Headache and dizziness Flashcards
Overview of secondary h/a
Meningitis - nuchal, fever, septic
SAH - sudden onset, nuchal
Mass lesions - neoplasm, subdural or epidural, abscess
Acute hydrocephalus, intracranial HTN, hypertensive enceph
Vascular - arteritis, venous sinus thrombosis
Metabolic - hypoxia, hypercapnea, anemia, chronic CO
Cervical - cord compression, occip neuralgia, arterial dissection
- referred pain from periosteum, ligaments, muscle spasm
- r/o compression with MRI, CT, lateral XR if trauma or s/sx
Extracranial - sinusitis, TMJ, glaucoma (narrow-angle -> behind eye), uveitis, dental
Root causes of h/a
Sensitive structures
- arteries - meningeal, proximal cerebral
- venous sinuses
- dura - esp basal
- CN 5, 7, 9, 10, cervical nerves 1-3
Mechanisms
- distortion of dura or arteries - localized mass (vs ICP pressure)
- traction on sinuses dt low pressure (CSF leak)
- distention of vessels - trigeminal nerve, occlusion -> colateral, migraine?
- inflammation of meninges -> vessels - infection, hemorrhage, chemical, autoimmune, migraine
- referral to somatic - lateral correct but local not reliable
- above tentorium -> dura -> trigeminal -> eye, forehead
- posterior fossa -> dura -> CN 9,10,cerv1-3 -> ear, posterior (can have eye in 50% dt posterior root of SN1 -> trigeminal)
- CN 5, 7, 9, 10 -> ear
Warning signs of dangerous h/a
- head, neck trauma
- seizure
- focal sx, abnormal neuro exam, lethargy, confusion
- fever, predisposing infection
- diastolic BP >120
- normal fundi
- neck supple
- no carotid bruits
suspicion
- precise, constant location
- ancillary sx other than n/v, photophob, phonophob
- sudden onset, new
- no return to baseline in between
May need CBC, ESR, imaging, neck XR to r/o
Subarachnoid hemorrhage
Sudden, severe onset - “thunderclap”, “worst of my life”
+/- focal, n/v, unwell appearance, nuchal rigidity
Can lead to hydrocephalus, seizures, vasospasm (-> focal loss)
Ddx inc venous sinus thrombosis
CT scan first
LP - RBCs or yellow xanthochromia
Most often burst aneurysm (ex congenital berry)
Meningitis
Fever, septic appearance, nuchal rigidity
Fewer s/sx in elderly, child, immune compromised
Dx with LP
Intracerebral masses
Neoplasm
- Often mild, dull
- Worse in morning or with vigorous head shaking (-> focal)
- Work up if focal s/sx, seizures or ICP (otherwise can dismiss)
Abscess - focal or mental + ICP
- ?source - ear, bronchiectasis
- ?susceptible - R->L shunt, immune suppression
Intracerebral hemorrhage
Usu trauma, HTN or coagulopathy
Focal s/sx
Epidural - acute trauma
Subdural - delayed weeks to months -> h/a
- increasing or lateralized
(vs post-concussion weeks to months, +dizzy, vertigo, mental)
Benign intracranial HTN
aka pseudotumor cerebri
Young, female, estrogen (PCOS, exogenous), Vit A tox, tetracycline
Diminished resorption of CSF -> ICP
-> papilledema
-> CN 6 palsy (abduction)
- no imaging lesions (+/- small ventricles)
Optic nerve damage -> blind spot -> constricting -> hemorrhage
- optic nerve sheath fenestration
Management - carbonic anhydrase inhibitor (acetazolamide), serial LPs, shunt, weight loss
Acute hydrocephalus
Obstruction of CSF (inflammation, blood, tumor)
- > confusion, lethargy, ataxia, incontinence
- papilledema if acute or severe
Giant cell arteritis
Systemic -> temporal, cranial
- polymyalgia rheumatica - malaise, fatigue, proximal myalgia and arthralgia
- non-specific h/a - +/- tender at temporal, occipital (but poor sensitive)
- arterial insufficiency
- vertebral -> brainstem, cerebellum, occipital
- external carotid -> jaw claudication, infarct of tongue, scalp
- internal carotid -> retinal ischemia, blind, CVA
Rare < 50 yo
ESR super high -> biopsy (b/l, >1” -> serial sections)
Steroids - can trial before dx
Similar with systemic - ex SLE
Hypertensive encephalopathy
Failure of autoregulation -> dilation of vessels
- > edema, hemorrhage
- retinal - papilledema, hemorrhage
- often with renal
High (DBP>120) or sudden rise in prev normotensive
- pheochromocytoma
- tyrosine + MAOI
- pre-eclampsia
PRES - posterior reversible encephalopathy syndrome
- localized to PCA/occip in acute rise -> edema, visual s/sx
Venous sinus thrombosis
Hypercoag (estrogen, peripartum), inc osmolarity (dehydration)
- > sinus stretch + ICP - most often sagittal
- dec mental, seizures
- intraparenchymal petechial hemorrhages
Often missed diagnosis with sudden or recurrent h/a’s
Cranial neuralgias
Classic - shooting, unilateral, provoked by movement (trigger point), par/hypesthesia -> refractory period
- may be b/l, dull, constant
- improves with nerve block, gabapentin, carbamaz, sx (transection or decomprssion)
- traumatic or structural
Trigeminal (“tic douloureux”) - usually 2nd, 3rd divisions, elderly
- no sensory loss (indicates structural lesion)
- r/o dental, malocclusion, MS (demyelin in spinal tract or root)
Greater occipital - C1-2 -> musculature
Glossopharyngeal - throat, ear, neck with swallowing
Arterial dissection
Neck pain + radiation to head - acute, localized - does not improve with rest \+/- trauma \+/- ischemic s/sx
May be difficult to diagnose!
Migraine presentation
Episodic - exact onset -> hours-3d, can have prodrome
- rare >1 wk (status migrainosus)
Severe, throbbing, usu unilateral
n/v/anorexia/diarrhea
Photophobia, phonophobia, worse w/ physical activity, strong smells
- resting with lights out, better after sleep
Onset child or adolescent - hx motion sickness, cyclic vomiting, fam hx
Aura - separate slide - usually missing
Triggers - stress, sleep, schedule,
- food (EtOH, nitrate, cheese, chocolate)
- menses, OCP
- allergies
- strong smell, light (glare, flickering)
Migraine aura
Can occur without h/a (elderly, “acephalgic”, “migraine equivalent”)
Slowly spreading excitation -> depression (3 mm/minute)
- usu improves (first in initial location)
- can persist in elderly (= infarction)
- vs TIA/CVA sudden, immediate involvement, vascular distribution, negative/ablative sx (numb, heavy)
Visual - scintillating scotoma (blind + shimmering), negative scotoma (blurring), photopsia (bright spots), fortification spectra (jagged lines), wavy lines
- often homonymous -> march (10-60 min)
Somatosensory - often paresthesias
Aphasia
Other - weakness, emotional, perception (micropsia, macropsia), olfact
- basilar -> diploplia, vertigo, coma
- ophthalmoplegia - CN3, 6 - can persist weeks (compression?)
Familial hemiplegic migraine
Onset early childhood, strong family hx
- lower threshold for spreading cortical depression
Type 1 - chrom 19 -> CACNA1A = Ca channel
Type 2 - chrom 1 -> ATP1A2 = Na/K pump
Type 3 - chrom 2 -> SCN1A = voltage Na channel
H/a -> sensory and weakness at peak -> outlast h/a (hours -> days)
- can have hemiplegia
- arterial spasm
Can be permanent = infarct on CT, MRI
Similar opthalmoplegic
Migraine pathophys and tx
Cortical spreading depression -> activation of nervi vasorum -> inflammatory (CGRP, substance P, neurokinin A) -> trigeminal -> trigeminal nucleus caudalis -> vasodilation and sx’s
- improved with vasoconstrictors, compression of temporal or carotid
- serotonin inc at onset -> depletion
Avoid triggers
Acute meds
- serotonin agonists - ergotamine, triptan -> trigeminal -> dec CGRP, substance P -> vasoconstriction
- most effective early
- lose effectiveness, rebound h/a - best for infrequent
Prophylaxis - beta block, Ca channel block
- TCA, anticonvulsant
- consider if frequent, severe, debilitating
Consider arterio-venous malform if persistent and unilateral (with only contralateral aura)
Cluster headaches
Rare but very severe
More common men (vs migraines)
Brief (15’-3h)
Daily (1-2x) - same time (often night) x weeks-months (“cluster”)
Agitated, pacing
Autonomic - tearing, congest, ipsilateral Horner’s, miosis (may persist)
No aura
Inc histamine? Overactive caudal hypothal? No change serotonin
Tx - 100% O2, ergotamine, triptans
- prophylaxis - Ca block, anticonvulsants
Tension headaches
Stress -> hyperactive musculature -> mild, fronto or cervical, b/l
- rare n/v, photo/phonophob, not worse with activity (keep working)
Can progress to or from migraine
Tx - relaxation - biofeedback, benzo, massage, PT, tricyclics?
- prophylaxis if severe (sim to migraine)
Avoid regular analgesic -> rebound, resistance
Indomethacin-sensitive headaches
Classified by response to indometh vs NSAIDs
Trigeminal autonomic cephalagia - unilateral + autonomic
- ex SUNCT - short-lasting, unilateral, neuralgiform + conjunctival injection and tearing
- middle aged men - seconds to minutes but recur frequently
- paroxysmal hemicrania - longer (2-45 min), women
- hemicrania continua - fluctuates throughout day, worse with activity
Worse with Valsalva
“Ice pick” - sharp stabbing/localized, short duration
Psych headaches
Severe depression, psychopathology -> intractable, debilitating, constant - no apparent cause Often resistant to all tx (even narcs!) High hx childhood abuse
Tx psych, antidepressants
Analgesic rebound h/a
Chronic migraine or tension -> dependence
-> bifrontal withdrawal (often morning)
OTC, narcotics, barbs, benzos, caffeine
Tx - education and withdrawal x weeks
- may require inpatient for acute phase
Overview of non-vertigo dizziness
Presyncope = diffuse ischemia - “light-headed”
- arrhythmia -> Holter or event monitor
- outflow obstruction, low output -> ECG
- autonomic failure - polyneuropathy, Parkinsons, meds
- vasovagal - brady with specific stress -> tilt-table
- migraine, hypervent -> vasoconstric
Disequilibrium - worse uneven ground, without vision (dark, shower), better with stable object
- usu multisensory - proprioception, vestibular
- ex idiopathic sensory loss in elderly
- improves with cane, walker
- r/o Parkinsons, cerebellar -> can’t respond to stimuli
Psych, anxiety - “floating”
Central vertigo
Usu less severe (nystagmus > sensation of movement)
Nystagmus - multi-directional, vertical
No hearing loss
Vestibulocerebellum or caudal brainstem
Cerebrovascular - CVA, TIA
MS - demyelination
Chiari malformation - lower cerebellum protrudes through foramen mag
-> occipital h/a + downbeat nystagmus (craniocervical junction)
Migraine aura
Peripheral vertigo overview
Inner ear or vestibulocochlear nerve (pre-nucleus)
Nystagmus - rotary or horizontal (lesion opposite fast phase)
- corresponds to severity of sensation
+/- hearing loss, tinnitus, n/v, veer while walking
No other CNS lesions - incoordination, diplopia, EOM, sensation, weak
Often in “attacks”
Without precipitation - labyrinthitis, neuroma
Movement - benign positional (otolith), cervicogenic, vertebrobasilar insufficiency
Noise - Meniere’s, perilymph fistula
Pressure (Valsalva, plane) - perilymph fistula
Hearing loss - Menierre’s, fistula, neuroma
Trauma - benign, fistula, cervicogenic
- labyrinthine concussion - direct hair cells -> gradual improvement
- vertebral artery dissection -> brain stem or cerebellar stroke
- post-concussion syndrome - instability of vessel regulation
Toxins - drugs, meds
Benign positional vertigo
Peripheral, worse with movement - most common cause
- reproduce Hall-Pike or Nylan-Barany
Otoliths (Ca carbonate crystals) - spontaneous (elderly) or post-trauma
Look up or bend down -> sudden onset (several seconds) -> 15-60s
Tx - dissolve spontaneously (weeks -> months)
- “otolith repositioning maneuver”
Neck-related vertigo
Cervicogenic - movement or sustained positions
- pain, reduced ROM
- sudden on/off sx’s with position
- often post trauma - ex whiplash
Vertebro-basilar insufficiency
- rotation -> constriction -> 5-15 s -> gradual ischemia and sx
- must investigate post circulation
Meniere’s syndrome vertigo
Diminished resorption of endolymph -> inc pressure -> small ruptures of membranes -> pressure gradient, mix endo/perilymph -> signalling
Precipitated by loud noises
Last 30 min -> several hours (gradient re-established)
Recurrent -> hair cell damage
- dec auditory to low tones
- low tinnitus (hum, buzz)
Ddx perilymph fistula, neuroma
Perilymph fistula
Leak bet middle and inner ear (inner ear or round window)
- post trauma or barotrauma
Leakage/attacks with pressure changes (Valsalva, altitude)
+/- Hennebert’s sign - precipitate with otoscope insufflation
Chronic damage to hair cells -> hearing loss
Labyrinthitis
aka vestibular neuronitis
Common cause of peripheral vertigo
Prodrome of viral or assoc URI, can be idiopathic
Sudden onset -> several weeks
- not acutely worse with movement, noise, etc
