Headaches Flashcards
What condition would you be concerned about in a pt who presents with visual loss?
Giant cell arteritis, acute angle closure glaucoma
What condition would you be concerned about in a pt with prolonged visual aura?
Arteriovenous malformation (AVM)
What condition would you be concerned about in someone with disequilibrium?
CVA, brain tumor
Confusion or lethargy?
Meningitis, encephalitis, brain tumor, brain abscess
New-onset seizure?
infection, brain tumor
Fever?
Meningitis, encephalitis, brain abscess
Speech changes?
Expressive or receptive aphasia (brain tumor)
History of malignancy?
Brain tumor, metastasis
History of HIV?
CNS lymphoma, toxoplasmosis, cryptococcal meningitis
History of neurosurgery or CNS shunt?
Hydrocephalus, meningitis
Eye pain?
Acute angle closure glaucoma
Thunderclap headache?
Subarachnoid hemorrhage
New onset after age 50?
brain tumor, CVA, giant cell arteritis
Progressive headache over weeks to months?
Brain tumor
Diplopia?
Brain tumor, CVA, AVM
Hemiparesis?
CVA, brain tumor, brain abscess
Aphasia?
CVA, brain tumor, brain abscess
Headache worse at work?
Carbon monoxide poisoning
Nausea?
Brain tumor, hydrocephalus, carbon monoxide poisoning
Neck stiffness?
Meningitis
Onset of headache with exertion, cough, or sexual activity?
Subarachnoid hemorrhage (SAH)
Unilateral in 60 to 70 percent, bifrontal or global in 30 percent
Migraine
Bilateral location
Tension
Always unilateral
Cluster headache (usually begins around eye or temple)
Gradual or abrupt onset, crescendo pattern, pulsating, aggravated by physical activity
migraine
pressure or tightness that waxes and wanes
tension
pain begins quickly. Deep, continuous, excruciating pain. Described as “hot poker” through the eye
Cluster
Patient may remain active or need to rest
Tension
Patient remains active, pacing around
Cluster
Duration is 4-72 hours
Migraine
Duration is 30 minutes to 3 hours
Cluster
Associated symptoms: N/V, photo/phonophobia, may have aura
migraine
Associated symptoms: Ipsilateral lacrimation and redness of the eye, stuffy/runny nose, sweating, pallor, Horner’s symptoms, sensitivity to alcohol.
Cluster headache
Focal neurologic symptoms are rare
Cluster headache
Women > men
migraines
Women = men
Tension
Men > women
Cluster
More common in smokers
Cluster
POUND: P
pulsatile quality
POUND: O
4-72 hOurs
POUND: U
Unilateral location
POUND: N
Nausea or vomiting
POUND: D
Disabling intensity
What should you consider if your patient is pregnant?
Benign intracranial hypertension (Pseudotumor cerebri), venous sinus thrombosis, and new-onset migraine
Chronic nasal stuffiness or chronic URI with headache suggests what?
Sinusitis (but can also be s/s of migraine)
Impaired vision or seeing “holes” around light suggests what?
Glaucoma (present within one hour with unilateral pain suspect sub acute angle closure glaucoma)
Visual field defects suggests what?
Presence of lesions in the optic chiasm
Bitemporal hemianopsia suggests what?
pituitary mass
Blurring of vision on forward bending of the head, and headaches with early morning awakening that improve with sitting up and double vision suggests what?
Increased intracranial pressure
Headaches that are relieved by recumbency and exacerbated with upright position suggests what?
Low CSF pressure or CSF leak. Recent lumbar puncture?
Sudden, severe, unilateral vision loss suggests what?
Presence of optic neurosis
Headache, fatigue, generalized aches and pains, and night sweats, blurred vision, jaw claudication in patients older than 55 suggests what?
Temporal arteritis! Check SED rate/ESR STAT!!!
Intermittant headaches with high blood pressure and symptoms of palpitations are suggestive of what?
Pheochromocytoma (Adrenal tumor)
Important things to check on PE:
Vitals, auscultate for bruits in neck and temporal arteries, assess spine and neck muscles, FULL neurologic exam (especially pt’s ability to get up from a seated position w/o support, walking on tiptoes and heels, cranial nerve exam, fundoscopy and otoscopy, tandem gait, romberg test, assess symmetry on motor, sensory, reflexes, cerebellar tests), and Mental status exam
Neck stiffness and resistance to passive neck flexion (meningismus) suggests what?
Meningitis
Papilledema suggests what?
Presence of mass in the brain, intracranial HTN, encephalitis, or meningitis
Focal neurologic signs suggests what?
Intracranial mass, AV malformation, or collagen vascular disease
If a bleed is suspected, what imaging study is done?
CT
In emergency situations, what imaging study is done?
CT (Fast!)
What imaging study is done if a mass is suspected?
MRI
What imagine study is done if suspect a stroke?
MRI
When is a lumbar puncture indicated?
- Clinical suspicion of subarachnoid headache with normal CT
- Suspicion for infection or inflammatory etiology