Headache Flashcards
What are differentials for an acute, single headache?
- febrile illness, sinusitis
- 1st attack of migraine
- following head injury
- subarachnoid haemorrhage
- meningitis
- tumour
- drugs, toxins
- stroke
- thunderclap
- low pressure
What are red flags with headaches?
- acute, subacute, thunderclap onset
- photophobia, phonophobia, stiff neck, vomiting–> meningism
- fever, rash, weight loss
- visual loss, confusion, seizures, hemiparesis, double vision, 3rd nerve palsy, Horner syndrome,
- unilateral
- orthostatic= better lying down headaches
How does a subarachnoid haemorrhage present?
- sudden generalised headache ‘blow to head’
- often occipital
- meningism- stiff neck and photophobia
- most caused by ruptured aneurysm
- v fatal
- nimodipine to prevent vasospasm and bp control
- CT brain, MR angiogram
What is coning?
- when the brain slides through the foramen magnum- squeezed out of skull
- due to raised intracranial pressure
What is papilloedema?
optic disc swelling due to raised intracranial pressure
Where might a headache be if a patient has a vertebral artery dissection?
occipital headache
Where might a headache be if a patient has a carotid artery dissection?
pain around eye/forehead ‘phantom of the opera’
How do you treat a carotid or vertebral artery dissection?
aspirin or anticoagulation
bc turbulent flow–>clots–>stroke
What is temporal arteritis?
- most common in females >55
- constant unilateral headache
- scalp tenderness and jaw claudication
- 1/4 have shoulder muscle pain
- involvement of posterior ciliary arteries causes blindness
- inc. ESR + CRP
- temporal artery inflamed and tortuous
- visible of US and biopsy shows inflammation and giant cells
- give steroids and aspirin
What is cerebral venous thrombosis?
- thrombosis in dural venous sinus or cerebral vein
- unusual amount of headache bc raised ICP
- venous infarcts, haemorrhage
- risk factors: thrombophilia, pregnancy, dehydration
How does meningitis present?
- malaise
- headache
- fever
- neck stiffness
- photophobia
- confusion
- alteration of consciousness
How does sinusitis present?
- malaise
- headache
- fever
- blocked nasal passages
- anosmia
- loss of vocal resonance
- nasal or postnasal catarrh
- local pain and tenderness
- periodic pain
What is idiopathic intracranial hypertension?
- psuedotumor cerebri
- often young obese women
- headache, visual obscurations, diplopia, tinnitus
- papilloedema +- visual field loss
- lose weight!
- diuretics, opti nerve sheath decompression, lumboperitoneal shunt, stunting of stenosed venous sinuses
What is a low pressure headache?
- CSF leak due to tear in dura
- traumatic post lumbar puncture or spontaneous
- pressure drops when stand up
- rehydration, caffeine, blood patch
What is a chiari malformation?
normal brain that sits very low in skull- descends further when you cough, tugging on meninges–> pain
Why does obstructive sleep apnoea cause a headache?
they retain CO2
What is atypical facial pain?
- most commonly in middle aged women
- depressed or anxious
- poorly localised eep aching or burning pain
- facial or jaw bones
- no sensory loss
- treat w/opiates, nerve blocks and tricyclic antidepressants
What is cervical spondylosis?
- commonest cause of new headache in older patients
- usually bilateral pain, occipital but can radiate
- steady pain, worse by moving neck
- no nausea or vomiting
- rest, deep heat, massage, anti-inflammatory analgesic
- over manipulation can be harmful
What is migraine disorder?
- repeated attacks
- triggers
- easily hungover
- visual vertigo
- motion sickness
- pain and/or focal symptoms
What is a prodrome?
changes in mood, urination, fluid retention, excessive yawning, food craving
What is an aura?
- weakness, speech arrest, visual/sensory
- +ve and -ve symptoms e.g. scintillations and blindspot
How do you treat an acute migraine attack?
- aspirin/ibuprofen and paracetamol
- metoclopramide (anti-emetic)
- soluble preparations to aid absorption
- triptans for the headaches
- treat headache hard and fast
- caution opiates!
- a short nap
- TMS interrupts spread of electrical depression across cerebral cortex
What is migraine prophylaxis?
- over counter e.g. magnesium, riboflavin
- serotonin antagonists e.g. methysergide
- CCBs
- anticonvulsants
- TCAs
- beta-blockers
- botox
- greater occipital nerve blocks
- suppress ovulation
- erenumab= injectable monoclonal antibody
What is tension headache?
- tight muscles around head and neck bilaterally
- NSAIDs
- paracetamol
- TCAs
- relaxation
What is cluster headache?
- more common in men
- severe unilateral pain lasting 15-180mins untreated
- trigeminal autonomic cephalgia
- conjunctival redness/lacrimation, nasal congestion, eyelid oedema
- forehead/facial sweating
- miosis and/or ptosis
- restlessness/agitation
- 1-3 attacks daily, often at night
- nausea rare
How do you treat cluster headaches?
- inhaled oxygen- inhibits neuronal activation
- nasal sumatriptan
- prevention: prednisolone, lithium, valproate, verapamil…
