Headaches 1-3 Flashcards
Primary headaches
migraine tension cluster
secondary headaches
caused by underlying organic disease
cervicogenic headaches
secondary although some classify as primary
abnormal findings with headaches warrant what?
neuroimaging to rule out intracranial pathology
what is the preferred method to rule out hemorrhage?
CT
MRI is necessary for imaging what?
posterior fossa
what are CSF analyses for?
hemorrhage infection tumor CSF disorders
headache onset after 50 years is?
a red flag
ddx for headaches beginning after 50 years
temporal arteritis mass lesion
possible work ups for headaches beginning after 50
ESR/CRP, neural imaging
ddx for sudden onset headache
subarachnoid hemorrhage mass lesion vascular malformation
possible workup for sudden onset headache
neuroimaging lumbar puncture if neuroimaging is negative
ddx for increased frequency and severity of headache
mass lesion subdural hematoma medication overuse
possible workup for increasing frequency and severity of headache
neuroimaging drug screening
red flags considering headaches
>50 years sudden onset increase in frequency and severity HIV/cancer systemic illness (fever, stiff neck, rash) focal neurological S&S papilledema subsequent to head trauma
ddx for headache from HIV/cancer
meningitis abcess metastasis
possible workup for headache from HIV/cancer?
neuroimaging lumbar puncture if neuroimaging is negative
ddx for headaches from systemic illness
meningitis encephalitis lyme disease systemic infection collagen vascular disease
possible workup for headaches from systemic illness
neuroimaging lumbar puncture serology
ddx for focal neurological S&S
mass lesion vascular malformation stroke collagen vascular disease
possible workup for headaches from focal neurological S&S
neuroimaging collagen vascular evaluation
ddx for a headache with papilledema
mass lesion meningitis
possible workup for headache with papilledema
neuroimaging lumbar puncture
ddx for headache from subsequent trauma
intracranial hemorrhage subdural/epidural hematoma posttraumatic headache
possible workups for headaches from subsequent trauma
neuroimaging of the brain, skull and possibly cervical spine
migrain pain location
unilateral
tension headache pain location
band like and bilateral
cluster headache location
strictly unilateral
temproal arteritis headache location
distribution of temporal artery
trigeminal neuralgia pain location
distribution of trigeminal nerve
acute glaucoma pain location
eye pain
what is one of the most common cause of headaches?
whiplash
4 primary headache patterns
migrain tension type cluster headache cervicogenic
when must acute headache be evaluated?
if associated with neurologic S&S
describe a migraine
associated with nausea, vomiting, or sleepliness and separated by pain free intervals
what is a chronic progressive headache? What may be suspected?
severity and frequency increase over time structural disorder of CNS
what is a chronic nonprogressive headache?
most typical type, usually related to stress
most patients presenting to physician’s office for evaluation of headache have what?
either a tension headache or migraine
S&S of a migraine
nausea photophobia phonophobia exacerbation by physical activity aura
intracranial organic pathologies are from what?
infection intracranial mass lesion hemorrhage hypertensive parenchymal hemorrhage, subdural hematoma ischemic conditions traumatic brain injury
other organic syndromes
cluster headache cranial bone pain scalp pain vascular involvement eye pain ear pain acute sinusitis dental pain facial nerve pain neck pain acute febrile illness metabolic disorders
red flags for headaches
sudden, severe headache new headache, older patient headache due to head trauma associated residual neurologic S&S cognitive changes vomiting w/o nausea persistent or progressive headache nuchal rigidity with or without fever suspicion of drug or alcohol dependance headache associated w’ 15-mm Hg persistent/severe headache in child
headaches associated with exertion may mean
underlying tumor or vascular weakness
when do you do a CT/MRI for post traumatic headaches?
signs of neurological dysfunction and loss of consciousness
most primary headaches occur when?
at an early age and are recurring
when should a new headache be a concern?
if they are middle aged or older complaining of a new headache
older patients with a temporal headache need to be considered to have..
temporal arteritis
headaches that are constant and more severe without reprieve likely indicate
intracranial process and should necessitate a referral for evaluation
how to manage a headache without red flags
modify patient behavior (sleep, diet, exercise) manage with CMT supplements or herbal alternates nonpharmacological treatments, if chiro is unsuccessful (acupuncture/biofeedback) refer for medical management if still unsuccessful
migraines with aura tend to occur in who?
females
how do migraines with aura usually present?
unilateral throbbing headaches that are preceeded by an aura
the prodome of a migraine with auraconsists of what?
a progressively increasing scotoma (blind spot) surrounded by flashing lights lasting for about 30 minutes
triggers for migraines with aura
sleeping or eating habits environmental pollutants certain medications food
primary food triggers for migraines with aura
chocolate caffeine nitrates cheese nuts wine etc
what neurological manifestations can be seen with migraines with aura?
aura olfactory paresthesias temporary weakness of facial muscles/limbs
how long do migraines with aura last?
4-72 hours
migraines without auras are usually..
female
what do patients complain of with a migraine with aura?
unilateral, pulsatile headache that is recurrent, having begun as a young adult
what neurological signs and symptoms are associated with migraines without aura?
there are none
what is unique about migraines without aura?
the headache is severe, but they can still function
what can relieve the migraine without aura?
vomiting (sometimes)
are migraines more common with or without auras?
without
what is the management for migraine without aura?
same as migraine with aura
how will a patient describe a tension type headache?
frequent occurence that is often worse in the afternoon or early evening
where is the pain for a tension headache?
bilateral in the suboccipital or supraorbital region
are tension headaches due to muscle tension?
no, there is no higher incidence of muscle hypertonicity with tension headaches
clinical features of tension headaches
bilateral headache mild to moderate intensity pressing or tightening quality (non-pulsating) non aggravated by routine physical activity absence of nausea and vomiting may have photophobia or phonophobia, but NOT BOTH
pure cervicogenic headache without overlap can present as?
daily headaches with no associated neurological signs one sided reduced neck motion in the neck helps associated with neck pain
cervicogenic headache is due to?
referral from soft tissues and articular structures in the neck
cluster headaches occur in who mostly?
middle aged men
what are the S&S of a cluster headache?
incredibly painful unilateral, orbital in location occur over days or weeks and then reappear again several weeks or months later history of smoking an possible alcohol use
what is the average frequency of cluster headaches?
several times per day, often at night, lasting for one to several weeks
what might the patient experience during a cluster headache?
lacrimation associated with a runny nose on the same side as the headache agitated and animated beat head against wall for relief they may attempt suicide
does chiropractic help those with cluster headaches?
not clear
what can be helpful in those with cluster headaches?
electrical stimulation of hypothalamus similar treatment to migraine with oxygen therapy
who does temporal arteritis occur in?
patients older than 50
what might the patient complain of with a tempral arteritis headache?
unilateral headache in temporal region tender nodule at the superficial temporal artery on side of forehead generalized aching and muscular tatigue int he upper trunk visual dysfunction or blindness of sudden onset
what do you do with people with temporal arteritis?
immediate referral (because blindness can result)
how is temporal arteritis treated?
corticosteroids
what is elevated in temporal arteritis?
ESR and C reactive proteins
what S&S would make you want to do advanced imaging on a headache patient
worsening with fever sudden onset w/ max intensity at 5 minutes new onset neurologic deficit or cognitive dysfunction change in personality impaired level of consciousness trauma within last 3 months headache from cough, valsalva or sneeze triggered by exercise orthostatic headache symptoms suggestive of giant cell arteritis, or acute glaucoma substantial change in characteristics of their headache
what are the two types of stroke?
ischemic* hemorrhagic
what do you do with someone who you suspect is having a stroke?
FAST face drooping arm weakness slurred speech time counts (911)
S&S of a hemorrhagic stroke
worst headache of my life extremely sudden onset if the doc can’t distinguish between migraine or tension type preceeded by sentinel*** headache in a lot of patients
sentinel headache
sudden, intense and persistene, preceeding spontaneous subarachnoid hemorrhage by days or weeks
warning signs of a potential dissection
sudden onset of headache, neck pain, face pain pain that is different than patient has experienced before 5Ds And 3Ns Dizziness Drop attacks Diplopia Dysarthria Dysphagia Ataxia Nausea Numbness Nystagmus
papilledema
optic swelling that is secondayry to elevated intracranial pressure
what happens to vision with papilledema?
nothing, usually well preserved acutely
what will you see in someone’s eye if they have papilledema
obliteration of physiologic cup tortuous vessels
what are the intracranial structures that are pain sensitive?
meningeal arteries proximal protions of cerebral arteries dura at the base of the brain venous sinuses CN 1, 2, 3, 5, 7, 9
brain tumor symptoms
headaches seizures sensory and motor loss hearing loss vision loss fatigue depression behavioral and cognitive changes endocrine dysfunction
describe the headaches of people who have brain tumors
steady pain, worse upon waking, better in a few hours persistent, progressive, non migraine aggravated by valsalva maybe vomiting maybe throbbing maybe worse with coughing, exercise or change in body position doesn’t respond to regular headache remedies maybe associated with new neurologic findings
symptoms specific to the location of the tumor
pressure or headache near the tumor
symptoms specific to a tumor of a cerebellum
loss of balance and difficulty with fine motor skills
symptoms specific to a tumor of the cerebrum
changes in judgement loss of initiative, sluggishness, muscle weakness, paralysis (frontal lobe) partial or complete loss of vision (occipital or temporal lobe of cerebrum) changes in speech, hearing, memory, or emotional state (aggressiveness)(frontal and temporal lobe of cerebrum) altered perception of touch or pressure, arm or leg weakness on one side of the body or confusion with left and right sides(frontal or parietal lobe)
pineal gland tumr
inability ot look upward
pituitary tumor
lactation and altered menstrual periods in women growth in hands and feet in adults
brain stem tumor
difficulty swallowing, facial weakness or numbness, double vision vision changes (temproal, occipital lobe, brain stem)
most prevalent brain tumor types
gliomas (glioblastoma multiforme, ependymomas, astrocytomas, oligodendrogliomas) meningiomas
most prevalent tbrain tumor types on children
astrocytoma medulloblastoma ependymoma
normal measurement for sella turcica
16 across x 12 depth on a 40” film
if the sella turcica is large, it could be?
empty sella tumor normal aneurysm
most common symptom of chiari malformation
headache that begins at the back of the head and radiates upward made worse by coughing, sneezing or straining
other common symptoms of chiari malformation
dizziness vertigo disequilibrium visual disturbances ringing in ears difficulty swallowing palpitations sleep apnea muscle weakness impaired fine motor skils chronic fatigue painful tingling of hands and feet
chiari measurement
vertical distance from tip of cerebellar tonsils to a line drawn betwen and anterior and posterior margins of the foramen magnum normal less than 3mm
