Headache I Flashcards
What is a headache?
What are the 3 categorical causes for headaches?
A symptom - a common symptom
Structural, Pharmacological, Psychological
What are the 5 different headache pattern categories?
Acute single headache Dull headache that increases in severity over time Dull headache, unchanged over months Recurrent headaches Triggered headaches
What are some possible causes of each of the headache categories?
Acute single headache Dull headache that increases in severity over time Dull headache, unchanged over months Recurrent headaches Triggered headaches
Acute single headache - sinusitis, migraine, following a head injury, subarachnoid haemorrhage, meningitis, tumour, dugs, toxins, stroke, low BP
Dull headache that increases in severity over time - usually benign, overuse of medication, OCP, HRT, neck disease, temporal arteritis, benign intracranial hypertension, cerebral tumour, cerebral venous sinus thrombosis
Dull headache, unchanged over months - chronic tension headache, depressive, atypical facial pain
Recurrent headaches - migraine, cluster headache, episodic tension headache
Triggered headaches - coughing, straining, exertion, coitus, food and drink
What are some red flags for headaches?
Onset - thunderclap (like they have been hit on the head), acute. subacute
Meningism (linings of the brain are irritated) - photophobia, stiff neck, vomiting
Systemic symptoms - fever, rash, losing weight
Neurological symptoms or focal signs - visual loss, confusion, seizures, double vision, CN III palsy, Horner’s syndrome
Orthostatic - better lying down
Strictly unilateral - same headache pain in exactly the same spot
What are some focal signs that can come with headaches?
Double Vision
Oculomotor palsy
Horner’s syndrome - damage to sympathetic nerves of the face = droopy eyelid and no sweating of the face
What are the headache symptoms of a subarachnoid haemorrhage?
What are subarachnoid haemorrhages usually caused by?
Sudden generalised headache - like they have been hit on the head
Develop meningism - stiff neck and photophobia
Most caused by ruptured aneurysms, some due to arteriovenous malformations, some unexplained
How are subarachnoid haemorrhages treated?
Around 50% fatal so:
Vasospasm may stop the leak
Nimodipine and BP control
High risk of a further bleed
Early neurosurgical assessment will confirm the bleed
and establish the cause
CT brain (to find bleed), Lumbar puncture (spinal fluid = contain blood) and angiogram (blood may obscure aneurysm on CT scan)
Aneurysm found and platinum coil fed up the vessels in the groin, to the cerebral arteries, and platinum coil is used to plug the aneurysm to prevent it from being filled with blood again
What is the issue with raised intracranial pressure (ICP)?
How does it lead to death?
Skull = fixed
Bleed takes up space
Brain can only tolerate up to a certain volume, before the pressure begin to increase exponentially
Brain gets pushed against areas of weakness e.g. brain squeezed out of the skull via foramen magnum
Brainstem = squashed = loss of blood supply = death (as brainstem is responsible for control of breathing, HR etc.)
How can a headache arise die to pathologies in the large arteries of the neck e.g. carotid artery, vertebral artery etc.
Carotid and vertebral arteries made up of many layers of tissue
Layers of tissue may split - blood collects in the split
Results in turbulent flow in the tube
Vertebral = pain back of neck and occipital lobe
Carotid = pain side of neck and front of head
How are pathologies in the neck arteries diagnosed?
How are these treated and why??
Diagnosed via - MRI, MR angiogram, ultrasound scan of the blood vessel to look for turbulent flow, doppler (dye injection to look at vessel)
Turbulent flow = sticky blood = easily clotting blood, therefore:
treated with: aspirin, anti-coagulation (prevention of stroke)
What is a chronic subdural haemorrhage?
How it is treated?
Collection of blood on the brain’s surface, under the dura
Forms after several days or weeks after bleeding starts
Shows up black on the MRI - old / rotting blood
(White = fresh blood)
Drill a hole into the skull and drain the blood
What is Temporal Arteritis?
How does it present clinically?
Most common in females aged over 55 - inflammation of arteries in the head and neck e.g. temporal artery (involvement of posterior ciliary arteries = blindness)
Constant unilateral headache, scalp tenderness, pain in the jaw when chewing (claudication), some shoulder muscle tenderness
How is Temporal Arteritis diagnosed?
Blood test - elevated ESR (erythrocyte sedimentation rate) and CRP
Temporal artery inflamed and torturous (lost their pulse)
Visible on ultrasound (halos seen around the arteries)
Biopsy - shows inflammation (disruption of the internal elastic lamina) and giant cells (many nuclei)
How is Temporal Arteritis treated?
Steroids - anti-inflammatory
Aspirin - prevents stroke
Course of 3-4 years
What is Cerebral Venous Thrombosis (CVT)?
How does it present clinically?
Thrombosis in dural venous sinus or cerebral vein
Unusual amount of headache due to raised ICP
Vein = fragile, therefore increased pressure = haemorrhage = venous infarcts
What can cause CVT to develop?
Due to sticky blood i.e. thrombophilia
Pregnancy
Dehydration
Behcets (blood vessel inflammation throughout the body)
What is meningitis?
How does it present clinically?
Infection of the meninges
Cause headaches - malaise, headache, FEVER (give away), neck stiffness, photophobia, confusion, alteration of consciousness
What can cause meningitis?
Viral - Coxs, ECHO, Mumps, EBV
Bacterial - most worrying, e.g. TB, pneumococci, haemophilus, meningococci
Fungal - usually in immunocompromised patients e.g. cryptococci
Granulomatous - infections that cause granulomas e.g. Lyme disease, Brucella, Syphillis, Sarcoid
Cancer cells - sugarcoating the meninges causing meningitis
Are meningitis patients diagnosed first or treated first?
What is the treatment for meningitis?
What can be used to diagnose meningitis?
Treat then diagnose - meningitis can kill v. quickly
Antibiotics
Blood and urine cultures
CT or MRI scan - looks for swelling
Lumbar puncture to look for: increased WCC, decreased glucose, antigens, cytology (abnormal cells), grow a bacterial culture
Why must an MRI or CT scan always be done before a lumbar puncture in meningitis patients?
Inflamed meninges and cerebral oedema = high pressure environment
Inserting needle into a patient’s back decompresses the high pressure, brain goes hurtling through foramen magnum
What is Herpes Simplex Encephalitis?
Usually affects temporal lobe
What is sinusitis?
How does it present clinically?
Malaise, headache, fever, blocked nasal passages, loss of vocal resonance, anosmia, local pain and tenderness, blocked nose
Frontal pain - worst 1-2 hours after rising, clears up during the afternoon
How can sinusitis be diagnosed?
Xray - sinus shows up more greyish, compared to normal air in sinus shows up as black
What is a brain tumour?
How does it present clinically?
Tumour in the brain
Tumour and swelling = raised ICP
Painful headaches
May have papilloedema at the back of their eyes
What is a pseudotumour cerebri?
What can cause this?
How is this treated?
All the signs of a tumour e.g. headaches, visual obscurations, diplopia, tinnitus, papilloedema, visual field loss, etc. but it is not a tumour, there is cerebral oedema causing raised ICP
Weight gain (overweight / obese), OCP, steroids, various antibiotics, excessive vitamins
Weightloss (as far as bariatric surgery), given diuretics, optic nerve sheath decompression (allow spinal fluid to leak out and decompress the optic nerve), lumboperitoneal shunt, stenting of stenosed venous sinuses (take away fluid to decrease pressure in the brain)
What is a low pressure headache?
What causes a low pressure headache?
CSF leak due to tear in dura
e.g. orthostatic headaches (comes on when you stand up)
Can be spontaneous, or a traumatic post-lumbar puncture
How is a low pressure headache diagnosed?
What is the treatment for this?
MRI scan with constrast (Aluminium) - imaging shows intense meningeal enhancement
Rehydration, caffeine, blood patch
What is a Chiari melformation?
What is the treatment?
Brain is normal, it just sits very low within the skull
Cerebellar tonsils descend through the foramen magnum
When patient coughs or sneezes, ICP increases and brain drops lower = snagging on meninges = headache
Treat cold - get rid of cough / sneeze; surgery - make foramen bigger to reduce snagging on meninges
What is obstructive sleep apnea?
Why does it cause a headache?
How do they present clinically?
History of loud snoring, apnoeic spells, disturbed sleep
Hypoxia and CO2 retention - CO2 is a potent vasodilator = painful headache in the morning, gradually decreases throughout the day
Non-refreshing sleep, headache, depression, impotence, poor performance at work
How is obstructive sleep apnea diagnosed?
What is the treatment for this?
Sleep study
Nocturnal non-invasive ventilation, stop apnea by forcing air into the lungs
Surgery - remodel back of the throat
What is trigeminal neuralgia?
How does it present clinically?
Condition affecting trigeminal nerve - neurovascular conflict at the pons (blood vessel lies too close to the nerve, so everytime the blood vessel touches the nerve = pain)
Electric shock like pain - often triggered by innocuous stimuli (e.g. chewing, wind blowing on the face)
Can be a symptom of MS
How can trigeminal neuralgia be treated?
Anti-convulsants - dampens pain e.g. carbamazepine, lamotrigine, gabapentin
Surgery - posterior fossa decompression (separate the nerve and blood vessel)
What is atypical facial pain?
How does it present?
Low grade, deep seated constant pain (i.e. around cheek, jaw, neck, ear etc.)
Common = middle aged females
Depressed or anxious
Dull pain, constant
How is atypical facial pain diagnosed?
How is it treated?
Exclude everything else by examining for pathology in teeth, temporomandibular joint, eye, nasopharynx and sinuses
Pain is treated via analgesics, opiates, nerve blocks and tricyclics (anti-depressants)
What are post-traumatic headaches?
Usually in those after head injury - victims of car accidents = likely, causing car accident = unlikely, sports injuries = unlikely
Shows there is a psychological element involved
What are the mechanisms for post-traumatic headaches?
- Neck injury
- Scalp injury
- Neuroendocrine change sets off inflammatory cascade = changes to blood supply (vasodilation) and ANS (damage)
- Depression - delayed
How are post-traumatic headaches treated?
Explanation - to patient that there is no structural defect
Prevent analgesic abuse - prevent addiction (using pain modulator drugs rather than painkillers)
Treatment: Non-steroidal anti-inflammatories - ibuprofen, naproxen
Tricyclic antidepressants - amitriptyline
3-4 years of treatment
What is cervical spondylosis?
How does it present clinically?
Commonest cause of new headaches in older patients (esp. if they have arthritis) - narrows joint between the discs)
Usually bilateral headache at the back of the head, worsened by moving the neck, steady pain, usually no photophobia or nausea
How can cervical spondylosis be diagnosed?
How is it usually treated?
Xray
Physical treatments - resting, deep heat, massage
Anti-inflammatory analgesics
Over-manipulation to neck with chiropractors etc. may be harmful
