Headaches Flashcards
Presentation of tension headache?
Recurrent, non-disabling, bilateral headache, often described as a ‘tight-band’. Non-pulsatile. Classically every day - can persist for months/years.
Presentation of migraine?
Recurrent, severe headache. Unilateral, Throbbing.
Associated with aura, nausea and photosensitivity
Aggravated by routine activities of daily living. Patients often describe ‘going to bed’.
Associated to women during period.
Presentation of medication overuse headache?
Present for 15 days or more per month.
Developed or worsened whilst taking regular symptomatic medication
Patients using opioids and triptans are at most risk
Causes of headache?
Tension
Cluster
Migraine
Med overuse
SAH
SOL
Meningitis
Idiopathic intracranial hypertension
Temporal arteritis/GCA
Post traumatic headache
Sinusitis
Acute angle closure glaucoma
Venous sinus thrombosis
Chairi malformation with syringomyelia
Presentation of cluster headache?
Male, smoker.
Pain once or twice a day, each episode lasting 15 mins - 2 hours. Clusters typically lasting 4-12 weeks
Unilateral pain
Associated with
- intense pain around one eye (recurrent attacks ‘always’ affect same side)
- restlessness during an attack.
- accompanied by redness, lacrimation, lid swelling/ partial Horner’s syndrome
Pathophysiology of tension headache?
Tiredness, anger, stress, tension in muscles of neck or head.
Investigations of tension headache?
Clinical Dx usually. (at a push = CT sinus, MRI brain, lumbar puncture)
Management of tension headache?
Simple analgesia
Amitriptyline 10mg if chronic
Mindfulness
Relaxation therapy
Differentials for tension headache?
Chronic migraine
Medicine overuse headache
Sphenoid sinusitis
GCA
TMJ disorder
Pit tumour / Brain tumour
Investigations for a migraine?
Clinical Dx.
ESR, Lumbar puncture, CSF fluid culture, MRI brain, CT head, angiography.
Management for a migraine?
- in ED = Rescue therapy e.g. metaclopramide +adequate hydration + high flow oxygen + IV dexamethasone.
- acute presentation:
—> mild to moderate Sx = NSAIDs + anti-emetic
—> severe Sx = triptan + anti-emetic
Differentials for a migraine?
Cluster headache
Med overuse headache
Headache after head or neck trauma
SAH
Brain tumour
Idiopathic intracranial HTN
CNS infection
GCA
Presentation of medication overuse headache?
Present for 15 days or more per month
Developed or worsened whilst taking regular symptomatic medication
Patients using opioids and triptans are at most risk
Pathophysiology of medication overuse headaches?
Regular use of med - paracetamol, NSAIDs, triptans, opiods. Pts develop new type of headache or have deterioration of pre-existing headache
Management of medication overuse headaches?
Check for red flags and causes of secondary headache
Withdraw from overused medication for at least 1 month.
Keep headache diary.
Differentials of medication overuse headaches?
-Chronic migraine
-Chronic tension headache
-Cluster headache
-Head / Neck trauma
-GCA
-Idiopathic intracranial HTN
-Substance misuse/withdrawal
-Infection - meningitis, encephalitis, cerebral abscess, systemic infection
-Hypoxia, HTN
- ENT differentials too —> Otitis media +/- effusion, TMJ disorder, sinusitis
Investigations of cluster headache?
Passmed
* most patients will have neuroimaging - underlying brain lesions are sometimes found even if the clinical symptoms are typical for cluster headache
* MRI with gadolinium contrast is the investigation of choice
Brain MRI without and with IV contrast
ESR
Pit function tests
Brain CT
Polysomnogram - check for sleep apnoea
ECG
Management of cluster headache?
Subcut sumatriptan
Oxygen
Intranasal triptan
Lidocaine
Verapamil
Presentation of a subarachnoid haemorrhage?
Sudden onset headache - ‘thunderclap’
Nausea and vomiting
Meningism (photophobia, neck stiffness)
Dizziness
Orbital pain
Diplopia
Visual loss
Coma
Seizures
Sudden death
ECG changes - ST elevation
The 2 main groups of causes of subarachnoid haemorrhage are t___ and s______?
Head injury (trauma)
Spontaneous
Causes of spontaneous subarachnoid haemorrhage?
Intracranial aneurysm aka berry aneurysm
AV malformation
HTN
Other causes:
Pituitary apoplexy
Arterial dissection
Infective/Mycotic aneurysm
Perimesencephalic (idiopathic venous bleed)
Investigations for subarachnoid haemorrhage?
1a) CT scan of the head
1b)Lumbar puncture (if CT is negative for showing blood)
2) CT intracranial angiogram - following confirmed Dx of SAH
When is LP done for SAH?
- if CT scan of head is negative for blood
- at least 12 hours following onset of symptoms
For a SAH, why is a LP done in the time frame suggested?
12 hours (at least) following symptoms BECAUSE:
- allow enough time for xanthochromia to develop
xanthochromia = RBC breakdown product. (Gives LP yellow tinge)
Investigation following confirmation of subarachnoid haemorrhage?
CT - do this ASAP (BMJ called this CT intracranial angiogram)
LP/CSF, MRI brain, angiography
Management for subarachnoid haemorrhage?
Referral to neurosurgery once SAH confirmed for cerebral angiogram
Treatment is based upon causative pathology
Intracranial aneurysms need to be treated within 24 hrs
Treated with a coil
Some pt need craniotomy and clipping by neurosurgeon
Other things:
1) Strict bed rest, well controlled BP (SBP<150), avoid straining to prevent re-bleed.
2) Treat vasospasm with nimodipine ( a CCB)
3) Hydrocephalus is treated with external ventricular drain
CSF findings in subarachnoid haemorrhage?
High protein
WCC not raised
Glucose normal
Xanthochromia
Complications of aneurysmal subarachnoid haemorrhage?
Re-bleeding
Vasospasm
Hyponatraemia
Seizures
Hydrocephalus
Death
Prognosis of subarachnoid haemorrhage?
V poor.
Up to 15% die before reaching hospital.
25% die in 24hrs
40% die in 1 month
50% overall mortality in 6 months
33% survivors have major neurological defecits
Presentation of space occupying lesion?
Headache
Worse on walking, worse when lying down or coughing/straining
Associated to vomiting
Visual field defects
Early symptoms are non-specific
Cranial nerve palsies may present
Advanced cases: drowsy, seizures, pupillary abnormalities, papillodema
Cushing’s reflex - raised BP, bradycardia and abnormal breathing
Investigation for space occupying lesion?
MRI of brain (+/- contrast)
CT head and spine (if can not have MRI)
Management of space occupying lesion?
Simple measures:
- elevate head of bed
- avoid pyrexia
- analgesia
Specific medical measures:
- anticonvulsants
- sedation / NM blockade
- mannitol or hypertonic saline
Surgical measures:
- ventriculostomy
- decompressive craniotomy
Presentation of meningitis?
Symptoms:
Headache
Fever
Nausea and vomiting
Photophobia
Drowsy
Seizures
Signs:
Neck stiffness
Purpuric rash
Investigation for meningitis?
(With regard to main investigation, what would findings be for causes of meninigits?)
LP for CSF - if no signs of raised intracranial pressure
FBC
CRP
Blood culture
Whole blood PCR
Blood glucose
Coag screen
Blood gas
Bacterial = cloudy, low glucose, high protein, 10-5000 polymorphs/mm3 of neutrophils. Culture +ve for bacteria
Viral = clear, normal protein (mildly raised), normal glucose, high lymphocytes. Culture -ve as no bacteria
Tuberculous = fibrin wed/cloudy, low glucose, high protein, 10-1000 lymphocytes/mm3
Management for meningitis?
Abx:
<3 months old = IV cefotaxime + amoxicillin
3m - 50years = IV cefotaxime
> 50yrs = IV cefotaxime + amoxicillin
Meningococcal meningitis = IV benzylpenicillin or cefotaxime
IV dexamethasone ( in certain circumstances, this is withheld)
Prophylaxis for household and close contacts
When is IV dexamethasone not given in meningitis management?
DO NOT give IV dexamethasone in:
Septic shock
Meningococcal septicaemia
Immunocompromised
Meningitis following surgery
What are complications of meningitis?
Sensorineural hearing loss
Seizures
Focal neurological deficit
Infective
—> sepsis
—> intracerebral abscess
Pressure
—> brain herniation
—> hydrocephalus
Risk of what syndrome with meningococcal meningitis?
Waterhouse-Friderichsen syndrome = adrenal insufficiency secondary to adrenal haemorrhage
Presentation of idiopathic intracranial hypertension?
Headache
Blurred vision
Papilloedema
Enlarged blind spot
Sixth nerve palsy
Risk factors for idiopathic intracranial hypertension?
Obesity
Female
Pregnancy
Drugs = COCP, steroids, tetracyclines, Vit A, lithium
Investigations for idiopathic intracranial hypertension?
MRI brain +/- contrast
Visual field testing
Dilated fundoscopy - may see papillodema
Visual acuity
Lumbar puncture at spinal L3/L4
Management for idiopathic intracranial hypertension?
- Weight loss
- Diuretics - acetazolamide
- Note: topiramate is also used, and has the added benefit of causing weight loss in most patients
- Repeated LP
- Surgery: optic nerve sheath decompression and fenestration. Lumboperitoneal or ventriculoperiotneal shunt
Presentation of temporal arteritis?
Patient over 50+
Rapid onset <1month
Headache
Jaw claudication
Visual disturbance
-amaurosis fugax
-blurring
-double vision
Tender, palpable temporal artery
PMR in 50% of patients
Lethargy
Depression
Fever
Anorexia
Night sweats
Investigations for temporal arteritis?
Raised inflammatory markers - ESR and CRP
Temporal artery biopsy
CK - normal
Treatment for temporal arteritis?
- Urgent high dose glucocorticoids as soon as Dx suspected (prednisolone if there is no visual loss or IV methylprednisolone if there is visual loss).
- Urgent ophthalmology review
- Bone protection with bisphosphanates while steroids are required.
- Low dose aspirin sometimes given
Presentation of post traumatic headaches?
- new headache within 7 days of a head injury - feels like migraine / tension like pain
- nausea and vomiting
- dizzy
- insomnia
- concentration issues / memory issues
- sensitive to light
Investigations for post traumatic headaches?
non-contrast CT head - rule out any bleeds in the brain
FBC, CRP, U+Es
XR /MRI - skull fractures?
Management for post traumatic headaches?
Pain killers - ibuprofen, naproxen
Triptans
assess GCS
Manage any other issues - e.g. drug intoxication
Complications for post traumatic headaches?
death
intracranial lesions
depression and anxeity
Presentation of sinusitis?
Hx of of nasal obstruction, recent local infection, swimming, smoking
Headache/ Facial pain in frontal area, worse on bending forward.
Nasal discharge - thick and purulent.
Nasal obstruction
Post nasal drip (in chronic).
Management for sinusitis?
Acute:
- analgesia.
- intranasal decongestants
- intranasal steroids if 10+ days
- abx for v severe presentations
Chronic:
- avoid allergen
- intranasal steroids
- nasal irrigation with saline
Red flags for sinusitis?
Unilateral Sx
Persistent Sx despite compliance with 3 months of treatment
Epistaxis
Presentation of acute angle closure glaucoma?
Severe pain - headache or ocular type pain
Decreased visual acuity
Symptoms worse with mydriasis (e.g watching TV in dark room)
Hard, red eye
Haloes around eye
Fixed, semi-dilated, oval non-reacting pupil
Coreneal oedema = get hazy cornea
Systemic upset = N+V, abdo pain
Predisposing factors for acute angle closure glaucoma?
Hypermetropia = long sighted
Pupillary dilatation
Lens growth with age
Investigations for acute angle closure glaucoma?
Gonioscopy = to visualise the anterior chamber angle
Slit lamp examination/fundoscopy
Tonometry - to assess intraocular pressure
Management for acute angle closure glaucoma?
EMERGENCY SITU - need urgent referral to optham
Emergency treatment to lower IOP - acetozolomide IV. This reduces aqueous secretions
Topical therapy - pilocarpine = opens trabecular meshwork to increase outflow of aqueous humour. - timolol = decrease aqueous humour production
Definitive management:
- laser peripheral iridotomy = create hole in peripheral iris to allow free flow of aqueous – the contralateral eye is treated prophylactically as it is predisposed to PACG
Complications for acute angle closure glaucoma?
Adverse reactions to glaucoma medication
Post-trabeculectomy complications:
- anterior uveitis/iritis
- blebitis
- sudden changes in IOP
Red flags for headaches?
1) Thunderclap headache = severe and sudden onset. ‘sudden means vascular until proven otherwise’.
2)Meningism = Neck stiffness +Photophobia
3)Non blanching purpuric rash = menigococcal septicaemia.
4) Fever = infection, vascular, inflammation, raised ICP or SOL.
5) Characteristics of raised ICP —> present on waking, worse if lying, exacerbated by leaning forward, coughing, valsalva, papillodema
6) Recent onset or change in character = secondary cause
7) Hx of malignancy = mets.
8) Constitutional symptoms = e.g. night sweats, scalp tenderness in pt 50+ = GCA
9) New onset in older person = new pathology
What is GCS?
Initially used for head injury, now reproducible way to measure consciousness.
Outline GCS
BEST MOTOR GRADE (6)
1- no response to pain
2-Extensor posturing to pain
3-Abnormal flexion to pain
4- withdraws to pain
5- localises response to pain
6- obeying a comment
BEST VERBAL RESPONSE (5)
1- none
2- incomprehensible speech
3- inappropriate speech
4- confused conversation
5-Orientated
EYE OPENING (4)
1- no eye opening
2-opening in response to pain
3- eye opening in response to any speech
4- spontaneously opening eyes
What are the characteristics of a migraine?
ICHD CRITERIA
A- At least 5 attacks fulfilling criteria B-D
B- Headache attacks lasting 4-72 hours (when untreated or unsuccessfully treated)
C- Headache has at least 2 of the following 4 characteristic: Unilateral location, pulsating quality, moderate or severe pain intensity, aggravation by or causing avoidance of routine physical activity (e.g. walking or climbing stairs)
D- During the headache at least one of following: N&v or photophobia/phonophobia
E- Not Bette accounted for by another ICHD-3 diagnosis
Migraine triggers?
Stress
Too much sleep
Too little/ poor/broken sleep
Missing meals
alcohol
dehydration
strong smells
Criteria for a headache to be medication overuse headache?
Headache occurring on 15 or more days/month in a pt with a pre-existing headache condition and as a consequence of taking analgesia regularly for 15 days/month (simple analgesics) or 10days/month (triptans, opioids, ergotamine)
What is a primary headache?
migraine, cluster, tension.
What is a secondary headache?
Caused by a separate underlying pathological process that may be amenable to treatment
Causes for secondary headaches?
Vascular
Haemorrhage
Infective
Neoplastic
Drugs
Inflammation
Raised ICP
Trauma
Metabolic
Toxins
Glaucoma
Sinus disease
HTN
CT scan for SAH:
- what is sensitivity of scan in first 24hrs?
- what is sensitivity of scan in 72hrs?
24 hrs = 90%
72hrs = 50%
