Headache/SAH Flashcards
How can headaches be categorised into two groups?
primary e.g. migraine, cluster headache, tension headaches
Secondary- SAH, brain tumour, meningitis
What are the red flags for a headache?
- first/worst headache with acute onset
- postural association
- > 50
- systemic symptoms e.g. fever, weight loss
- neurological signs
Unilateral headache. What are the differentials?
cluster headache, migraine
Bilateral headache. Differentials?
tension headache, migraine
Ocular headache. Differentials?
cluster headache, migraine
Occipital headache. Differentials?
haemorrhagic, meningitis
Diffuse headache differentials?
raised ICP
Sudden onset headache differentials?
SAH
Acute headache differentials?
meningitis, migraine, venous sinus thrombosis, temporal arteritis, intracranial haemorrhage
Differentials for chronic headache?
migraine, medication overuse, tension
Patient with headache has facial pain. What are the differentials?
trigeminal neuralgia, ENT/dental causes
Patient with headache and jaw claudication. What is the likely cause?
temporal arteritis
What are associated symptoms of migraine?
N/V, photophobia/phonophobia, sensory aura
Headache last a few seconds and is recurrent. What is the likely cause?
trigeminal neuralgia
Headache lasts <4 hr. What is the likely cause?
cluster headache
Headache 4-72hr, what is the likely cause?
migraine
Headache worse on awakening. Differentials?
raised ICP, obstructive sleep apnoea
Headache worse during night. Likely source?
cluster headache
Headache worse at the end of the day/work. Which headache is this?
tension headache
Which headaches can worsen during menstruation?
migraine
Which specific questions should you ask about in the history of headache?
HTN, analgesia, alcohol/cocaine, sleep, diet, caffeine intake, travel history (infective causes), fam hx migraine and SAH
Which specific things can you do to examine for temporal arteritis and meningitis, SAH?
neck stiffness for meningitis and SAH
scalp tenderness- temporal arteritis
What is a key question to ask when querying SAH?
when did the headache reach its peak onset? SAH reach peak pain within 5 mins.
What percentage of SAH are observable on CT?
99%
If SAH is suspected but the CT is normal, what is the next investigation?
lumbar puncture at least 12 hours after onset of headache to detect xanthochromia
Which meningeal layer houses CSF?
subarachnoid space
What are the risk factors for SAH?
smoking, cocaine use, HTN, fam hx SAH, connective tissue disorders, (AD polycystic kidney disease)
What are complications of LP?
headache (most common, improves with lying), infection, bleeding, nerve damage, back pain
Management of post LP headache?
IV fluids, bed rest, simple analgesia, caffeinated drink?
Acronym for headache differentials?
VITAMIN CDEF vascular- SAH infection- meningitis trauma- traumatic brain injury autoimmune- temporal arteritis metabolic- DKA/HHS iatrogenic- post LP neoplastic- brain tumour functional- stress
In suspected meningitis, what is the first step of management/investigation?
start antimicrobials
Differentials for sudden onset headache
Raised ICP, encephalitis, meningitis, SAH
When should LP be performed in patient with sudden onset headache and nil findings on CT brain
After 12 hours of headache onset and within 12 days of symptoms onset
List two checks that should be made for safety prior to commencing LP
fundoscopy/CT head (to show evidence of raised ICP)
Clotting and platelets
Which findings in LP would indicate positive result?
xanthochromia if SAH, positive gram stain/PCR if meningitis
List three complications from LP
headache, introduction of infection, nerve injury, meningeal herniation
Differential for acute headache?
VICIOUS
Vascular: SAH, intracranial, sinus thromboembolism
Infection/inflammation: meningitis, encephalitis, abscess
Compression: tumour
ICP
Opthlalmic: acute glaucoma
Unknown: cough, exertion
Systemic: phaochromocytoma, sinusitis, tonsilitis, CO
Differential for chronic headache?
MCD TINGS
Migraine Cluster headaches Drugs Tension headaches ICP Neuralgia (trigeminal) Giant cell arteritis Systemic: HTN
List three drug classes that can cause headaches
analgesics
caffeine
vasodilators: CCB, nitrates
Patient with acute headache and papilloedema. What are you worried about?
venous sinus thrombosis
Which sign is positive in meningism?
kernig’s
Name two features of tension headache
bilateral, non-pulsatile, band-like
What is the distribution of headache in migraine?
unilateral
Patient with rapid onset pain around one eye. The attack lasts 2 hours and happens every day for 5 weeks. Which type of headache do they have?
cluster headache
Rapid onset very severe pain around/behind one eye.
Red, watery eye, nasal congestion
Miosis, ptosis
Attacks last 15min–3hrs, 1-2x/day, mostly nocturnal
Clusters last 4-12wks, remission lasts 3mo-3yrs. Can
be chronic vs. episodic.
Treatment for cluster headache?
oxygen and sumitriptan
Name two triggers for trigeminal neuralgia
washing area, shaving, eating, talking
What are the symptoms of trigeminal neuralgia
Paroxysms of unilateral intense stabbing pain in trigeminal distribution (usually V2/3)
Name a treatment for trigeminal neuralgia
gabapentin
What worsens increased ICP headaches?
worse in AM, stooping, worse sitting or standing
Name a risk factor for migraines
obesity
Describe the pathophysiology of migraine
Vascular: cerebrovascular constriction → aura,
dilatation → headache.
Brain: spreading cortical depression
Inflammation: activation of CN V nerve terminals in
meninges and cerebral vessels.
List four triggers for migraine
CHOCOLATE CHeese OCP (oral pill) Caffeine alcohOL Anxiety Travel Exercise
Lack of sleep, stress, hunger, mesntruation
Describe three symptoms of migraines?
Prodrome-> aura -> headache
Prodrome: hours-days
Aura: mins before headache
Headache- unilateral throbbing
What are the features of prodrome?
yawning, food cravings, changes in sleep/appetite/mood
What are the types of auras?
Visual: distortion, lines, dots, zig-zags, scotoma,
hemianopia
Sensory: paraesthesia (fingers → face)
Motor: dysarthria, ataxia, ophthalmoplegia,
hemiparesis (hemiplegic migraine)
Speech: dysphasia, paraphasia
Differential for migraine?
Cluster / tension headache Cervical spondylosis HTN Intracranial pathology Epilepsy
Treatment for migraine?
aspirin, ibuprofen, triptan, amitriptyline
When should triptan be taken ideally for migraine if patient has auras?
In patients who experience aura with their migraine, it is recommended that 5HT1-receptor agonists are taken at the start of the headache and not at the start of the aura (unless the aura and headache start at the same time).
What is the first line prophylaxis for migraine?
avoidance of triggers, propranolol and topiramate (antiepileptic), TCAs (amiltiptyline)
List three complications of SAH
- rebleeding
- Cerebral ischaemia
- Hydrocephalus
- Hyponatraemia
- Seizures
What is Terson’s syndrome?
vitreous haemorrhage of the eye associated with SAH
Only when should LP be performed for suspected SAH?
if negative CT findings, 12 hours after onset
Which drug is used to manage delayed ischaemia in SAH?
nimodipine
Name a cardio complication of SAH?
LVF- tako-tsubo cardiomyopathy
Who should you image with headache?
SNOOP- SSSNOOPPP: systemic symptoms e.g. fever, secondary risk fx, seizures, neuological symptoms, onset, older, progression, papilloedema, precipitated by cough or exertion or sleep.
CSF- change in nature of headache, S- systemic symptoms of signs, F-focal neurological deficit
List three features of postdrome migraine?
euphoria, depression, poor concentration, fatigue
First line triptan for headache?
sumitriptan
What are examination findings of raised pressure headaches?
optic disc swelling, impaired visual acuity, restricted visual fields, 3rd and 6th nerve palsy, focal neurological signs
