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)
