms of meningitis?
Malaise Headache Fever Neck stiffness Photophobia Confusion Alteration of consciousness
What is herpes simplex encephalitis (and what it affects)?
Affects temporal lobes
haemorrhagic traces
What is the management plan for meningitis?
Treat then diagnose as it can kill in minutes
How do you treat meningitis?
Blood and urine culture
Look for signs of raised ICP
If no: Lumbar puncture within an hour Increased White Cell Count, decreased glucose, Antigens IV Abs Dexa 10mg IV
If yes:
ABs
Airways support
Fluid resus
What are the main symptoms of sinusitis?
Malaise, headache, fever. Blocked nasal passages. Loss of vocal resonance. Anosmia. Nasal or postnasal catarrh. Local pain and tenderness.
Frontal pain characteristically starts 1-2 hours after rising and clears up during the afternoon.
How can a brain tumour cause headache?
Oedema around tumor generates huge amount of pressure
What are the symptoms of idiopathic intracranial hypertension?
Headache, visual obscurations, diplopia, tinnitus
Papilloedema, +/- visual field loss
Who gets idiopathic intracranial hypertension?
Often young obese women
What causes idiopathic intracranial hypertension?
Weight gain
Drugs: hormones, steroids, antibiotics, vitamin E
How do you treat idiopathic intracranial hypertension?
weight loss (bariatric surgery) diuretics optic nerve sheath decompression lumboperitoneal shunt stenting of stenosed venous sinuses
Can low pressure cause headaches?
Yes
What causes low pressure headaches?
CSF leak due to tear in dura
Traumatic post lumbar puncture or spontaneous
How do you treat low pressure headaches?
Treatment rehydration, caffeine, blood patch
What is characteristic of low pressure headaches?
Orthostatic
How do you diagnose low pressure headaches?
MRI shows meningeal enhancement
What is chiari malformation?
Normal brain that just sits very low within the skull
How doe chiari malformation cause headache?
Cerebellar tonsils descending through the foramen magnum
Descend further when patient cough and tug on the meninges causing cough headache
How do you treat chiari malformation?
Operation to remodel base of brain
What are the features of obstructive sleep apnoea?
Hypoxia, CO2 retention, non-refreshing sleep
Depression, impotence, poor performance at work
Require sleep study
Nocturnal NIV, Surgery
What is trigeminal neuralgia?
Electric shock like pain in the distribution of a sensory nerve.
Often triggered by innocuous stimuli.
Any division of the trigeminal can be affected.
Neurovascular conflict at the point of entry of the nerve into the pons.
Can be symptom of M.S.
How do you treat trigeminal neuralgia?
Carbamazepine, lamotrigine, gabapentin.
Posterior fossa decompression.
What is atypical facial pain?
Most commonly in middle aged women. Depressed or anxious.
Daily, constant, poorly localised deep aching or burning.
Facial or jaw bones, but may extend to the neck, ear or throat.
Not lancinating.
Not conforming to the strict anatomical distribution of any nerve.
No sensory loss.
Pathology in teeth, temporomandibular joints, eye, nasopharynx and sinuses must be excluded.
How do you treat atypical facial pain?
Unresponsive to conventional analgesics, opiates and nerve blocks.
Mainstay of management tricyclics
What are the different mechanisms of post-traumatic headache?
Neck injury
Scalp injury
Vasodilation ? autonomic damage
Depression - often delayed
What does post-traumatic headache depend on?
Correlates with previous history of headache
Nature of head injury:
High in victims of car accidents
Low in perpetrators of car accidents
Low in sports injuries
How do you manage post-traumatic headache?
Explanation
Prevent analgesic abuse
Non-steroidal anti-inflammatories - ibuprofen, naproxen
Tricyclic antidepressants - Amitriptyline
Be patient 3-4 years
What are the symptoms of cervical spondylosis?
Usually bilateral Occipital pain can radiate forwards to the frontal region Steady pain No nausea or vomiting Worsened by moving the neck
How do you manage cervical spondylosis?
Rest, deep heat, massage.
Anti-inflammatory analgesics.
Over-manipulation may be harmful.
Why is cervical spondylosis common in older patients?
Arthritis
Narrowing of join space due to worn disc
What signs are found in meningitis?
Kernig’s sign
Brudzinski’s sign
What are the different properties of lumbar puncture
Bacterial - turbid, low glucose, high protein
Viral - clear
TB - fibrin web
What ABs do you give in hospital for Meningitis?
Ceftriaxone
Cefotaxime
+ amoxcicillin if immunocompromised
What is the most common cause of encephalitis in the UK?
Herpes Simplex Virus
How does encephalitis present?
Prodome
Odd behaviour
Seizure’s
What investigations should be done for encephalitis?
Blood cultures
LP
EEG
Contrast enhanced CT/MRI (will see bilateral temporal oedema)
What are RFs for Trigeminal neuralgia?
60-80 years
MS
Female
HTN
What are RFs for Trigeminal neuralgia?
60-80 years
MS
Female
HTN
What are the investigations for subarachnoid haemorrhge?
Urgent CT < 12 hours
LP > 12 hours if CT is normal
Xanthochromic fluid
What is the difference between Subarach and SDH?
More gradual onset
Venous bleed
What are the features of extradural haemorrhage?
Extradural or Epidural
Acute build up of blodd between dura and periosteum
Due to trauma
What are the presenting features of EDH?
Acute onset after lucid interval
Deteriorating of GCS and history of direct trauma
What would a crescent shape bleed be on a CT?
Sub-dural haemorrhage
What is the immediate management of haemorrhages?
A-E Immediate neurosurgical referral Cardiopulmonary support Maintain BP Raise head of bed to 30 degrees Osmotic diuretic
