Headache12/04 Flashcards
basis for generation of headaches (3)
- structural
- pharmacological
- psychological
a drug which can cause headache
- GTN
- treat angina
- relaxes blood vessels around heart
- dilates brain blood vessels - throbbing headache
How to distinguish one headache from another
- history
types of headache (2)
- acute single headache
- dull headache; increasing in severity
type of haemorrhage that can cause an acute single headache
- subarachnoid haemorrhage
what type of tumour causes a dull headache?
- cerebral tumour
what type of venous sinus thrombosis can cause a dull headache?
- cerebral
headache onset patterns (3)
- dull headache; unchanged over months
- triggered headache
- recurrent headache
what can cause a dull headache which is unchanged over months
- chronic tension headache
- depressive
- atypical facial pain
what can cause a recurrent headache which is unchanged over months (4)
- migraine
- cluster headache
- episodic tension headache
- trigeminal or post-herpetic neuralgia (severe pain due to irritated or damaged nerve)
what can trigger a triggered headache which is unchanged over months (3)
- coughing
- coitus
- food and drink
what are the more worrying types of headache?
acute single headache
- dull headache, increasing severity
onset red flags (4)
thunderclap,
acute (hours or days),
subacute (Days or weeks),
orthostatic
meningism red flags (4)
photophobia, phonophobia, stiff neck, vomiting
systemic red flags (3)
fever, rash, weight loss
neurological symptoms or focal signs red flags (8)
visual loss, confusion, seizures, heimparesis, double vision, 3rd nerve palsy, horner syndrome, papilloedoma
red flag for placement of headaches
strictly unilateral
which cranial nerves control the eyes?
- 3rd, 4th, 6th
- damage can cause double vision, horner syndrome, and oculomotor palsy (no control of eyelid and eyeball pointing outwards)
what is horners syndrome
damage to sympathetic innervation of eye
- looks droopy (Ptosis), enophthalmos, anisocoria
another scary red flag
orthostatic headache
subarachnoid haemorrhage features
- sudden generalised headache - blow to the head
- meningism - stiff neck and photophobia
- most cause by a ruptured aneurysm; few from arteriovenous malformations and some unexplained
How should a subarachnoid haemorrhage be diagnosed and treated?
Around 50% of SAH are instantly fatal:
vasospasm (vasoconstriction) may stop leak
nimodipine (vasodilates to prevent cerebral ischaemia) and BP control
early neurosurgical assessment confirm bleed and establish cause
CT brain, lumbar puncture, MRA (does not need catheter) and angiogram (needs catheter)
how to treat an aneurysm
filled with platinum coils
- aneurysms used to be clipped or wrapped
acute intracerebral bleed is called?
coning
- fatal
what is the mechanism of coning?
raised intracranial pressure
- brain starts to seep under weak areas
- -> falcine herniation
- -> tentorial herniation
What is seen on the retina with a papiloedema
optic disc swelling due to raised ICP
what neck artery pathology can cause headache?
large arteries - carotid and vertebral
Carotid artery dissection causes what type of pain?
- phantom of the opera mask distribution pain
how to diagnose artery dissection?
MRI/MRA. doppler (USS which measures blood flow), angiography
how to treat artery dissection - first line
aspirin or anticoagulation
Tear can lead to clot, which can lead to ischaemia and then stroke
what can turbulent flow cause the blood to become?
stick - it can clot
- hence why given anticoagulants when artery dissection occurs
are arteries of veins more easily damaged?
veins
- can shear veins to form a subdural.
what does it mean when blood in a subdural is dark on a CT?
blood is hyperdense has began to degrade -> chronic bleed
- may see falcine herniation. Midline moves and ventricles squashed
who is temporal arteritis most common in and what are common symptoms?
women (3x more likely than men)
- over the age of 55
- constant unilateral headache, scalp tenderness and jaw claudication
- 25% see polymyalgia rheumatica: proximal muscle tenderness
- see disruption of the internal elastic lamina
what can happen if the posterior ciliary arteries are involved in temporal arteritis?
blindness
what are markers elevated in temporal arteritis
ESR
CRP
- temporal artery usually inflamed and tortuous
what type of imaging can be used to visualise temporal arteritis?
ultrasound
biopsy shows inflammation and giant cells
how to treat temporal arteritis?
high dose steroids and aspirin for 3/4 weeks
what is cerebral venous thrombosis?
thrombosis in dural venous sinus or cerebral vein
- unusual amount oh headache due to raised ICP
- blood coming in but can’t leave
- non-territorial ischaemia
- haemorrhage
- caused by thrombophili, pregnancy, dehydration, Behcets
what viral infections can causes meningitis?
- coxsackie
- ECHO
- Mumps
- EBV
what bacterial infections can causes meningitis?
- Meningococci
- Pneumococci
- Haemophilus
- TB
what fungal infections can causes meningitis?
- cryptococci
what granulomatous infections can causes meningitis? (4)
- sarcoid
- Lyme
- Brucella
- Syphilis
Seeding of what can cause meningitis?
Carcinomas
Presenting symptoms of meningitis (6)
malaise headache neck stiffness photophobia confusion alteration of consciousness
how can herpes simplex affect the brain?
haemorrhagic changes to the temporal lobes
+ encephalitis
How to treat and diagnose meningitis?
- AB
- Blood/urine culture
- CT/MRI
- lumbar puncture:
* increased WCC
* low glucose
* antigens
* cytology
* bacterial culture
why do you give AB before diagnosis of meningitis?
Because meningitis kills very quickly
Why do you do CT/MRI before lumbar puncture for meningitis?
Need to ensure its not bacterial meningitis:
- bacterial meningitis makes the brain swell
- cerebral oedema with effacement (disappearance of) of ventricles and sulci and inflamed meninges
- If you were to put a needle in here then you’d get sudden decompression if the brain
Symptoms of sinusitis? (8)
- malaise
- headache
- fever
- loss of voal resonance
- anosmia
- nasal/postnasal catarrh
- local pain and tenderness
- frontal pain characteristically starts 1/2 hours after rising and clears up during the afternoon
how do you see sinusitis on imaging?
opacification of paranasal sinus
what does a glioblastoma multiforme cause loss of?
sulci markings on imaging
- this tumour has cystic features
What is also known as pseudotumour cerebri?
intracranial hypertension
who are likely to suffer from pseudotumour cerebri?
- young obese women
symptoms of pseudotumour cerebri?
- headache, visual obscurations, diplopia, tinnitus
- papilloedema, +/- visual field loss
drug causes of pseudotumour cerebri? (4)
- hormones
- steroids
- ABs
- vitamin e
treatment of pseudotumour cerebri (5)?
- weight loss – may even give bariatric surgery
- diuretics
- optic nerve sheath decompression
- lumboperitoneal shunt
- stenting of stenosed venous sinuses
what do you see on a scan in pseudotumour cerebri?
raise ICP but still no tumour even if presents similarly
what is a low pressure headache caused by and how would it show on scans?
CSF leak due to tear in dura
- on scans see meningeal enhancement
causes of CSF leak in low pressure headache?
- traumatic post lumbar puncture or spontaneous
- treatment for CSF leak?
rehydration,
caffeine - seal the hole
blood patch - take out blood and put into epidural space. Fibrin makes it act like glue
what is chiari malformation
- normal brain that sits low within skull
- cerebellar tonsils descending through the foramen magnum
- descend further when patient cough; causes tugging on the meninges -> headache
why do people with obstructive sleep apnoea get headaches?
hypoxia
CO2 retention (vasodilator so causes banging headache)-> non-refreshing sleep
- causes depression, impotence, poor performance at work
- require sleep study
how to treat obstructive sleep apnoea?
nocturnal NIV, surgery
symptom of trigeminal neuralgia
- electrical shock like pain in the distribution of a sensory nerve
- Affects any division of the trigeminal nerve (provides sensory innervation of face)
Triggers:
- there are trigger zones -> can be caused by wind on face or trying to shave
- often triggered by innocuous (non-harmful) stimuli
Causes:
- neurovascular conflict (contact between blood vessels and CN) at the point of entry of the nerve into the pons
- can be symptom of MS
treatment of trigeminal neuralgia (4)
carbamazepine
lamotragine
gabopentin
posterior fossa decompression
atypical facial pain most common in who?
middle aged women
- depressed or anxious
characteristics of atypical facial pain?
- daily constant poorly localised aching or burning
- affects facial or jaw bones; may extend to neck
- not lancinating
- not conforming to strict anatomical distribution
- no sensory loss
- pathology in teeth, temporomandibular joints, eye, nasopharynx and sinuses must be excluded
what is atypical facial pain unresponsive to>
- conventional analgesics, opiates and nerve blocks
- mainstay of management - tricyclics
can trauma cause a headache?
yes - post traumatic headache
- 1/3 people in accidents come back with headache
mechanisms of post traumatic headache?
neck injury
scalp injury
vasodilation -> autonomic damage
depression -> often delayed
is the incidence of post traumatic headache high in victims of sport injuries and perpetrators of car accidents
no
is the incidence of post traumatic headache high in victims of car accidents
yes
management of post traumatic headache
NSAIDs - avoid opiates as addictive
tricyclic antidepressants e.g. amitriptyline (pain modulators)
Be patient - 3/4 years
Explain to patient that there’s no structural damage and it’s not irreversible damage- full recovery can be made
cervical spondylosis
narrowing of jointspace due to worn disc
- usually bilateral
- occipital pain can radiate forwards to frontal region
- steady pain
- no nausea or vomiting
- worsened by moving neck
management of cervical spondylosis
- rest, deep heat, massage
- NSAID
- over manipulation may be harmful
three forms or migraine attacks
- pain
- focal symptoms
- pain and focal symptoms
Symptoms of migraine disorder
- tendency to repeated attacks
- usually hemicranial
- triggers (people get to know theirs)
- easily hungover
- visual vertigo
- motion sickness
examples of focal symtoms
- aphasia
- weakness in the left arm
- paresis
- plegia.
examples of migraine prodromes (5)
- change in mood
- urination
- fluid retention
- food craving
- yawning
features of migraine aura
- can be positive or negative
- visual (scintillations & blindspot)
- sensory (numbness/paraesthesia)
- weakness
- speech arrest
features of migraine headache
- head and body pain
- nausea
- photophobia
resolution for migraine
rest and sleep
What does recovery of a migraine feel like?
like a hangover
- disturbed mood
- food intolerance
- lasts around 48 hrs
what is a negative migraine aura
black spots
what is a positive migraine aura
bright spots
why do people hold-off on prescribing opiates?
- analgesic abuse potential
how does TMS help relieve migraine?
interrupts complex networks that trigger and perpetuate migraine, which is caused by spreading electrical depression across the cerebral cortex
what do triptan tablets synergise with?
NSAID
what medication is given first to treat migraines?
aspirin/ibuprofen and paracetamol and metoclopramide (anti-emetic)
- soluble preparations to aid absorption
- can also take a short nap
what are lifestyle issues for people who suffer from migraines?
- they have sensitive heads even in between attacks
- overreact to any sort of stimulation
- Can’t ignore the world around them , overstimulates their brain
migraine triggers (5)
dietary environmental hormonal weather (biometric pressure change) stress
Lifestyle changes recommended for if you suffer from migranes
- dont skip meals and eat fresh food (avoid preservatives and sulphates in alcohols)
- Don’t oversleep - electronics downstairs
- no analgesic abuse
- drink 2l water/day
what is prophylaxis?
treatment given/action taken to avoid disease
examples of migraine prophylaxis
Over the counter meds: feverfew, coenzyme Q10, riboflavin, magnesium, EPO, nicotinamide
Tricyclic antidepressants (TCAs): amitriptyline 7pm
Beta-blockers - Propranolol, Atenolol
Serotonin antagonists: pizotifen, methysergide
Calcium channel blockers: flunarazine, verapamil
Anticonvulsants: valproate, topiramate, gabapentin
Greater occipital nerve blocks
Botox: crown of thorns like distribution
Suppress ovulation: (progesterone only pill or implant/injection)
Erenumab:
- Injectable drug erenumab (Aimovig)
- cut number of days people had migraines from an average of 8 a month to between 4 and 5 a month.
- Monoclonal antibody
disables calcitonin gene-related peptide or its receptor (CGRP mAbs)
- Episodic migraine, chronic migraine, or cluster headache.
what causes tension headache?
- tight muscles around head and neck bilaterally, as though head is in a vice
how to treat headache tension?
- NSAIDS preferred (ibuprofen, naproxen, diclofenac)
- paracetamol
- tricyclic antidepressants
- Amitriptyline 50-75mg daily
- 30-60% derive some symptomatic relief
- SSRI’s probably less effective
- Biofeedback and relaxation unproven
what is a cluster headache?
severe unilateral pain last 15-180 mins untreated
- classified as a trigeminal autonomic cephalgia
- at least one of the following, ipsilaterally
- Conjunctival redness and/or lacrimation
- Nasal congestion and/or rhinorrhoea
- Eyelid oedema
features of cluster headache
- Forehead and facial sweating
- Miosis and/or ptosis
- A sense of restlessness or agitation
- Frequency between one on alternate days to 8 per day - diurnal pattern
- Not associated with a brain lesion on MRI (primary headadches)
examples of primary headaches? (3)
- cluster headaches (phantom of the opera distribution)
- migraine
- tension
Cluster headache: treatment
- acute
- prevention
acute cluster headache treatment
- Inhaled oxygen. Oxygen inhibits neuronal activation in the trigeminocervical complex
- S/C or Nasal Sumatriptan
Prevention cluster headache
- Verapamil
- Prednisolone
- Lithium
- Valproate
- Gabapentin
- Topiramate
- Pizotifen
migraine distribution - more common in m/f
f
migraine distribution - more common in m/f
m
duration of migraine
3-12hrs
duration of cluster headache
45min-3hrs
frequency of migraine
1-8 attacks monthly
frequency of cluster headache
1-3 attacks daily
remission of migraine
long remissions unusual
remission of migraine
remission is common
nausea migraine - is this common?
frequent
does nausea occur in a cluster headache?
nausea rare
How would you describe the pain in migraine?
Pulsating hemicranial pain
How would you describe the pain in a cluster headache?
Steady, exceptionally severe, well localised pain, unilateral in each cluster
What are visual symptoms of a migraine
visual or sensory auras seen
symptoms of cluster headache
Eye waters, nose blocked, ptosis etc
What can a patient do whilst having a migraine to help them?
Patient can lie in the dark
cluster headache behaviour by patients
Patients pace about
