Headache Flashcards
Causes of dull headache
Overuse of medication (e.g. codeine)
Contraceptive pill, hormone replacement therapy
Causes acute single headache
Thunderclap (sudden onset), low pressure
Febrile illness, sinusitis head injury Subarachnoid haemorrhage Meningitis, drugs, toxins, stroke
What headache patterns are these? Cluster Migraine Episodic tension headache Trigeminal / post herpetic neuralgia
Recurrent
Triggered headache
Coughing, straining, exertion
Coitus
Food and drink
Red flags
onset?
presence of systemic symptoms?
what neuro symptoms?
better standing or lying down?
Onset : Thunderclap, acute, subacute
Meningism : Photophobia, phonophobia, stiff neck, vomiting
Systemic symptoms : Fever, rash, weight loss
neurological symptoms / focal signs : Visual loss, confusion, seizures, hemiparesis, double vision, 3rd nerve palsy, Horner syndrome, papilloedema,
Orthostatic-better lying down
Strictly unilateral
Horner syndrome?
decreased pupil size, a drooping eyelid and decreased sweating on the affected side of your face
inhibition of sympathetic nerve supply
3rd Nerve Palsy
CN III impacted so actions of CN IV/ VI
completely closed eyelid and deviation of the eye outward and downward
the eye cannot move inward or up, and the pupil is typically enlarged and does not react normally to light
Papilloedema
Papilledema or papilloedema is optic disc swelling that is caused by increased intracranial pressure due to any cause. The swelling is usually bilateral
Signs headache is due to Subarachnoid haemorrhage
- blow to the head
- stiff neck photophobia
- ruptured aneurysm , arteriovenous
Subarachnoid Haemorrhage headache : Course of action
what drug? what needs monitoring
- Vasospasm : stop leak
- Nimodipine : calcium channel blocker used in preventing vasospasm secondary to subarachnoid hemorrhage
- BP control needed
Markers of Subarachnoid Haemorrhage ?
- CT brain
- Lumbar Puncture : will show xanthochromia
- MRA, Angiogram
what is xanthochromia ?
yellowish appearance of cerebrospinal fluid that occurs several hours after bleeding into the subarachnoid space
- sign of Subarachnoid Haemorrhage
How is an unruptured aneurysm dealt with ?
- Clipped
- Wrapped
- Platinum coils
Optic disc swelling
- due to raised intracranial pressure
Temporal Arteritis
characteristics
<55
3x more in women
Constant unilateral headache
Scalp tenderness and jaw claudication + present w polymyalgia rheumatica
Elevated ESR, CRP
Inflamed and tortuous
Biopsy inflammation and giant cells : disruption of internal elastic lamina
Polymyalgia Rheumatica
Proximal muscle tenderness
Temporal Arteritis
can cause blindness why?
inflamed temporal artery can get posterior ciliary arteries are involved
ESR and CRP what do they show?
signs of inflammation
Unusual amount of headache due to raised ICP
- Cerebral Venous Thrombosis
Why does Cerebral Venous Thrombosis occur?
Non-territorial ischaemia “venous infarcts”
Haemorrhage
Thrombophilia, pregnancy, dehydration,
- Behcets :blood vessel inflammation throughout your body
Cause of Headache
Viral- Coxsackie, ECHO, Mumps, EBV
Bacterial - Meningococci, Pneumococci, Haemophilus
Tuberculous
Fungal - Cryptococci
Granulomatous- Sarcoid, Lyme, Brucella, Behçet’s, Syphilis
Carcinomatous
Meningitis
Presenting symptoms
Malaise Headache Fever Neck stiffness Photophobia Confusion Alteration of consciousness
Herpes Simplex Encephalitis
Classic haemorrhagic changes in the temporal lobes
Meningitis
Treat then diagnose
Antibiotics Blood and urine culture Lumbar puncture Increased White Cell Count, decreased glucose Antigens Cytology Bacterial Culture CT or MRI Scan
Bacterial Meningitis
characterisitic
Cerebral oedema with effacement of ventricles and sulci and inflamed meninges
Sinusitis
characteristic
Malaise
Headache
Fever
Blocked nasal passages
loss of vocal resonance (increased air present)
build of mucus in nasal / postnasal : Catarrh
Anosmia: loss of smell
Idiopathic Intracranial Hypertension
Pseudotumor Cerebri
- young , obese women
- headache, diplopia, tinnitus
What can cause? idiopathic intracranial hypertension?
Treatment?
Hormones, steroids, antibiotics, Vit E
-weight loss, diuretics, optic nerve sheath decompression, lumboperitoneal shunt, stenting of stenosed venous sinuses
Low Pressure Headache
CSF leak due to tear in Dura
What can cause L-Pessure Headcache
Traumatic post lumbar puncture or spontaneous
Treatment for LPH
Treatment rehydration, caffeine, blood patch
Chiari Malformation
Normal brain sits low within skull
Why in Chiari Malformation does a cough trigger a headache?
Cerebellar tonsils descending through the foramen magnum. Descend further when patient cough and tug on the meninges causing cough headache.
Cause of headache : Obstructive sleep apnoea
causes of headache is due to?
treatment?
- loud snoring
- apnoeic spell
Hypoxia, CO2 retention, non refreshing sleep
Nocturnal NIV
Surgery
Cause of headache : Trigeminal Neuralgia
why?
Drug treatments?
Electric shock like pain in the distribution of a sensory nerve
Neurovascular conflict at point of entry of nerve into pons
Can be symptom of MS
Carbamazepine [ inhibts sodium channels] , lamotrigine [ binds sodium channels, inhibits glutamate], gabapentin [ mimic GABA? inhibits calcium channels not sure hot it works]
Cause of headache : Trigeminal Neuralgia
Drug treatments? [3]
sodium channel inhibitor?
calcium channel blocker
Carbamazepine, lamotrigine, gabapentin.
Atypical facial pain
Middle aged women
- Depressed or anxious
- Daily, constant, poorly localised deep aching or burning.
- Not piercing pain [ exclude any nerve pain]
- No sensory loss
- Pathology in teeth, temporomandibular joints, eye, nasopharynx and sinuses must be excluded.
treatment for :
Atypical facial pain
Unresponsive to conventional analgesics, opiates and nerve blocks.
- Mainstay of management tricyclics.
Post traumatic headache
who?
mechanims?
High in victims of car accidents
Low in perpetrators of car accidents
Low in sports injuries
- Neck, Scalp, Vasodilation, depression
What is the most common cause of new headache in older patients?
Cervical Spondylosis
Cervical Spondylosis
- Bilateral
- Occipital pain radiates forwards to the frontal region
- steady pain
- worsened by neck movements
- steady pain
management of
Cervical Spondylosis
Rest, deep heat, massage
Anti-inflammatory analgesics
Vascular and Circulatory causes of headaches:
- Subarachnoid Haemorrhage [circle of willis]
- Acute intracerebral haemorrhage
- Raised Intracranial Pressure (ICP) > - Cerebral Venous Thrombosis
- Chronic subdural haemorrhage [venous]
- Temporal Arteritis [temporal artery]
3 most common types of Primary headaches?
Migraine , Cluster , Tension
Migraine
common characteristic
repeat attacks has triggers unilateral pulsating visual vertigo motion sickness
Migraine phases
5
Prodrome : Changes in mood, urination, fluid retention, food craving, yawning
Aura (can occur wo) : Visual, sensory, weakness, speech arrest
Headache: pain , nausea, photophobia
Resolution : rest / sleep
Recovery :mood disturbed, food intolerance, feeling hungover - 48 hours or so
Define visual aura
Migraine
Scintillations and blindspots
Treatment for
Acute Migraine attack
NSAIDS: aspirin / ibuprofen
Anti-emetic: metoclopramide [anti nausea]
Vasoconstrictors synergise with NSAIDS
Triptans : ssragonist : triptans work by stimulating serotonin, a neurotransmitter found in the brain, to reduce inflammation and constrict blood vessels, thereby stopping the headache or migraine
Nap
Migraine
long term treatment
dietary, environmental, hormonal, weather, dehydration, stress
Drink 2 litres water/day
Avoid caffeinated drinks
Don’t skip meals. Fresh food. Avoid ready meals & take-aways
Don’t oversleep or have late nights. Electronics downstairs.
Analgesic abuse
Migraine
prophylaxis
over the counter
feverfew coenzyme Q10 riboflavin magnesium EPO nicotinamide
MIgraine treatments prophylaxis
TCA's Beta blockers Serotonin antagonists calcium channel blockers anticonvulsants Suppress ovulation (progesterone only pill or implant/injection greater occipital nerve blocks
Migraine wonder drug?
also for episodic migraine, chronic migraine or cluster headache
Erenumab
CGRP mAbs: targets calcitonin gene related peptide or its receptor
8 a month to 4/5 a month
injectable
Tension type headache
Bilateral
‘Head in a vice’
Nsaids : naproxen , diclofenac
Paracetamol
TCAs
SSRIs - less effective
Cluster
Severe unilateral
15-180 mins
Trigeminal autonomic cephalgia
ipsilateral : Conjunctival redness and/or lacrimation
Nasal congestion and/or rhinorrhoea
Eyelid oedema
restlessness
miosis / ptosis
site of pain most common : EYE , FOREHEAD , TEMPLE
Cluster : headache
Acute
Acute : Inhaled oxygen. Oxygen inhibits neuronal activation in the trigeminocervical complex
S/C or Nasal Sumatriptan
Prophylactic treatment Cluster
what type of drugs is Verapamil?
: steroid example?
drug which inhibits glutamate[nmda downregulations] and upregulates inhibitory NT GABA
increases GABA
blocks voltage-dependent sodium and calcium channels
calcium channel blocker Prednisolone : steroid Lithium Valproate Gabapentin Topiramate Pizotifen
how does erenumab work?
what is it used for?
migraines
monoclonal antibody which blocks calcitonin gene-related peptide
Neck disease Temporal arteritis Benign intracranial hypertension Cerebral tumour Cerebral venous sinus thrombosis
these present as what type of headache?
Dull
temporal arteritis pathophysiology, imaging and treatment?
temporal artery is inflamed
serious and needs clinical attention
straight away ultrasound : see inflamed temporal artery
give HIGH dose steroids [anti-inflammatory]
and aspirin [antiplatelets /avoid clot]
impact posterior ciliary arteries
= causing blindness
migraine drug which
‘blocks serotonin (or 5HT) receptors in the brain. Blocking these receptors stops blood vessels in the brain from dilating and contracting. Pizotifen also blocks histamine receptors in the brain. Histamine is responsible for causing inflammation and widening of blood vessels’
Pizotifen
for cluster headaches
