Headache Flashcards
List patterns of headache.
acute single headache dull headache, increasing in severity dull headache, unchanged over months recurrent headache triggered headache
Possible explanations for dull headache increasing in severity?
usually benign, medication overuse, HRT/contraceptive pill, neck disease, temporal arteritis, benign intracranial hypertension, cerebral tumour, cerebral venous sinus thrombosis
Possible explanations for acute single headache?
febrile illness, sinusitis, 1st attack of migraine, after head injury, subarachnoid haemorrhage, meningitis, tumour, drugs, toxins, stroke, thunderclap
Possible explanations for dull headache unchanged over months?
chronic tension headache
depressive, atypical facial pain
Possible explanations for recurrent headaches?
migraine
cluster headache
episodic tension headache
trigeminal or post herpetic neuralgia
Possible explanations for triggered headaches?
coughing, straining, exertion
coitus
food and drink
What are red flags for headaches?
onset: thunderclap, acute, subacute
meningism: photophobia, phonophobia , stiff neck, vomiting
systemic symptoms, neurological symptoms, orthostatic, strictly unilateral
List examples of focal signs.
double vision Horner syndrome 3rd nerve (oculomotor) palsy
list vascular and circulatory causes of headache
subarachnoid haemorrhage, coiling an aneurysm, acute intracerebral bleed, raised intracranial pressure, papilloedema, carotid and vertebral arteries, chronic subdural haemorrhage, temporal arteritis, cerebral venous thrombosis
list infective causes of headache
herpes simplex encephalitis
meningitis
sinusitis
list causes of headaches involving intracranial pressure
brain tumour
idiopathic
chiari malformation
obstructive sleep apnoea
list facial pain causes of headache
trigeminal neuralgia
atypical facial pain
list traumatic causes of headache
post traumatic headache
management of post traumatic headache
list cervicogenic pain causes of headache
cervical spondylosis
symptoms of subarachnoid haemorrhage
sudden generalised headache, meningism - stiff neck and photophobia
most subarachnoid haemorrhages are caused by?
ruptured aneurysm
some subarachnoid haemorrhages are caused by?
arteriovenous malformations
unexplained
what % of subarachnoid haemorrhages are instantly fatal?
50
what physiological action may stop the leak in a subarachnoid haemorrhage?
vasospasm (sudden constriction of a blood vessel)
list medication used to treat subarachnoid haemorrhage
diazepam (manage mental conditions)
amlodipine (reduce BP)
clonazepam (seizure prevention)
list surgical procedures used to treat subarachnoid haemorrhage
craniotomy
endovascular coiling
why is nimodipine used in subarachnoid follow up treatment?
prevention of problems after a subarachnoid haemorrhage > high risk of further bleed
imaging used in assessment of subarachnoid haemorrhage
CT brain
lumbar puncture (RBC and xanthochromia) and MRA
angiogram
what is aneurysm coiling?
instead of clipping ro wrapping, fill the aneurysm with platinum coils
cause of acute intracerebral bleed?
coning
coning refers to?
the herniation of the brain through the foramen magnum
mechanism of coning
raised intracranial pressure
what is papilloedema?
optic disc swelling due to raised intracranial pressure
headache can arise due to pathology of what large neck arteries?
vertebral
carotid
mean age for carotid/vertebral artery dissection
40
which is more common: carotid or vertebral artery dissection?
carotid
carotid and vertebral artery dissection can be divided into what causative categories?
traumatic
spontaneous
imaging for carotid + vertebral artery dissection
MRI/MRA
Doppler
angiography
treatment for carotid and vertebral artery dissection
aspirin or anticoagulation
epidemiology of temporal arteritis
> 55
3x commoner in females
temporal arteritis presents as?
constant unilateral headache, scalp tenderness, jaw claudication
25% present with polymyalgia rheumatica - proximal muscle tenderness
involvement of the posterior ciliary arteries in temporal arteritis causes?
blindness
what is notable in lab results of temporal arteritis?
elevated ESR and CRP
describe the temporal artery in temporal arteritis
inflamed
tortuous
is the state of the temporal artery visible on ultrasound?
yes
biopsy shows what in temporal arteritis?
inflammation and Giant cells
treatment for temporal arteritis
high dose steroids
aspirin
cerebral venous thrombosis
thrombosis in dural venous sinus or cerebral vein
risk factors for cerebral venous thrombosis
thrombophilia
pregnancy
dehydration
Behcet’s
causes of meningitis
viral, bacterial, tuberculous, fungal, granulomatous, syphilis, carcinomatous
how does meningitis present?
malaise, headache, fever, neck stiffness, photophobia, confusion, alteration of consciousness
herpes simplex encephalitis causes what changes in the brain?
haemorrhagic changes in the temporal lobes
what is the approach for meningitis?
treat then diagnose
treatment for meningitis
antibiotics
investigations for meningitis
blood and urine culture
lumbar puncture: antigens, cytology, bacterial culture
CT or MRI
lab findings for meningitis
increased white cell count
decreased glucose
classic findings on imaging of bacterial meningitis
cerebral oedema with effacement of ventricles and sulci and inflamed meninges
how does sinusitis present?
malaise, headache, fever, blocked nasal passages, loss of vocal resonance, anosmia, nasal or postnasal catarrh, local pain and tenderness
describe the pattern of pain in sinusitis
frontal pain characteristically starts 1-2 hours after rising and clears up during the afternoon
imaging findings in sinusitis
opacification of the paranasal sinus
what is pseudotumor cerebri?
increased pressure inside the skull for an unknown reason
pseudomotor cerebri is also known as?
idiopathic intracranial hypertension
pseudotumor cerebri often presents in what population?
young obese women
pseudotumor cerebri presents as?
Headache, visual obscurations, diplopia, tinnitus
Papilloedema, +/- visual field loss
treatment of pseudotumor cerebri
weight loss, diuretics, optic nerve sheath decompression, lumboperitoneal shunt, stenting of stenosed venous sinuses
what is the cause of low pressure headache?
CSF leak due to tear in dura
low pressure headache occurs in response to?
spontaneous or traumatic post lumbar puncture
treatment for low pressure headache
rehydration
caffeine
blood patch
imaging findings for low pressure headache
meningeal enhancement
what is the chiari malformation?
cerebellar tonsils descend through foramen magnum
when a patient with chiari malformation coughs, what happens?
brain tissue descends further and tugs on the meninges causing cough headache
imaging findings with chiari malformation
normal brain that just sits very low within the skull
risk factors for obstructive sleep apnoea
often characteristic body habitus, history of loud snoring and apnoeic spells
consequences of obstructive sleep apnoea
hypoxia, CO2 retention, non-refreshing sleep, depression, impotence, poor performance at work
diagnosis + treatment of obstructive sleep apnoea
require sleep study
nocturnal NIV, surgery
describe the pain in trigeminal neuralgia
Electric shock like pain in the distribution of a sensory nerve
trigeminal neuralgia is often triggered by?
innocuous stimuli
which divisions of the trigeminal can be affected by neuralgia?
any division
where is the neurovascular conflict in trigeminal neuralgia?
at the point of entry of the nerve into the pons
trigeminal neuralgia can be a symptom
multiple sclerosis
treatment of trigeminal neuralgia
carbamazepine, lamotrigine, gabapentin
posterior fossa decompression
atypical facial pain presents most commonly in what population?
middle aged women
how does atypical facial pain present?
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
for a diagnosis of atypical facial pain, pathology in what must be excluded?
in teeth, temporomandibular joints, eye, nasopharynx and sinuses
atypical facial pain is unresponsive to?
conventional analgesics, opiates and nerve blocks
atypical facial pain is managed by?
tricyclics
post traumatic headache can occur after?
car accidents
sports injuries
treatment of post traumatic headache
NSAIDs - ibuprofen, naproxen
Tricyclic antidepressants - amitriptyline
what is the commonest cause of new headache in older patients?
cervical spondylosis
how does cervical spondylosis present?
usually bilateral, occipital pain can radiate > frontal region, steady pain, no nausea or vomiting, worsened by moving the neck
imaging findings of cervical spondylosis
narrowing of joint space due to worn disc
management of cervical spondylosis
Rest, deep heat, massage.
Anti-inflammatory analgesics.
Over-manipulation may be harmful.
