headache (see DM) Flashcards
8 causes of secondary headache
- meningitis;
- subarachnoid haemorrhage;
- raised intracranial pressure;
- GCA;
- venous sinus thrombosis;
- pituritary apoplexy;
- carotid dissecton;
- acute closed angle glaucoma
4 primary headache disroders
- tension headache;
- migraine;
- cluster headache;
- trigeminal neuralgia
red flags for headache
new; “worst ever”; thunerclap (peak intensity reached in seconds-minutes); systemically unwell; symptoms of raised ICP; B symptoms (fever, night sweats, weight loss); meningism; focal signs
where does the pain in a secondary headache arise from
outside the brain (meninges in particular) - the brain itself has no sensory neurons to detect pain
what does a haemorrhage do to the meninges
causes inflammation
how to irritate the meninges (test for it)
slowly, gently, move the head forwards
what condition is motion sensitivity prominent in
migraine
what is a red flag for raised ICP
short onset of pain when lying down
why is raised ICP worse when lying down
when standing - excess CSF pools in the sacral area which is more lax and the meninges is less stretched;
when lying down - CSF is distributed more evenly in the CNS meaning that there is greater volume in the cranial region -> less flexible and so meninges is more irritates
signs of raised ICP (4)
headache worse on lying down, coughing, sneezing and straining
what is papilloedema
swelling of the optic disc due to elevated intracranial pressure (ICP)
what does venous pulsation in the retina indicate
ICP normal - this is a normal finding (however, absence of this does not necessariy mean there is raised ICP)
time frame for a lumbar puncture in a SAH pt
12hrs -2weeks (peak time for blood degredaton products)
what does an angiogram negative SAH indicate
cortical SAH rather than the usual basal
2 examples of causes of cortical based SAHs
reversible cerebrum vasoconstricton syndrome (seen in cocaine abuse and chronic nasal decongestion users);
amyloid angiopathy
what is amyloid angiopathy
a type of cerebrovascular disorder characterized by the accumulation of amyloid within the leptomeninges and small/medium-sized cerebral blood vessels
SAH vs meningitis headache
SAH - sudden onset, thunderclap;
meningitits - acute onset but gradually gets worse (rather than thunderclap)
pt comes in with neck + head pain after going on a rollercoaster, L pupil is constricted - what does this pt hv and what is the immediate mgx
carotid artery dissection causing horner’s syndrome (pressure on sympathtic chain) -> high risk of stroke;
give Aspirin (300mg)
what is Horner’s syndrome
a condition that arises due to damage to the sympathetic supply to the eye, resulting in unilateral partial ptosis (drooping or falling of the upper eyelid), miosis (constricted pupil), and facial anhydrosis
Horner’s syndrome ptosis vs CN III palsy
Horner’s - patial ptosis due to sympathetic stimulation only innervating the superior tarsal muscle (smooth muscle) which only contributes to 1/3 of the upper eyelid’s opening power;
CN III palsy - complete ptosis due to lack of motor stimulation to the levator palpebae superior (skeletal muscle) which contributes to 2/3 of the upper eyelid opening
pt presents with thunderclap headache and Hx of galactorrhea and bitermptal hemianopia - what does this pt hv and what is the immediate mgx
Pituitary apoplexy (blockage in blood flow or hemorrhage in your pituitary gland) which may result in addisionian crisis; give steroids
what kind of thrombosis does the pill increase the risk of
cerebral venous sinus thrombosis
venous sinus thrombosis CT findings
- dense clot sign;
- empty delta sign ;
- hemorrhage in sinuses (not typical areas seen);
venous sinus thrombosis Mgx
heparin
what is the commonest cause of headache
tension
tension headache presentation (4)
- band like distribution;
- Dull, aching head pain;
- Feeling of tightness or pressure bilaterally across the forehead or on the sides and back of the head;
- tenderness in the scalp, neck and shoulder muscles;
tension headache mgx (3)
1.Over-the-counter analgesics (e.g., paracetamol, ibuprofen);
2. If over-the-counter treatments are ineffective, consider prescribing stronger analgesics;
3. amitriptyline
migraine presentation (7)
- unilateral throbbing;
- gradual onset;
- photophobia/phonophobia;
- motion sensitivity;
- naursea/vomiting;
- prodrome/aura preceeding (flashing lights, silvery zigzags etc.);
- non responsive to painkillers
what counts as analgesia overuse in headaches
opiates/triptans - 10 days per month;
other analgesisc - 15 days per month
cluster headache presentation (6)
- unilateral periorbital pain;
- boring/dull pain;
- lacrimation;
- red eye;
- nasal stuffiness;
- restlessness (walks about);
cluster headache epidemiology
men (5:1) in their 20/30s
what overarching group of headaches does a cluster headache belong to
trigeminal autonomic cephalgia
chronic cluster headache treatments (6)
- verapamil (needs ECG monitoring);
- topiramate;
- gabapentin;
- sodium valporate
- lithium (toxic, so only use if others don’t work);
- gammacore device (contraversial, targets vagus nerve);
other examples of trigeminal autonomic cephalgia (not cluster headache)
- paroxysmal hemicrania (boring, orbital pain);
- short lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (severe, stabbing pain, orbital);
trigeminal neuralgia presentation (5)
- sudden onset;
- severe, stabbing pain (like an electric shock);
- lasts seconds-minutes but may leave a dull ache;
- occurs in bouts of pain throughout the day (sometimes multiple);
what can trigger trigeminal neuralgia
wind, movement (e.g chewing), cold, touch etc.
trigeminal neuralgia mgx (5)
pharma:
1. carbamazepine/oxcarbazepine;
2. gabapentin;
3. baclofen (muscle relaxant);
etc.
non pharma:
1. radiofrequency ablation of CN V;
2. neurovascular decompression (but significant complication rate so not usually done)
trigeminal neuralgia pathophys
compression of trigeminal nerve by ectatic blood vessel (diffuse dilation of bv)
increase in tenderness of what muscles is seen in tension headaches and how does this contribute to tension headaches occuring
pericranial and cerviacle muscles -> increased sensitisation -> hyperalgesia -> further sensitisation -> allodynia
