Headaches Flashcards
Red flags associated with headaches
Fever, photophobia or neck stiffness
New neurological symptoms
Dizziness
Visual disturbance
Sudden onset occipital headache
Worse on coughing or straining (raised intracranial pressure)
Postural, worse on standing, lying or bending over
Severe enough to wake the patient from sleep
Vomiting
History of trauma
Important assessment in headaches
Fundoscopy examination to look for papilloedema is an important part of an assessment of a headache. Papilloedema indicates raised intracranial pressure, which may be due to a brain tumour, benign intracranial hypertension or an intracranial bleed.
Presentation of tension headaches
Classically they produce a mild ache across the forehead and in a band-like pattern around the head.
This may be due to muscle ache in the frontalis, temporalis and occipitalis muscles.
Tension headaches comes on and resolve gradually and don’t produce visual changes.
What are tension headaches associated with
Stress Depression Alcohol Skipping meals Dehydration
Treatment of tension headaches
Reassurance
Basic analgesia
Relaxation techniques
Hot towels to local area
What can secondary headaches be secondary to
Underlying medical conditions such as infection, obstructive sleep apnoea or pre-eclampsia
Alcohol
Head injury
Carbon monoxide poisoning
How does sinusitis usually present
Causes a headache associated with inflammation in the ethmoidal, maxillary, frontal or sphenoidal sinuses.
This usually produces facial pain behind the nose, forehead and eyes. There is often tenderness over the affected sinus, which helps to establish the diagnosis.
Sinusitis disease course
usually resolves within 2-3 weeks. Most sinusitis is viral.
Management of sinusitis
Nasal irrigation with saline can be helpful.
Prolonged symptoms can be treated with steroid nasal spray.
Antibiotics are occasionally required.
What is an analgesic headache
Caused by long term analgesia use. It gives similar non-specific features to a tension headache.
They are secondary to continuous or excessive use of analgesia.
Withdrawal of analgesia important in treating the headache, although this can be challenging in patients with long term pain and those that believe the analgesia is necessary to treat the headache.
What are hormonal headaches related to
They produce a generic, non-specific, tension-like headache.
They tend to be related to low oestrogen
Presentation of hormonal headache
Two days before and first three days of the menstrual period
Around the menopause
Pregnancy. It is worse in the first few weeks and improves in the last 6 months.
Headaches in the second half of pregnancy should prompt investigation for pre-eclampsia.
What can help improve hormonal headaches
Oral contraceptive pill
What is cervical spondylosis caused by
Degenerative changes in the cervical spine. It causes neck pain, usually made worse by movement. However, if often presents with headache.
Which condition is associated with trigeminal neuralgia
MS
How does trigeminal neuralgia present
Presents with intense facial pain that comes on spontaneously and last anywhere between a few seconds to hours. It is often described as an electricity-like shooting pain. Attacks often worsen over time.
Possible triggers for pain in patients with trigeminal neuralgia
Cold weather
Spicy food
Caffeine
Citrus fruits
First line treatment for trigeminal neuralgia
Carbamazepine
Surgery to decompress or intentionally damage the trigeminal nerve is an option
Typical migraine symptoms
Headaches last between 4 and 72 hours. Typical features are:
Moderate to severe intensity Pounding or throbbing in nature Usually unilateral but can be bilateral Discomfort with lights (photophobia) Discomfort with loud noises (phonophobia) With or without aura Nausea and vomiting
What does aura refer to
Aura is the term used to describe the visual changes associated with migraines. There can be multiple different types of aura:
Sparks in vision
Blurring vision
Lines across vision
Loss of different visual fields
What type of migraines can mimic stroke
Hemiplegic migraines can mimic stroke. It is essential to act fast and exclude a stroke in patients presenting with symptoms of hemiplegic migraine.
Symptoms of hemiplegic migraine
Symptoms of a hemiplegic migraine can vary significantly. They can include:
Typical migraine symptoms Sudden or gradual onset Hemiplegia (unilateral weakness of the limbs) Ataxia Changes in consciousness
Migraine triggers
Stress Bright lights Strong smells Certain foods (e.g. chocolate, cheese and caffeine) Dehydration Menstruation Abnormal sleep patterns Trauma
5 stages of migraine
Premonitory or prodromal stage (can begin 3 days before the headache)
Aura (lasting up to 60 minutes)
Headache stage (lasts 4-72 hours)
Resolution stage (the headache can fade away or be relieved completely by vomiting or sleeping)
Postdromal or recovery phase
Acute management of migraine
Paracetamol
Triptans (e.g. sumatriptan 50mg as the migraine starts)
NSAIDs (e.g ibuprofen or naproxen)
Antiemetics if vomiting occurs (e.g. metoclopramide)
Triptans in migraines
Triptans are used to abort migraines when they start to develop. They are 5HT receptors agonists (serotonin receptor agonists).
How do triptans abort migraines
They have various mechanisms of action and it is not clear which mechanisms are responsible for their effects on migraines. They act on:
Smooth muscle in arteries to cause vasoconstriction
Peripheral pain receptors to inhibit activation of pain receptors
Reduce neuronal activity in the central nervous system
Migraine prophylaxis
Keeping a headache diary can be helpful in identifying the triggers. Avoiding triggers can reduce the frequency of the migraine.
Propranolol
Topiramate (teratogenic)
Amitriptyline
Acupuncture
B2 supplements
Most common cause of SAH
Head injury - traumatic SAH
Causes of spontaneous SAH
Berry aneurysm
AVM
Pituitary apoplexy
Aortic dissection
Classical features of SAH
Thunderclap headache Nausea and vomiting Meningism Coma Seizures Sudden death
How is SAH confirmed
CT head
LP if CT is negative 12 hrs after onset of symptoms
IX post confirmation of SAH
CT intracranial angiogram
+/- digital subtraction angiogram(catheter)
Mx of SAH
Coil by IR
Craniotomy
Bed rest
Vasospasm treated with 21-day course of nimodipine
Complications of aneurysmal SAH
Re-bleeding Vasospasm(7-14 days after onset) Hyponatraemia due to SIADH Seizures Hydrocephalus
Risk factors for SAH
HTN Smoking Excessive alcohol consumption Cocaine use FHx
Signs of SAH in LP
Red cell count will be raised. If the cell count is decreasing in number over the samples, this could be due to a traumatic lumbar puncture.
Xanthochromia (the yellow colour of CSF caused by bilirubin)
When should you suspect bacterial aetiology for sinusitis
Symptoms for more than 10 days
Discoloured or purulent nasal discharge (with unilateral predominance).
Severe local pain (with unilateral predominance).
A fever greater than 38°C.
A marked deterioration after an initial milder form of the illness (so-called ‘double-sickening’).
Elevated ESR/CRP
Examination in sinusitis
Inspecting and palpating the maxillofacial area to elicit swelling and tenderness.
Performing anterior rhinoscopy (using the largest speculum of an otoscope, or a head light and nasal speculum) to identify:
Signs which support a diagnosis of acute sinusitis such as nasal inflammation, mucosal oedema, and purulent nasal discharge.
Associated pathology such as nasal polyps, or anatomical abnormalities such as septal deviation.
What should be examined in trigeminal neuralgia
Examine the person’s face and oral cavity (including the trigeminal nerves) to rule out dental causes of pain, and to detect any abnormalities that require referral to a neurologist
Which conditions can lead to compression of the trigeminal nerve or cause symptoms similar to those of trigemninal neuralgia
Tumours, such as posterior fossa tumours, extracranial masses along the trigeminal nerve, perineural spread of existing malignancy, cavernous sinus masses
Multiple sclerosis
Epidermoid, dermoid, or arachnoid cysts
Aneurysm, or arteriovenous malformation
Common adverse effects of carbamazepine
Nausea and vomiting
Sedation
Dizziness
Ataxia
Leuopenia
Switching to MR preparation of carbamazepine may help
Symptoms of cluster headaches
Red, swollen and watering eye Pupil constriction (miosis) Eyelid drooping (ptosis) Nasal discharge Facial sweating
Acute management of cluster headaches
Triptans (e.g. sumatriptan 6mg injected subcutaneously)
High flow 100% oxygen for 15-20 minutes (can be given at home)
Prophylaxis for cluster headaches
Verapamil
Lithium
Prednisolone (a short course for 2-3 weeks to break the cycle during clusters)
What can trigger cluster headaches
Alcohol
Strong smells
Exercise
Presentation of parietal lesions
sensory inattention apraxias astereognosis (tactile agnosia) inferior homonymous quadrantanopia Gerstmann's syndrome
Presentation of occipital lobe lesions
homonymous hemianopia (with macula sparing)
cortical blindness
visual agnosia
Presentation of temporal lobe lesions
Wernicke’s aphasia
superior homonymous quadrantanopia
auditory agnosia
prosopagnosia (difficulty recognising faces)
Presentation of frontal lobe lesions
Broca's aphasia Disinhibition Perseveration Anosmia Inability to generate a list
Presentation of cerebellum lesions
midline lesions: gait and truncal ataxia
hemisphere lesions: intention tremor, past pointing, dysdiadokinesis, nystagmus
