headaches Flashcards
what is a headache?
a symptom
half to three quarters of adults age 18-65 in the world have had a headache in the past year
among those 30% or more have reported a migraine
what are the general bases of generation of headaches?
some structural
some perhaps pharmacological (eg. GTN used to treat angina)
some psychological
what are the main patterns of headache?
acute single headache
dull headache, increasing in severity
dull headache, unchanged over months
recurrent headaches
triggered headaches
what are causes of an acute single headache?
much more serious than other headaches
febrile illness, sinusitis, first attack of migraine, following a head injury, subarachnoid haemorrhage, meningitis, tumour, drugs, toxins, stroke, thunderclap, low pressure
what are causes of a dull headache that worsens in severity?
usually benign, but may be worrying
overuse of medication (eg. codeine), OCP, HRT, neck disease, temporal arteries, benign intercranial hypertension, cerebral tumour, cerebral venous sinus thrombosis
what are causes of a dull headache, unchanging over months?
people complain most about these
chronic tension headache
depressive, atypical face pain
what are causes of recurrent headaches?
lots of complaining about these
migraine, cluster headache, episodic tension headache, trigeminal or post herpetic neuralgia
what are causes of triggered headaches?
coughing, straining, exertion, sex, food and drink
what are headache red flags?
onset:
thunderclap, acute, subacute
meningism:
photophobia, phonophobia, stiff neck, vomiting
systemic symptoms:
fever, rash, weight loss
neurological symptoms or focal signs:
visual loss, confusion, seizures, hemiparesis, double vision, 3rd nerve palsy, horner syndrome, papilloedema
orthostatic:
better lying down
strictly unilateral
what are focal signs of headaches that are red flags?
double vision
3rd nerve (occulomotor) palsy
horner syndrome
what is 3rd nerve palsy?
palsy of the occulomotor nerve , it doesn’t work
symptoms:
one eye has a ptosis - levator palpabrae innervated by CN III
dilated pupil - as CNIII constricts pupil
eye points down and out - as lateral rectus and superior oblique are only extraoccular muscles not supplied by CNIII
what is horner syndrome?
when sympathetic nerve supply to an eye is affected, doesnt work
sympathetic dilates the pupil and opens it
so in horners, one eye is smaller, constricted, looks pushed in (enopthalmos)
what is the headache caused by a subarachnoid haemorrhage like?
sudden generalised headache “blow to the head”, thunderclap
often occipital
causes meningism - stiff neck and photophobia
blood irritates the meninges
most are caused by a ruptured aneurism, a few from arterovenous malformations and some are unexplained
what are the risks and treatments of subarachnoid haemorrhages?
50% are fatal
high risk of further bleed
may be automatic vasospasm which may stop the leak
we give nimodipine and BP control
early neurological assessment. will confirm the bleed and assess the cause
CT brain, lumbar puncture (for RBC and Xanthochromia) (if cant tell if there is a bleed from CT), MRA and angiogram
how are aneurisms treated?
used to be clipped or wrapped physically
now they are filled with platinum coils. doesnt require opening of the head. instead you use a catheter.
the platinum causes the aneurism to sclerose and seal
what is an intracerebral bleed?
fatal haemorrhage due to coning
it increases ICP.
brain can tolerate a certain amount of bleeding into the brain due to compliance, but then it gets past this point and a small increase in volume highly increases the pressure
coning is when the brain creeps around the falx, or the tentorium, or the skull (worst coz this is the area that controls respiration)
what is papilloedema?
optic disc swelling
due to raised ICP
visible when you look at the eye
what are carotid and vertebral artery dissections?
the arteries leading up to the neck can split, blood collects in the split between layers, and causes turbulent flow
causes headache and neck pain
cause 20% of ischaemic strokes <45 yrs (young stroke)
mean age is 40, Carotid>vertebral
can be traumatic/spontaneous
diagnosed with MRI,MRA, doppler, angiography
how are carotid and vertebral artery dissections treated?
aspirin or anticoagulation
as turbulent flow causes sticky blood prone to clotting
what are symptoms of a vertebral vs carotid artery dissection?
vertebral - occipital and back of neck pain
carotid - phantom of the opera mask pain distribution
what is chronic subdural haemorrhage?
SDH
due to a venous bleed. so slow.
causes blood to accumulate under the dura
can cause compression of the ventricles and the brain
common in old people who are on anticoagulants and fall
causes headache, unsteadiness and weakness on the (ipsilateral?) side
may be solved by just draining the blood
what is temporal arteritis?
inflammation of the arteries in the temporal lobe
occurs in people over the age of 55.
three times more common in females
disruption of the internal elastic lamina is the main sign of vasculitis
what are symptoms of temporal arteritis?
constant unilateral headache
scalp tenderness
jaw claudication
25% also get polymyalgia rheumatica - proximal muscle tenderness
involvement of the posterior ciliary arteries can cause blindness
how is temporal arteritis diagnosed and treated?
may be seen on ultrasound. the arteries
biopsy shows inflammation and giant cells
elevates ESR and CRP (inflammatory markers)
treatment:
high dose steroids and aspirin
what is cerebral venous thrombosis?
thrombosis in dural venous sinus or cerebral vein. blood cant leave the brain
unusual high amount of headache due to raised ICP
non territorial ischaemia “venous infarcts”
haemorrhage
may be caused by thrombophilia (sticky blood), pregnancy, dehydration, behcets
what are causes of minigitis?
viral - Caxsackie, ECHO, mumps, EBV
bacterial - menincococci, pneumococci, haemophilus, tubrculosis. (bacterial is more worrying)
fungal - cryptococci
granulomatous - sarcoid, lyme, brucella, syphilis
carcinomatous
what are the symptoms of meningitis?
very similar to that of a subarachnoid haemorrhage
malaise, headache, fever, neck stiffness, photophobia, confusion, alteration to consciousness
but the main one is fever
they may look septic if they have been left untreated
what is herpes simplex encephalitis?
infection that effects the brain tissue
commonly effects the temporal lobe
(meningitis affects the meninges, encephalitis affects the brain)
how is meningitis treated and diagnosed?
treat first then think about diagnosis (because it kills fast)
antibiotics
diagnosis:
blood and urine culture
CT, MRI
lumbar puncture (increased white cell count, decreased glucose, antigens, cytology, bacterial culture)
CT, MRI must come before lumbar puncture.
as meningitis causes cerebral oedema with effacement of ventricles and sulci and inflamed meninges. so LP will decompress this, and the brain might hurtle through the foramen magnum
what are the symptoms of sinusitis?
causes a really bad headache but wont kill you
malaise, headache, fever.
blocked nasal passages, loss of vocal resonance, anosmia. nasal or postnasal catarrh.
local pain and tenderness (sinuses, either side of nose, or above eyes)
frontal pain starts 1-2 hours after waking up then clears up during the afternoon
what is idiopathic intracranial hypertension?
people may think they have a brain tumour but they have this instead
causes raised ICP
aka pseudotumour cerebri
often seen in overweight people and women
may be caused by drugs:
hormones, steroids, antibiotics, vitamin E
what are symptoms of idiopathic intracranial hypertension?
headache, visual obscurations, diplopia, tinnitus, papilloedema +/- visual field loss
how is idiopathic intracranial hypertension treated?
weight loss (maybe even bariatric surgery), diuretics, optic nerve sheath decompression, lumboperitoneal shunt, stenting of stenosed venous sinuses
what is a low pressure headache?
headaches caused caused low ICP
orthostatic headaches are a hallmark of these. (when they stand up)
possible causes:
CSF leak due to tear in dura.
traumatic post lumbar puncture
may be no apparent cause
diagnosis:
MRI with gadrolinium contrast. shows intense meningeal enhancement
how are low pressure headaches treated?
rehydration, caffeine (seals the hole), blood patch (remove blood then inject it straight into the dura. it will find and seal the hole)
what is chiari malformation?
normal brain, but it just sits very low down in the cranium
cerebellar tonsils descend through the foramen magnum. they descend further when the patient coughs (as the pressure in the head goes up a bit). when this happens they tug on the meninges which causes a sudden, short lived horrible headache.
treat the cold or the cough. or do an operation to remodel the base of the skull
what is obstructive sleep apnoea (related to headache)?
cant breathe at night due to obstruction. may go with obesity. history of loud snoring and apnoeic spells
causes hypoxia, CO2 retention, non refreshing sleep, depression, poor performance at work
headaches - due to retained CO2. it is a potent vasodilator. vasodilates blood vessels in the brain. headache decreases over the course of the morning ass they breathe normally
requires a sleep study.
treatment: nocturnal NIV, surgery
what is trigeminal neuralgia?
not necessarily a headache cause
but causes really bad pain on the face.
trigeminal: 3 branches
electric shock like pain in the distribution of a sensory nerve
often triggered by innocuous stimuli
any division of the trigeminal can be effected
cause:
neurovascular conflict at the point of entry of the nerve into the pons
can be a symptom of MS
treatment: carbamazepine, lamotrigine, gabapentin, posterior fossa decompression
what is atypical facial pain?
daily, constant, ill defined, poorly localised deep aching or burning.
in facial or jaw bones, but may extend to neck ear or throat.
not lancinating
commonly occurs in middle aged women who are depressed or anxious
doesn’t conform to strict anatomical distribution of ay nerve
no sensory loss
unresponsive to conventional analgesics
opiates and nerve blocs may be used
also antidepressants
what is post traumatic headache?
of people admitted with head injury, headaches are present in:
36% at discharge
24% at 6 months
16% at 1 year
it correlates with a previous history of headache
but unrelated to duration of post traumatic amnesia
it depends on the nature of the head injury: high in victims of car accidents low in perpetrators low in sports injuries (so psychological element)
multiple mechanisms: neck injury scalp injury vasodilation? autonomic damage? depression - often delayed
how is post traumatic headache treated?
give them an explanation stop them from abusing analgesics patience non steroidal anti inflammatories - ibuprofen, naproxen tricyclic antidepressants
what is cervical spondylosis?
common cause of new headaches in old patients, due to arthritis
pain: bilateral normally occipital constant no nausea or vomiting worsened by moving the neck
management:
rest, deep heat, massage
anti inflammatory analgesics
