Headaches Flashcards
what are all the causes of acute single headaches?
febrile illness, sinusitis first migraine attack post trauma headache subarachnoid haemorrhage meningitis tumour drugs toxins stroke thunderclap
what are all the causes of dull headaches increasing in severity?
overuse of medication contraceptive pill neck disease temporal arteritis benign intracranial hypertension cerebral tumour cerebral venous sinus thrombosis
what are all the causes of a dull headache, unchanging over months
chronic tension headache
depressive, atypical facial pain
what are all the causes of a triggered headache?
coughing, straining, exertion
sexual intercourse
food and drink
what are all the causes of recurrent headaches?
migraine
cluster headache
episodic tension headache
trigeminal or post hepatic neuralgia
what are the red flag signs of headaches?
acute/subacute and thunderclap headaches
photophobia, phonophobia, stiff neck, vomiting
fever, rash, weight loss
vision loss, confusion, seizures, hemiparesis, double vision, 3rd nerve palsy, Horner syndrome, papilloedema
orthostatic
unilateral
what is horners syndrome?
sympathetic supply to eyes disrupted
eye looks pushed in, pupil smaller, eyelid droopy
how fatal are subarachnoid haemorrhages?
~50% instantly fatal
how do you assess for the possibility of a subarachnoid haemorrhage?
neurological assessment CT brain lumbar puncture (pink/red colour - RBC and xanthochromia) MRA angiogram
how do you treat a burst aneurysm?
filled with platinum coils via catheter
used to be clipped or wrapped
what is the cause of death following an acute intracerebral bleed?
coning - raised intracranial pressure forcing the brain out of weak areas e.g tentorium/falsine herniation
what is papilloedema?
optic disk swelling due to raised ICP
what is the mechanism of coning?
the brain can handle a small increase of fluid volume without increasing pressure until it hits a limit, pressure increases exponentially, causing herniation
what are the investigations for a carotid or vertebral dissection?
MRI/MRA
doppler ultrasonography
angiography
what is the pain distribution for a carotid dissection?
headache and neck pain - phantom of opera
what is more likely, carotid or vertebral dissection?
carotid
how should you treat carotid or vertebral dissection?
aspirin or anticoagulation x 6/12
how does a chronic subdural haemorrhage present?
long standing one sided headache, limb weakness on one side
commonly elderly patients
how do you treat a subdural haemorrhage?
drill a hole to release blood buildup
what is temporal arteritis
inflammation of the temporal arteries, often with presence of giant cells
what is the typical patient for temporal arteritis?
females over 55
what is the presentation of temporal arteritis?
constant unilateral headache, scalp tenderness, jaw claudication
possible shoulder pain
visual disturbances acutely
what investigations can be done for suspected temporal arteritis?
elevated ESR and CRP
temporal artery visibly inflamed on ultrasound
biopsy showing giant cells
how can temporal arteritis cause blindness?
involvement of posterior ciliary arteries
how should temporal arteritis be treated?
high dose steroids and aspirin
what is cerebral venous thrombosis?
thrombosis in dural venous sinus or cerebral vein causes lack of venous drainage and therefore raised ICP
what are the causes of cerebral venous thrombosis?
non-territorial ischaemia haemorrhage thrombophilia pregnancy dehydration Behcets
what are all the types of meningitis?
viral bacterial - pneumococci most common tuberculosis fungal granulomatous syphilis carcinomatous
what are the presenting symptoms of meningitis?
malaise headache fever neck stiffness photophobia confusion alteration of consciousness
what is the main thing to remember with meningitis?
treat then diagnose
what are the investigations for suspected meningitis?
CT or MRI
lumbar puncture
blood and urine culture
what would a lumbar puncture in someone with meningitis show?
increased white cell count decreased glucose antigens cytology bacterial culture possible
what are the first line treatments for suspected meningitis?
IV antibiotics
sometimes corticosteroids
fluids and oxygen
what are the presenting symptoms for sinusitis?
malaise headache fever blocked nasal passages, anosmia loss of vocal resonance local pain/tenderness frontal pain in morning, resolves slowly
how do you investigate brain tumours?
head CT or MRI
what is idiopathic intracranial hypertension?
buildup of pressure around the brain for no apparent cause
pseudotumour cerebri
who is most affected by idiopathic intracranial hypertension?
young obese women
what are the symptoms of idiopathic intracranial hypertension?
headache, visual obscurations, diplopia, tinnitus, papilloedema, possible visual field loss especially upon standing
how can you treat idiopathic intracranial hypertension?
hormones, steroids, antibiotics, vitamin E
weight loss, diuretics, optic nerve sheath decompression, lumboperitoneal shunt, stenting of stenosed venous sinuses
how does raised ICP appear on a head CT?
cerebral oedema with ventricle and sulci effacement with no mass lesion
what are low pressure headaches?
rupture of meninges (usually dura) causes CSF to leak
how do low pressure headaches typically occur?
traumatic post lumbar puncture or spontaneously
how do you treat low pressure headaches?
rehydration by fluids, caffeine, blood patch
what is chiari malformation?
normal brain but sits low in the skull from birth
how does chiari malformation cause headaches?
cerebellar tonsils descend through the foramen magnum, descend further upon coughing causing tugging of the meninges
how do you manage chiari malformation?
treat any underlying cough/sneeze
can do surgery to remodel the skull base
what is obstructive sleep apnoea?
walls of the throat relax during sleep interrupting normal breathing
what is a typical presentation of obstructive sleep apnoea?
high BMI, history of loud snoring and apnoeic spells
what are the symptoms of obstructive sleep apnoea?
hypoxia, co2 retention, non-refreshing sleep, depression, impotence, work difficulties, morning headaches
why does obstructive sleep apnoea cause morning headaches?
buildup of CO2 causes vasodilation of brain vessels
how do you diagnose obstructive sleep apnoea?
requires sleep study
what are the treatments for obstructive sleep apnoea?
nocturnal NIV, surgery
what is trigeminal neuralgia?
facial/neck pain (electric shock-like) in distribution of sensory nerve due to irritation of trigeminal
how is trigeminal neuralgia triggered?
by innocuous stimuli e.g chewing, something touching teeth
how is trigeminal neuralgia caused?
neurovascular conflict at point of entry of nerve to pons (nerve touches/is pinched by vessel)
can be a symptom of MS
what is the treatment for trigeminal neuralgia?
carbamazepine, lamotrigine, gabapentin (anti-convulsants)
posterior fossa decompression
what is atypical facial pain?
daily, constant, poorly localised deep aching or burning in facial or jaw bones (may extend to neck ear or throat)
no numbness or sensory loss
what is the typical presentation of atypical facial pain?
middle aged woman who is depressed or anxious, with daily constant poorly localised pain
how should you diagnose atypical facial pain?
exclude pathology in teeth, TMJ, eye, nasopharynx, sinuses
how do you manage atypical facial pain?
tricyclics
what is a post traumatic headache?
no previous history of headaches, dependent upon nature of head injury
what is the prevalence of post traumatic headaches?
high in victims of car accidents
low in perps of car accidents
low in sports injuries
(psychological aspect?)
how do you manage post traumatic headaches?
explain the cause of headache
prevent analgesic abuse
NSAIDs
tricyclic antidepressants (amitriptyline)
what is cervical spondylosis?
bilateral steady pain worsened by moving the neck, caused by narrowing of the joint space due to worn discs
what is the most common cause of new onset headaches in elderly?
cervical spondylitis
how do you manage cervical spondylitis?
rest, deep heat, massage, antiinflammatory analgesics
chiropraction not recommended
typical SOCRATES for a migraine
S- unilateral
O- sudden recurrence/intensification of symptoms
C - pulsating/throbbing
R- none
A- nausea/vom, aura (lights, halluc), tingling, tinitis, paralysis, photophobia, phonophobia
T - 4-72 hrs
E - physical activity, foods, bad sleep, hormones
S - moderate/severe
treatment for acute migraine
aspirin
nasal sprays
short naps
TMS
lifestyle recommendations for migraines
dietary - fresh foods, avoid MSG takeaways hormonal - OCP drink plenty of water dont have late nights or oversleep avoid caffeine
prophylaxis for migraines
OTC - magnesium etc TCAs - amitriptyline beta blockers - propanolol serotonin agonists - PIZOTIFEN (very effective) anticonvulsants botox suppress ovulation - OCP ERENUMAB injections monthly
how is erenumab used in treating headaches?
prophylactic injections for migraines 2x month
monoclonal antibody
what are the phases of a migraine?
prodromal aura headache resolution recovery
what is the prodromal phase of a migraine
changes in mood inc urination fluid retention food craving yawning
what is the aura phase of migraine
visual or sensory numbness/tingling weakness speech arrest hallucinations
what is the headache phase of migraine
head and body pain
nausea
photophobia
phonophobia
what is the recovery like from a migraine
mood disturbed
food intolerance
feeling hungover
for about 48hrs
what are positive and negative auras
positive - flashes, zigzags
negative - blindspots
what is the SOCRATES of a tension headache
S - generalised, bilateral O - gradual onset usually C - dull, tight band-like R - neck/shoulders A- pericranial muscle tenderness, NO NAUSEA/vomiting/photophobia etc T - 3-4hrs E - analgesics, rest S - moderate
treatments for tension headache
analgesics - NSAIDs preferred, paracet
if chronic, TCAs and SSRIs
when should TCAs/SSRIs be considered for tension headaches?
if chronic - 7-9 headache days/month
SOCRATES for cluster headaches
S - strictly unilateral, behind eye common, usually same side each time
O- acute onset, same time of day
C - excruciating, steady pain
R - none
A - eye watering, nose blocked, ptosis, eye redness, sweating, restlessness (autonomic features), photophobia, phonophobia
T - 15min-3hr, same length each time, often nocturnal, come in clusters with long remissions
E -
S - worst pain ever experienced
acute management of cluster headaches
high flow O2
serotonin agonist - Sumatriptan (subcut or nasal)
what autonomic disorder is associated with cluster headaches
horners syndrome
prophylaxis of cluster headaches
verapramil prednisolone lithium valproate gabapentin topiramate pizotifen
differences between cluster and migraine
women migraine, men cluster
migraine longer duration but cluster have long remissions and daily attacks
nausea in migraine not cluster
pain in migraine is pulsating, cluster is steady
migraine has aura, cluster has ptosis etc
migraine patients lie in dark, cluster patients pace around
