Headache Flashcards
How common are headaches?
One of the most common symptoms
Symptoms are unpleasant, disabling and common worldwide and have substantial economic impact due to time lost from work
What is a primary headache?
No underlying cause relevant to headache
Migraine, cluster, tension
What is a secondary headache?
A headache with underlying cause
Need to identify underlying cause eg giant cell arteritis
What are the red flags for secondary headache?
HIV/immunosuppressed Fever Thunderclap headache Seizure and new headache Suspected meningitis Suspected encephalitis Red eye - acute glaucoma Headache + new focal neurology eg papilloedema
Give an example of a secondary cause of secondary headache?
Meningitis
SAH
GCA
Medication overuse headache
Name another type of headache
Trigeminal neuralgia
What is a cluster headache?
Most disabling of primary headache disorders
Headache causing excruciating pain around one eye, temple or forehead
How common are cluster headaches?
Distinct from migraines Much rarer than migraines 1 per 1000 More common in men Affects adults between 20-40 Commoner in smokers
What can increase your risk of getting cluster headaches?
Smoker
Male
Autosomal dominant gene has role
What is the pathology of cluster headache?
Unknown
Superficial temporal artery smooth muscle hyper-reactivity to serotonin
Hypothalamic grey matter abnormalities
How do cluster headaches present?
Sudden onset of excruciating pain around on eye, temple or forehead
Ipsilateral cranial autonomic features
- Eye may become watery and bloodshot with lid swelling and lacrimation
- Facial flushing
- Rhinorrhoea
- Miosis +/- ptosis
Pain unilateral and almost always affects same side
Rises to crescendo over minutes lasts 15-160 mins, one/twice per day - usually at same time
Nocturnal/early morning
+/- vomiting
Episodic - clusters last 4-12 weeks and followed by pain-free periods of months or even 1-2 years before next
Can be chronic (last for more than 1 year without remission)
What could be a differential diagnosis of cluster headaches?
Migraine
SAH
How are cluster headaches diagnosed?
Clinical diagnosis
Rule out differentials
At least 5 headache attacks fulfilling above criteria
How can you treat an acute attack of cluster headaches?
Analgesics don’t help
100% 15L for 15mins via non-rebreathable mask
Triptan
How can you prevent cluster headaches?
CCB eg verapamil first line
Avoid alcohol
Corticosteroids can help
What is a migraine?
Recurrent throbbing headache often preceded by aura and associated N&V, and visual changes
What might you get in a migraine aura?
Fortification spectra (zig-zag lines) Shimmering Scotomas (black holes in visual field) Results in pins and needles Dysphasia Weakness of limbs and motor function
How common is migraine?
Most common cause of episodic recurrent headache
More common in women
90% onset before 40
If > 50 then pathology sought
Usually severity decreases with advancing age
What can trigger a migraine?
CHOCOLATE Chocolate Hangovers Orgasms Cheese Oral contraceptives Lie-ins Alcohol Tumult - loud noise Exercise
What might cause a migraine?
Brain chemical imbalance
Changes in brainstem and interactions with trigeminal nerve
What can increase your risk of migraine?
Strong genetic component - FHx
Female
Age - can occur at any age but majority have first migraine in adolescence
What is the pathology of migraine?
Genetic and environmental factors play role
Genetics - neuronal hyper-excitability
Changes in brainstem blood flow lead to unstable trigeminal nerve nucleus and nuclei in basal thalamus
Cortical spreading depression - self-propagating wave of neuronal and glial depolarisation spreading across cerebral cortex thought to cause aura of migraine and leads to release of inflammatory mediators impacting on trigeminal nerve nucleus
Results in release of vasoactive neuropeptides including calcitonin gene related peptide and substance P - results in process of neurogenic inflammation - vasodilation and plasma protein extravasation leading to pain the propagates all over cerebral cortex
What might you get before a migraine and what might it entail?
Prodrome hours/days before - yawning, cravings, mood/sleep changes
Aura
- Visual - chaotic cascading, jumbling, distorting lines, dots, zigzags, scotoma, hemianopia
Somatosensory
- Paraesthesia spreading from fingers to toes
How does a migraine present?
Attacks lasting 4-72 hours Two of the following - Unilateral - Pulsing - Moderate/severe pain - Aggravated by routine physical activity During headache at least one of - Nausea and/or vomiting - Photophobia and phonophobia Not attributable to another disorder
How might a migraine with aura present?
At least 2 attacks
Aura precedes attack by minutes and may persist during it
Unilateral, pulsatile headache
What could be a differential diagnosis of migraine?
Tension headache Cluster headache Medication over-use headache Meningitis/SAH if sudden Thromboembolic TIA Brain tumour Temporal arteritis
How do you diagnose migraine?
Clinical diagnosis
What might you examine to rule out other differentials?
Eyes - papilloedema and other eye issues
BP
Head and neck (scalp, neck muscle and temporal arteries)
What tests might you do to rule out other differentials?
CRP and ESR
MRI/CT if red flags
LP
When would you do an LP?
Worst headache of life
Severe rapid onset headache
Progressive headache
Unresponsive headache
How do you treat migraine?
Reduce triggers Acute - Triptans - NSAIDs - +/- anti-emetic Prevention - Beta-blocker/tricyclic antidepressant/anti-convulsant if > 2 attacks per month or acute treatment required > 2x per week
What are the side effects of triptans?
Arrhythmias
Angina
MI
When are triptans CI?
IHD
Coronary spasm
Uncontrolled high BP
What is a tension headache?
Most chronic daily and recurrent headaches are tension headaches
How common are tension headaches?
Commonest primary headache
Can be episodic < 15 days/month or chronic > 15 days/month for at least 3 months
No organic cause
What can cause tension headaches?
Stress Sleep deprivation Bad posture Hunger Eyestrain Anxiety Noise
How do tension headaches present?
Usually has one of the following - bilateral, pressing/tight non-pulsatile, mild/moderate pain, +/- scalp muscle tenderness No vomiting/sensitivity to head movement No aura Not aggravated by physical activity Tight band-like sensation Pressure behind eyes Last from 30 mins to 7 days Not attributed to another disorder
What could be a differential diagnosis for tension headaches?
Migraine
Cluster
GCA
Drug-induced
How are tension headaches diagnosed?
Clinical
How can you treat tension headaches?
Reassurance and lifestyle advice Stress relief Symptomatic treatment - Aspirin/paracetamol/NSAIDs Limit analgesia to prevent medication overuse
When might you get medication over-use headaches?
Worsens whilst on regular analgesics espec opioids
Other causes are mixed analgesics
What is trigeminal neuralgia?
Chronic, debilitating condition resulting in intense and extreme episodes of pain
What are the branches of the trigeminal nerve?
1 - ophthalmic
2 - maxillary
3 - mandibular
How common is trigeminal neuralgia?
Peak incidence between 50-60 More common in women Prevalence increases with age May be due to genetic predisposition Almost always unilateral
What is the cause of trigeminal neuralgia?
Compression of trigeminal nerve by a loop of vein or artery
Local pathology - aneurysms, meningeal inflammation, tumours eg vestibular schwannoma - local pathology more common in younger people as cause of compression
5th nerve lesion due to pathology
- With brainstem - tumour, multiple sclerosis, infarction
- At cerebellopontine angle - acoustic neuroma, another tumour
- Within petrous bone - spreading middle ear infection
- Within cavernous sinus - aneurysm of internal carotid, tumour or thrombosis of cavernous sinus
What can increase your risk of trigeminal neuralgia?
Hypertension
Triggers - washing affected area, shaving, eating, talking, dental prothesis
What happens when the nerve is compressed in trigeminal neuralgia?
Demyelination and excitation of nerve resulting in erratic pain signalling
How does trigeminal neuralgia present?
Almost always unilateral
At least 3 attacks of unilateral facial pain
Facial pain occurring in one or more distribution of trigeminal nerve, with no radiation beyond trigeminal distribution
Pain has at least 3 of the following
- Reoccurring in paroxysmal (sudden and frequent) attacks from a fraction of a second to 2 minutes
- Severe intensity
- Electric shock like, shooting, stabbing, or knife-like
- Precipitated by innocuous stimuli by affected side of face eg washing or shaving
What are the differential diagnoses of trigeminal neuralgia?
GCA/temporal arteritis Dental pathology Temporomandibular joint dysfunction Migraine Cluster headaches
What is the diagnosis of trigeminal neuralgia?
Needs to be at least 3 attacks with unilateral facial pain
Clinical diagnosis based on above criteria and based on history
MRI to exclude secondary causes or other pathologies
Not attributed to another disorder
What is the treatment of trigeminal neuralgia?
Typical analgesics and opioids don’t work
Anticonvulstants eg oral carbamazepine
Less effective - phenytoin, gabapentin, lamotrigine
May spontaneously remit after 6-12 months
If drugs fail then surgery
- Microvascular decompression - anomalous vessels separated from trigeminal root
- Gamma knife surgery - directly at trigeminal nerve ganglion or nerve root
- Stereotactic radiosurgery
What can cause temporal arteritis?
Giant cell arteritis
What is giant cell arteritis?
Inflammatory granulomatous arteritis of large cerebral arteries as well as other large vessels
How common is GCA?
Primarily in those over 50
Incidence increases with age
More common in women
What can increase your risk of GCA?
Over 50
Female
RA, SLE, scleroderma
What is the pathology of GCA?
Arteries become inflamed, thickened and can obstruct blood flow
What arteries are most likely to be affected in GCA?
Cerebral arteries
- Temporal artery
- Ophthalmic artery
How does GCA present?
Severe headaches (temporal pulsating) Tenderness of scalp or temple Claudication of jaw when eating Tenderness and swelling of one or more temporal or occipital arteries Sudden painless vision loss - emergency Malaise Lethargy Fever Dyspnoea Morning stiffness Unequal or weak pulses
What could be a differential diagnosis of GCA?
Migraine
Tension headache
Trigeminal neuralgia
Polyarteritis nodosa
How do you diagnose GCA?
3 or more of - Over 50 - New headache - Temporal artery tenderness/decreased pulsation - ESR raised - Abnormal artery biopsy - inflammation infiltrates present Normochromic, normocytic anaemia Raised ESR ANCA very high CRP very high Serum alkaline phosphatase raised Temporal artery biopsy
How do you treat GCA?
High dose steroid - prednisolone to prevent vision loss - gradual reduction of steroids over 12-18 months
Used long term so GI and bone protection
Monitor treatment by ESR/CRP
What can cause raised intracranial pressure?
Bleeds Tumour Stroke - oedema/haematoma Aneurysm Hypertension Brain infection Idiopathic intracranial hypertension Meningitis or encephalitis Abnormal blood vessel - arteriovenous fistula or arteriovenous malformation Venous sinus thrombosis Chiari malformation Vasculitis
How does raised intracranial pressure present?
Headache Blurred or temporary loss of vision Feeling less alert than usual N&V Fatigue Irritability Changes in behaviour Weakness/problems with moving or talking Present on waking - worse in morning, may improve on standing up Made worse by coughing, sneezing, straining Papilloedema
How is raise ICP diagnosed?
Neuroimaging - to rule out mass lesions, venous sinus thrombosis, hydrocephalus
LP - measure opening pressure
How do you treat raised ICP?
Treat underlying cause
Diuretics
Carbonic anhydrase inhibitors - acetazolamide (reduces CSF production)
LP
Surgery - shunts, protection of optic nerve
What is idiopathic intracranial hypertension?
Build up of pressure around brain that is attributed to no other cause
What can increase your risk of getting IIH?
Young, overweight, female Polycystic ovary disease Cushing's Hypoparathyroidism Hypo/hyperthyroidism Medications - some antibiotics, steroids, combined OCP Iron deficiency anaemia Polycythaemia Lupus
What causes IIH?
Reduced CSF resorption
How does IIH present?
Headaches Transient visual obscuration due to papilloedema 6th nerve palsy CSF pressure elevated Brain imaging normal
What must you do when someone presents with symptoms of raised ICP?
Look at eyes
CT/MRI
THEN LP
How is IIH diagnosed?
Rule out other differentials
How can you treat IIH?
Weight loss
Stop medications causing symptoms
Diuretics
Carbonic anhydrase inhibitors eg acetazolamide
Short course steroids
Regular LP
Surgery - shunts, protection of optic nerve
What is hydrocephalus?
Build up of fluid in brain causing extra pressure to be exerted on brain which can cause damage
What is normal pressure hydrocephalus?
Triad of symptoms
- Difficulty walking
- Urinary frequency urgency, incontinence
- Mental slowing (mild dementia)
What can cause hydrocephalus?
Haemorrhage Thrombosis Meningitis (particularly TB) Brain tumours - posterior fossa and brainstem obstructing aqueduct or 4th ventricle outflow Head injury Stroke Idiopathic 3rd ventricle colloid cyst Choroid plexus papilloma - rare but secretes CSF
How does hydrocephalus present?
Headache Neck pain N&V Sleepiness - can progress to coma Changes in mental state such as confusion Blurred or double vision Difficulty walking Urinary and bowel incontinence Ataxia
How can you diagnose hydrocephalus?
CT/MRI Assessment of gait/mental ability LP Lumbar drainage test Lumbar infusion test
How is hydrocephalus treated?
Shunt surgery
Endoscopic third ventriculostomy
What is meningitis?
Inflammation of the meninges of the brain
Often implies infection
How common is meningitis?
Occurs in people of all age groups but more common in infants, young children, and the elderly
Meningococcal disease is a notifiable disease
What are the main causes of meningitis in adults and children?
Neisseria meningitides - gram negative diplococci - droplet spread
Strep pneumoniae or pneumococcus
Less common - H influenzae due to vaccine
What is the main cause of meningitis in pregnant women/older adults?
Listeria monocytogenes - found in cheese
What are the most common causes of meningitis in neonates?
E coli
Group B haemolytic strep eg streptococcus agalacticae
What is the most common cause of meningitis in the immunocompromised?
Cytomegalovirus Cryptococcus neoformans (fungi) TB HIV HSV
What bacteria can cause meningitis?
Neisseria meningitides Strep pneumoniae Strep aureus Group B strep Listeria monocytogenes Gram negative bacilli eg E coli TB Teponema pallidum
What viruses can cause meningitis?
Enterovirus - ECHO, coxsackie Mumps HSV HIV EBV
What fungi can cause meningitis?
Cryptococcus neoformans
Candida albicans
What are the non-infective causes of meningitis?
Malignant meningitis
Intrathecal drugs
Blood following SAH
What can increase your risk of getting meningitis?
Intrathecal drug administration Immunocompromised Elderly Pregnant Bacterial endocarditis Crowding eg military base, university students Diabetes Malignancy IVDU
How can microorganisms reach the meninges?
Direct extension - from ears, nasopharynx, cranial injury, congenital meningeal defect
Bloodstream
How do you get meningococcal septicaemia?
Bacteria invade into blood
Presence of endotoxin on bacteria leads to inflammatory cascade
Petechial rash + signs of sepsis
What does the pia arachnoid look like?
Congested with polymorphs (neutrophils)
Layer of pus forms which may organise to form adhesions leading to cranial nerve palsies and hydrocephalus
What does chronic meningitis with TB look like?
Brain covered in viscous grey-green exudate with numerous meningeal tubercles
What does viral meningitis look like?
Predominantly lymphocytic inflammatory CSF reaction without pus formation
Little or no cerebral oedema unless encephalitis develops
What is the triad of symptoms of meningitis?
Headache
Neck stiffness
Fever
What is the clinical presentation of acute bacterial infection causing meningitis?
Onset sudden
Papilloedema usually bilateral can occur over hours to weeks due to raised ICP
Intense malaise, fever, rigors, severe headache, photophobia, vomiting
Irritable and preferring to lie still
Neck stiffness, positive Kernig’s and Brundzinski’s sign
Septicaemia - non-blanching petechial and purpuric skin rash
Altered mental state and GCS
Seizures and focal CVS signs
Progressive drowsiness, materialising signs and cranial nerve lesions indicated complications
What complications can you get in meningitis?
Venous sinus thrombosis Severe cerebral oedema Cerebral abscess Hearing loss Seizures Developmental problems
What is viral meningitis?
Benign self-limiting condition lasting 4-10 days
Headache may follow for some months
What can cause chronic meningitis and what are the symptoms?
TB
Long history of vague symptoms - headache, anorexia, vomiting
Signs of meningeal triad often absent/late
What could be a differential diagnosis for meningitis?
Aseptic meningitis (due to tumour)
SAH
Encephalitis
How do you diagnosed meningitis?
Blood cultures before LP Bloods - FBC, U&E, CRP, glucose LP - if unable to perform within 30 mins give empirical antibiotics - Send for microscopy and sensitivity CT head - exclude lesions Throat swabs Pneumococcal and meningococcal serum PCR Don't do LP with non-blanching rash
What would the LP for bacterial meningitis look like?
Neutrophils, raised protein, low glucose, turbid colour
What would the LP for viral meningitis look like?
Lymphocytes, normal protein and glucose
What would the LP for TB meningitis look like?
Lymphocytes, raised protein, low/normal glucose
What are the indications for CT before LP in suspected meningitis?
Age > 60 Immunocompromised Hx of CNS disease New onset/recent seizures Decreased conscious level Focal neurological signs Papilloedema
How do you treat meningitis?
If suspect bacterial start antibiotics before tests come back
IV benzylpenicillin/cefotaxime if septicaemia
IV cefotaxime/ceftriaxone - 3rd gen cephalosporins
IV chloramphenicol if severe anaphylaxis to penicillin
Over 50/immunocompromised - add IV amoxicillin to treat listeria
Consider steroids to reduce cerebral oedema
IV vancomycin if recently travelled
What prophylaxis do you give to contacts?
Oral ciprofloxacin stat
Oral rifampicin - can’t give to pregnant women
What is encephalitis?
Infection and inflammation of brain parenchyma
How common is encephalitis?
Most frequent in children and elderly - mainly viral cause
More common in immunocompromised
What are the viral causes of encephalitis?
HSV 1 and 2 Varicella zoster EBV Cytomegalovirus HIV Mumps Measles Enteroviruses Adenoviruses
What are the non-viral causes of encephalitis?
Bacterial meningitis
TB
Malaria
What are the causes of autoimmune encephalitis?
Paraneoplastic limbic encephalitis
Voltage-gated potassium channel limbic encephalitis
Anti-NMDA receptor anti-body encephalitis
What can increase your risk of encephalitis?
Extremes of age
Immunocompromised
What is the pathology of encephalitis?
Disease mostly affecting the frontal and temporal lobes resulting in decreased consciousness, confusion, and focal signs
How does encephalitis present?
Whole brain affected - problems with consciousness
Insidious onset over days or can be abrupt
Triad - fever, headache, altered mental status
Begins with features of viral infection - fever, headaches, myalgia, fatigue, nausea
Progresses to personality and behavioural changes, decreased consciousness, drowsiness and confusion
Focal neurological deficit - hemiparesis, dysphasia, seizures, raised ICP, midline shifting = coning, coma
Hx of travel and/or animal bites
What are the differentials of encephalitis?
Meningitis
Stroke
Tumour
What investigations should you do in suspected encephalitis?
MRI - areas of inflammation and swelling, generally in temporal lobes in HSV encephalitis, midline shifting
EEG - period sharp and slow wave complexes
LP - high lymphocytes, PCR
Blood and CSF serology
How is encephalitis treated?
If viral - acyclovir before investigation results 10mg/kg TDS for 14-21 days
Early treatment can reduce mortality and long term damage
Anti-seizure medication eg primidone
What are the complications of encephalitis?
Memory impairment
Personality change
Epilepsy
What are the symptoms of limbic encephalitis?
Facio-branchial dystonic seizures, confusion, agitation, hyponatraemia
What is paraneoplastic limbic encephalitis?
Seen with small cell lung cancer and testicular tumours
Associated with variety of antibodies inclu anti-Hu and anti-Ma2
MRI - high hippocampal signal
Precedes diagnosis of cancer in most cases and should prompt investigations
What is voltage-gated potassium channel limbic encephalitis?
Produce a variety of disorders Usually occurs in patients over 50 Can be associated with thymoma (v rare) Treatment - high dose steroids Neuromyotoninand peripheral nerve hyperexcitability syndromes seen with antibodies to VGKC
What is anti-NMDA receptor antibody encephalitis?
Limbic encephalitis followed by coma and status epilepticus
Orofacial dyskinesias characteristic
Patients usually younger and most have teratomas eg ovarian
May respond to immunotherapy - IV Ig or plasma exchange initially, followed by steroids, rituximab or cyclophosphamide
