headache Flashcards
15 mins to 2 hours headache
cluster headache
2s - 3mins headache
trigeminal neuralgia
4-72hrs
migraines
triggers of cluster headahe
more common in men (3:1)
smokers
Alcohol may trigger an attack and there also appears to be a relation to nocturnal sleep.
examples of primary headache
TTH
Migraine
Cluster Headache
Others
examples of secondary headache
Vascular Infective Neoplasia Drugs Inflammation RICP Trauma Metabolic Toxins
examples of drugs causing chronic headache
paracetamol, aspirin or NSAIDs used for 15 days per month or more
triptans, opioids or ergot preparations for 10 days a month or more
red flag signs for headache
Thunderclap Headache Neck Stiffness Rash Photophobia Focal Neurology Nausea/ Vomiting Characteristics of RICP headache - Present on waking - Worse if lying - Exacerbated by valsalva/ bending/ cough - Papillodema Fever Recent Onset or Change in character
causes of raised ICP
- SOL
- Idiopathic Intracranial Hypertension
- Venous S§inus Thrombosis
- Hydrocephalus
- infection - meningitis
Symptoms of raised ICP
papilloedema
Cushing’s triad - HTN, bradycardia, irregular respiration
Headache – worst on waking, inc. or ass with visual obscurations with valsalva, bending, coughing etc
vomiting
If severe, bradycardia and ↑BP
Respiratory changes – periodic breathing, apnoea
False localising signs eg VI palsy - abducen
If fever, leucocytosis look for ear, nose infection preceeding headache
SOL in the cerebellum signs
Dysdiadochokinesis ataxia nystagmus intention tremor slurred speech
SOL in the temporal lobe
depersonalisation
deja vu - hallucinations of smell, taste, sound and sight.
visual field defects - inferior fibres so upper quadrant
SOL in the frontal lobe
anosmia
change in personality, dishonesty
dysphasia
hemiparaesis
SOL in the parietal lobe
hemisensory loss
decreased 2 point discrimination
features of cerebellopontine angle
ipsilateral deafness. Tinnitus. Nystagmus. Reduced corneal reflex. Facial and trigeminal nerve palsies. Ipsilateral cerebellar signs.
features of midbrain lesion
Unequal pupils.
Inability to direct the eyes up or down.
Amnesia for recent events, with confabulation.
Somnolence.
risk factors of idiopathic intracranial hypertension
obese females
recent weight gain
hypertension
menstrual irregularity
pregnancy
drugs*: oral contraceptive pill, steroids, tetracycline, high vitamin A, lithium
aetiology of idiopathic intracranial hypertension
- obstruction to CSF
- excess CSF production
- increased cerebral oedema
endocrine - adrenal insufficiency, dushings, thyroid
medication - cimetidine, steroids
PCV
Iron deficiency anaemia
CKD
SLE
presentation of idiopathic intracranial hypertension
generalised throbbing - worst morning and night
relieved on standing
aggravated by straining, coughing or change in position
blurred vision
enlarged blind spot
NV
CNVI PALSY - diplopia
papilloedema
treatment for idiopathic intracranial hypertension
Weight loss
Acetazolamide - reduces rate of CSF production by choroid (diuretics)
Topiramate - cause weight loss
repeated LP
amitryptilline - headache
Urgent LP
Optic nerve sheath fenestration
Shunts
surgery: optic nerve sheath decompression and fenestration may be needed to prevent damage to the optic nerve. A lumboperitoneal or ventriculoperitoneal shunt may also be performed to reduce intracranial pressure
prognosis of idiopathic intracranial HTN
not really ass with death
relapse and remission are common
significant threat to sight
upto 50% visual loss
what is GCA
type of chronic vasculitis characterized by granulomatous inflammation in the walls of medium and large arteries. The extracranial branches of the carotid artery and branches of the ophthalmic artery, such as short ciliary branches, are preferentially involved,
complications of GCA
visual loss
Large artery complications
- aortic aneurysm
- aortic dissection
- large artery stenosis
- aortic regurgitation
CVS
- MI
- Heart failure
- stroke
- PAD
Peripheral neuropathy.
Depression.
Confusion and encephalopathy (in about 30% of people).
Deafness.
prognosis of GCA
Relapses are common and can occur if corticosteroid treatment is reduced or withdrawn too quickly
clinical manifestations of GCA
above 50
-new onset localized headache that is usually unilateral, in the temporal area
- temporal artery - tender, thick or nodule
Systemic features (fever, fatigue, anorexia, weight loss, and depression
Features of polymyalgia rheumatica (bilateral upper arm stiffness, aching, and tenderness; and pelvic girdle pain
scalp tenderness
intermittent jaw claudication
visual disturbances - shade in one eye
DD of GCA
herpes zoster
cluster headache
acute angle galucoma
TIA
Temporomandibular joint pain, sinus disease, and ear problems.
Cervical spondylosis or other upper cervical spine disease.
Tx for GCA
For people with visual symptoms — 60–100 mg as a one-off dose (they should be seen by an ophthalmologist the same day) IVmethyl prednisolone prior to oral0,5-1.0g daily for 3/7.
For people without visual symptoms — 40–60 mg daily (minimum 0.75 mg/kg).
Reduce the dose of prednisolone to zero over 12–18 months providing there are no signs and symptoms or laboratory markers of inflammation.
Consider the need for a proton pump inhibitor for gastroprotection in people at high risk of gastrointestinal bleeding or dyspepsia
every 2-8 weeks for first 6 months
Ix for GCA
LFTs - ALP esp
CRP
ESR
FBC - normochromic normocytic anaemia and an elevated platelet count are common.
DD for papilloedema
tilted optic disc
myelinated nerve fibres
Ix for idiopathic intracranial HTN
MRI or MR/CT venography to exclude
- hydrocephalus
- mass lesion
- venous thrombosis
triggers for migraine
Ch – chocolate O – Oral contraceptive C – caffeine (or withdrawal) O- orgasm L - lack of sleep A – alcohol T – travel E – exercise
irregular 💤
prognosis of migraine
improves with increasing age
pregnancy - improvement in frequency and severity of attacks the second and third trimesters
complications of migraine
Reduced functional ability and quality of life
Medication overuse headache
progression to chronic migraine
Status migrainosus — debilitating migraine attack lasting for more than 72 hours.
Migrainous infarction — symptoms of aura lasting for more than 60 minutes with evidence of an ischaemic brain lesion on neuroimaging.
Persistent aura without infarction — aura symptoms lasting for more than 1 week, with no radiographic evidence of infarction.
increased risk of stroke
- infarction
- haemorrhagic
features of migraine without aura
Headache lasting 4–72 hours in adults or 2–72 hours in adolescents.
Headache with at least two of the following characteristics:
- UNILATERAL location (more commonly bilateral in children).
- PULSATING quality — may be described as ‘throbbing’ or ‘banging’ in young people.
- MODERATE/SEVERE intensity.
- AGGRAVATION by, or causing avoidance of, routine activities of daily life (for example walking or climbing stairs).
Headache with associated symptoms including at least one of:
- N/V
- PHOTOPHOBIA (sensitivity to light) and PHONOPHOBIA (sensitivity to sound)
migraine with aura symptoms
One or more typical fully reversible aura symptoms including:
- VISUAL - zigzag lines / scotoma
- transient hemianopic disturbance
- spreading scintillating scotoma (‘jagged crescent’).
- SENSORY -> symptoms such as unilateral pins and needles or numbness.
- SPEECH and/or language symptoms such as dysphasia.
At least three of the following:
- At least one aura symptom spreads gradually over at least 5 minutes.
- Two or more aura symptoms occur in succession.
- Each individual aura symptom lasts 5-60 minutes.
- At least one aura symptom is unilateral.
- At least one aura symptom is positive.
- The aura is accompanied, or followed within 60 minutes, by headache.
acute management for migraine
- simple analgesia
- oral sumatripatan (50-100mg)
fails - intra-nasal or subcutaneous - antiemetic - such as metoclopramide 10mg or prochlorperazine 10mg even in the absence of N/V
when to consider preventative treatments for migraine
- significant impact on quality of life and daily function
- acute treatment is shit
- at risk of medication overuse headache
what medical preventative treatment for migraines are available
the aim of treatment is to reduce the frequency and severity of migraine symptoms and not complete remission or cure of migraine.
- Propranolol (80–160 mg daily, in divided doses) or
- Topiramate (50–100 mg daily, in divided doses [contraindicated in pregnancy — highly effective contraception is required prior to initiation]) or
- Amitriptyline (25–75 mg at night).
what nonmedical preventative treatment for migraines are available
- Behavioural interventions (such as relaxation techniques [for example mindfulness or meditation] or cognitive behavioural therapy).
- Acupuncture (up to 10 sessions over 5–8 weeks) if both topiramate and propranolol are unsuitable or ineffective.
- Riboflavin 400 mg once a day — may be effective in reducing migraine frequency and intensity for some people (avoid if planning a pregnancy or pregnant).
preventative drug Tx for menstrual migraine
Frovatriptan (2.5 mg twice daily) on the days migraine is expected or from two days before until three days after bleeding starts.
Zolmitriptan (2.5 mg twice or three times daily) on the days migraine is expected or from two days before until three days after bleeding starts.
risk factors of subarachnoid haemorrhage
HTN smoking cocaine alcohol genetic - D polycystic kidney disease, EDS, neurofibromatosis
marfans - berry
what are berry anuerysms
circle of willis
clinical manifestations of SAH
sudden explosive headache - thunderclap
vomiting
confusion/altered level of consciousness
neck stiffness and other signs of meningism 6 hours after onset of SAH
DD of SAH
Other causes of stroke.
Meningitis (rarely features thunderclap headache).
Trauma.
Thunderclap headache of other aetiology.
Primary sexual headache.
Cerebral venous sinus thrombosis.
Cervical artery dissection.
Carotid artery dissection.
Hypertensive emergency (severely raised blood pressure).
Pituitary apoplexy (infarction or haemorrhage of the pituitary gland).
Ix for SAH
first line CT scanning without contrast
FAILS
lumbar puncture should be undertaken over 12 hourse after the onset for xanthochromia to be detected by spectrophotometry
what is cerebral panangiography
gold standard for detection, demonstration and localisation of ruptured aneurysms
how to determine the origin of the bleed of SAH
cerebral angiography
CT angiography
ECG changes for SAH
QT prolongation
Q waves
dysrhythmias
ST elevation.
aim of Tx for SAH
prevent further bleeding or rebleeding
complications of SAH
death
rebleeding - endovascular coiling/neurovascular clipping
vasospasm - nimodipine 60mg
hydrocephalus - CSF shunt
epilepsy
cognitive dysfunction
Stroke/poor cerebral perfusion -> maintain hydration/control BP
MAIN red flags of headache
- Vomiting more than once with no other cause.
- New neurological deficit (motor or sensory).
- Reduction in conscious level (as measured by the Glasgow coma score).
- Valsalva (associated with coughing or sneezing) or positional headaches.
- Progressive headache with a fever.
what is post traumatic headache
within one week after an injury or when they regain consciousness
features are similar to a migraine
features of post LP headache
usually develops within 24-48 hours following LP but may occur up to one week later
may last several days
worsens with upright position
improves with recumbent position
tx for post LP headache
analgesia rest
caffeine and fluids
usually develops within 24-48 hours following LP but may occur up to one week later
may last several days
worsens with upright position
improves with recumbent position
migraine criteria
A- At least 5 attacks fulfilling criteria B-D
B Headache attacks lasting 4-72 hours* (untreated or unsuccessfully treated)
C Headache has at least two of the following characteristics:
- unilateral location*
- pulsating quality (i.e., varying with the heartbeat)
- moderate or severe pain intensity
- aggravation by or causing avoidance of routine physical activity (e.g., walking or climbing stairs)
D During headache at least one of the following:
- nausea and/or vomiting*
- photophobia and phonophobia
E Not attributed to another disorder (history and examination do not suggest a secondary headache disorder or, if they do, it is ruled out by appropriate investigations or headache attacks do not occur for the first time in close temporal relation to the other disorder)
children with migraine features
attacks are shorter lasting
more commonlu bilateral
GI distubrance is more prominent
features of auras
- are fully reversible
- develop over at least 5 minutes
- last 5-60 minutes
atypical aura symptoms that may prompt further investigation/referral
- motor weakness
- double vision
- visual symptoms
- affecting only one eye
- poor balance
- decreased level of consciousness.
Ix for raised ICP
CT/MRI scanning to determine any underlying lesion.
Check and monitor blood glucose, renal function, electrolytes and osmolality.
who do we monitor ICP in
- management of severe closed head injury.
- Appropriate in patients with severe head injury (GCS between 3 and 8 after CPR) and an abnormal CT scan (haematomas, contusions, oedema or compressed basal cisterns).
- Appropriate in patients with severe head injury and a normal CT scan if two or more of the following features are noted on admission
- – age over 40 years
- – unilateral or bilateral motor posturing
- – systolic blood pressure <90 mm Hg.
- Subarachnoid haemorrhage with associated hydrocephalus: ventriculostomy allows therapeutic drainage and ICP monitoring.
- Reye’s syndrome: active treatment of raised ICP decreases mortality.
- Brain tumours: may be of value in selected patients deemed at high risk of swelling or obstructive hydrocephalus - eg, following posterior fossa surgery.
- Normal pressure hydrocephalus.
- Decompensated hydrocephalus: can be a valuable diagnostic tool in complex cases.
- Idiopathic intracranial hypertension
- — diagnostic test
- — monitor response to treatment
Other potential indications include hypoxic brain swelling after drowning, meningitis, encephalitis, venous sinus thrombosis and hepatic encephalopathy.
what is raised ICP the values
above 20mmHg
Mx of ICP
- head elevation to 30° improves jugular venous outflow and lowers intracranial pressure
mannitol osmotic diuretic
- > controlled hyperventilation
- aim is to reduce pCO2 → vasoconstriction of the cerebral arteries → reduced ICP
- leads to rapid, temporary lowering of ICP. However, caution needed as may reduce blood flow to already ischaemic parts of the brain
-> removal of CSF, different techniques include: drain from intraventricular monitor (see above) repeated lumbar puncture (e.g. idiopathic intracranial hypertension) ventriculoperitoneal shunt (for hydrocephalus)
what is tension-type headache and classification
primary headache disorder
infrequent - <1 day per month
frequent - at least 10 episodes of headache
chronic TTH - >15 per month for 3 months
clinical manifestations of Tension headache
Sx
Signs
bilateral
Quality - pressing or tightening (non-pulsating)
intensity - mild to moderate
duration - lasting minutes to days.
no aggravating factors or ass Sx
pericranial tenderness on manual palpation may be present.
DD for tension type headache
migraine
trigeminal neuralgia
trauma
treatment for tension type headache
analgesia
sleep hygiene
chronic TTH
- A course of up to 10 sessions of acupuncture over 5–8 weeks.
- low dose amitryptilline 10-75 mg
triggers for tension headache
stress
tiredness
squint
Prognosis of TTH
- > Infrequent episodic tension-type headache (TTH) occurs in a large proportion of the population. It is self-limiting and simple analgesia is usually effective.
- > Chronic TTH can evolve from frequent episodic TTH, with daily or very frequent episodes of headache. It is a serious condition which decreases quality of life and leads to high disability.
complications of TTH
- > Frequent episodic tension-type headache (TTH) and chronic TTH can be associated with considerable disability and loss of quality of life.
- > Self-medication is common in TTH and may lead to medication overuse headache.
prodromal and postdromal Sx of migraine
Prodromal
- fatigue
- poor concentration
- neck stiffness
- yawning
- occur hours or 1–2 days before onset of other symptoms of migraine.
Postdromal
- fatigue
- elated
- depressed mood
- may occur after resolution of the headache and last up to 48 hours.
DDx for migraine
- > Tension-type headache.
- > Trigeminal autonomic cephalgias for example cluster headache and paroxysmal hemicranias.
- > Other primary headache disorders such as primary cough headache and cold-stimulus headache.
prognosis of medication overuse headache
improve after discontinuation of the overused medication
Mx of medication overuse headache
Drugs such as triptans and simple analgesics (such as NSAIDS and paracetamol) can generally be stopped abruptly.
Advise the person to stop taking all overused acute headache medications for at least 1 month.
Warn the person that withdrawal may initially worsen symptoms and that headache improvement may not occur for weeks after discontinuation.
Advise the person to keep a diary recording symptoms and medication use during withdrawal and to maintain good hydration.
classification of cluster headache
Episodic cluster headache — attacks occur in periods lasting from 7 days to 1 year and are separated by pain-free periods lasting at least 1 month.
Chronic cluster headache — attacks occur for more than 1 year without remission, or with remission periods lasting less than 1 month.
prognosis of cluster headache
lifelong disorder - periods of remission may lengthen with increasing age.
features of cluster headache
unilateral peri-orbital pain associated with ipsilateral cranial autonomic symptoms (such as conjunctival injection, lacrimation and eyelid oedema).
rhinorrhoea
- pulsating, boring, burning, or pressure-like.
- 15 and 180 minutes.
- characteristically restless or agitated, cannot lie still and may pace the floor.
International Classification of Headache Disorders (ICHD)
diagnostic criteria
- At least five attacks of severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15–180 minutes and
- Headache associated with at least one of: ipsilateral conjunctival injection and/or lacrimation; nasal congestion and/or rhinorrhoea; eyelid oedema; forehead and facial sweating or flushing; a sensation of fullness in the ear; or miosis and/or ptosis; and/or a sense of restlessness or agitation.
- Attacks occur between one every other day and eight per day for more than half of the time when the disorder is active.
acute treatment for cluster headache
- Sumatriptan by subcutaneous injection (for adult) - 6mg for one dose contraindicated in pts w CAD have potential to cause coronary vasospasm
- Sumatriptan by intranasal administration (for adult aged 18–65 years - 10-20mg
- provide 100% oxygen at a flow rate of 12–15 litres per minute via a non-rebreather face mask for 15 to 20 minutes.
preventative treatment for cluster
verapamil
what is meningitis
inflammation of the two inner meninges (the pia and arachnoid mater) of the brain and spinal cord.
causative organisms of meningitis
bacterial -> Neisseria meningitidis (meningococcus), Streptococcus pneumoniae (pneumococcus), and Haemophilus influenzae type b
viral -> enteroviruses
mycobacterium TB
incubation period of neisserria and strep pnuemonia
neisseria - 3/5 days
strep - 1-3 days
risk factor of meningitis
young age winter absent or non-functioning spleen immunocompromised cancer organ dysfunction smoking
complications of meningitis
hearing loss brain abscess seizures visual impairment distal limb loss in septicaemia hemi and quadraparaesis cognitive impairment hydrocephalus reduced QOL anciety learning difficulties
poor prognosis of meningitis in adults
Low Glasgow Coma Scale score on admission (low level of consciousness).
Tachycardia.
Absence of rash.
Thrombocytopenia.
Elevated erythrocyte sedimentation rate (ESR).
Positive blood culture.
Cerebrospinal fluid leucocyte count of less than 1000 x 109 cells per mL.
specific symptoms of meningitis
- Non-blanching rash.
- Stiff neck.
- Capillary refill time of more than 2 seconds, cold hands and feet.
- Unusual skin colour.
- Shock and hypotension.
- Leg pain.
- Back rigidity.
- Bulging fontanelle.
- Photophobia.
- Kernig’s sign (person unable to fully extend at the knee when hip is flexed).
- Brudzinski’s sign (person’s knees and hips flex when neck is flexed).
DD for meningitis
viral - conservative management - enteroviruses, HSV
fungal - life threatening
TB meningitis
sepsis
pneumonia
encephalitis
Management of meningitis
single dose of parenteral benzylpenicillin (intravenously or intramuscularly)
Children younger than 1 year of age — 300 mg.
Children 1–9 years of age — 600 mg.
Adults and children 10 years of age or older — 1200 mg.
after discharge what happens meningitis
All children should have a review with a paediatrician 4–6 weeks after hospital discharge to assess their recovery.
what is encephalitis
inflammation of the brain parenchyma - caused by viral infections
HSV1
presentation of encepahlitis
acute TRIAD Fever headache altered mental status
Viral - may begin flu or headached altered consciousness confusion drowsiness seizures coma
increased ICP Sx
DDx of encephalitis
meningitis behcet SLE stroke MS syphillis leukaemia
Ix foe encephalitis
CSF - lymphocytosis, elevated protein
PCR test for HSV, VXV and enteroviruses
- Elevated protein
- elevated CSF specific antibody levels
FBC and blood film - leukocytosis
CT scan - rule out SOL, strokes and basilar fractures
- identify ICP
EEG
Mx for encephalitis
- urgent hospital admission
- immediate parentral ABx
- IV aciclovir
- no specific Mx for other causes
- role of steroids
complications of encephalitis
inappropriate antidiuretic hormone secretion
DIC
cardiac and respiratory arrest
epilepsy
clinical manifestations of acute sinusitis
examination
chronic
- nasal blockage (obstruction/congestion) or nasal discharge (anterior/posterior nasal drip)
- facial pain/pressure (or headache)
- loss) of the sense of smell.
- Altered speech indicating nasal obstruction.
- Tenderness, swelling, or redness over the cheekbone or periorbital areas.
- Cough.
Inspecting and palpating the maxillofacial area to elicit swelling and tenderness.
Performing anterior rhinoscopy (using the largest speculum of an otoscope, or a head light and nasal speculum) to identify:
Signs which support a diagnosis of acute sinusitis such as nasal inflammation, mucosal oedema, and purulent nasal discharge.
Associated pathology such as nasal polyps, or anatomical abnormalities such as septal deviation.
more than 12 weeks
DDx for sinusitis
URTI allergic rhinits nasal foreign body adenoiditis/tonsillitis sinonasal tumour turbinate hypertrophy
Mx for acute sinusitis
more than 10 days
high dose nasal corticosteroid for 14 days
bacterial meningitis CSF findings
Appearance: cloudy and turbid
Opening pressure: elevated (>25 cm H₂O)
WBC: elevated >100 cell/µL (primarily polymorphonuclear leukocytes (>90%))
Glucose level: low (<40% of serum glucose)
Protein level: elevated (>50 mg/dL)
viral meningitis CSF findings
Appearance: clear
Opening pressure: normal or elevated
WBC: elevated (50 – 1000 cells/µL, primarily lymphocytes, can be PMN early on)
Glucose level: normal (>60% serum glucose, however, may be low in HSV infection)
Protein level: elevated (>50 mg/dL)
TB meningitis CSF findings
Appearance: opaque, if left to settle it forms a fibrin web
Opening pressure: elevated
WBC: elevated (10 – 1000 cells/µL, early PMNs then mononuclear)
Glucose level: low
Protein level: elevated (1-5 g/L)
SAH CSF findings
Appearance: blood-stained initially, then xanthochromia (yellowish) >12 hours later
Opening pressure: elevated
WBC: elevated (WBC to RBC ratio of approx 1:1000)
RBC: elevated
Glucose level: normal
Protein level: elevated
GBS CSF findings
Appearance: clear or xanthochromia
Opening pressure: normal or elevated
WBC: normal
Glucose level: normal
Protein level: elevated (>5.5 g/L)
when might CSF maybe
- Suspected subarachnoid haemorrhage
- Suspected meningitis/encephalitis
- Immunological disorders such as multiple sclerosis or Guillain-Barré Syndrome
migraine and menstruation
mefanamic acid or a combination of aspirin, paracetamol and caffeine. Triptans are also recommended in the acute situation
what do u do if someone comes in with sudden headache confusion
full set of obs including BM Full neuro examination including fundoscopy CT scan NBM cannulate
DDx of subdural haematoma
stroke intoxicated/drug overdose metabolic imbalance - hypoglycaeamia septicaemia acute bleed into a brain tumour
RFs fo subdural haematoma
Mx
increasing age - brain shrinkage occurs chronic alcoholism epilepsy long term anticoagulation falls
surgical evaluation of the haematoma thru burr holes
Triggers of trigeminal neuralgia
washing shaving touching brushing teeth brushing hair cold wind eating
causes if trigeminal neuralgia
MS
lesions of the cerebellopontine angle
atrioventricular malformation
tumors of CNV
Mx of post herpetic neuralgia
amitryptilline
