Headaches Flashcards
What is the most common presenting symptom in family and emergency medicine?
Headache
What are the two main headache issues that bring patients in?
Severity
Chronicity
What are the characteristic of pain (quality) which you should look for in headache?
Throbbing with heart beat then its vascular
Steady pressure or ache it is most likely muscular
What should you do for all new onset headache pts?
Complete neurological examination
Ophthalmoscopy of retina
What should be done if the neuro test is positive?
Refer to a neurologist and neurosurgeon
If the headache is always in the same place what should you think?
Local disease ex:
Sinusitis, brain tumor, arteriovenous malformation, circle of Willis aneurysm
If a pt is 50 or older complaining of headache what possible etiologies should you think about?
Temporal arteritis
Brain tumor
If a pt is 50 or older complaining of headache what exams should be done?
Neurologic
Erythrocyte sedimentation rate (ESR)
MRI or CT brain scan
Which type of imaging exam is often the first image obtained in headache with a potentially life threatening diagnosis?
CT scan
What are some things a CT scan will miss in terms of vascular disease?
Aneurysm, malformations, hemorrhage, artery dissection, infarction, thrombosis, vasculitis, hematomas
More things a CT scan can miss of neoplastic diesase?
Meningeal carcinomatosis
Pituitary Tumor and hemorrhage
What things will a CT miss in termds of a cervicomeduallary lesion?
Chiari malformations
Foramen magnus tumors
What things will a CT scan miss in terms of infections?
Paranasal sinuses
Meningoencephalitis
Cerebritis and brain abscess
What possibilities should be considered is the headache is sudden onset?
Subarachnoid hemorrhage
Pituitary apoplexy
Bleed into tumor or arteriovenous malformation
Posterior fossa brain tumor
What tests should be done if a pt complains of sudden onset headache?
MRI/MRA
CT scan
Lumbar puncture for CSF evaluation
If the onset of the headache occurred during extension what should you expect?
Possbility of leaking cerebral aneurysm or arteriovenous malformation
Do complete neurological exam
What is the mortality rate of aneurysm?
70-90%
What is a pituitary apoplexy?
Sudden massive degeneration with hemorrhagic necrosis of the pituitary gland
Associated with a pituitary tumor
Signaled by abrupt headache, followed by loss of sight, diplopia, drowsiness, confusion or other mentally deranged states and coma
Is a pts headache diary, what should they keep track of?
Accelerating pattern of headaches (more frequent more severe)
In the event of frequency and severity what could an accelerating pattern of headaches and what should be done?
Brain tumor
Subdural hematoma
Medication overuse
MRI/MRA and Drug history/drug screen
Meningitis
Infection of the meninges
Encephalitis
Infection of the brain substance
What should you suspect if a cancer pt has a headache and what tests should be done?
Meningitis (chronic, carcinomatous)
Brain abscess (toxoplasmosis)
Metastasis
MRI/MRA and lumbar puncture for CSF analysis
What should you suspect in a pt with new headache who has presents with fever, stiff neck or rash?
Meningitis Encephalitis Lyme Disease Systemic Infection Connective Tissue Disease
What should you test for in a pt that has new headache with fever, stiff neck or rash?
MRI / MRA Lumbar puncture for CSF Analysis Blood Tests -CBC -ESR -ANA -Lyme Titre
What should you look for in a pt who presents with focal neurologic symptoms and headache?
Tumor AVM Stroke Connective Tissue Disease -Antiphospholipid -Antibody Disease
What should you test for in a pt who has a focal neurologic symptoms?
MRI /MRA CT of Brain Blood Test -ESR -ANA -Other Connective -Tissue Disease Tests
What should be done in a physical examination for a headache?
High: maybe hypertensive headache
Low: maybe ischemic headache
If the patient has nuchal rigidity what should be ruled out?
Subarachnoid hemorrhage
If nuchal rigidity if found, what is next emergency step? And what are the steps after that?
CT scan
If normal follow iwth lumbr puncture for CSF analysis
Fluid has blood transfer to neurologist
Fluid is clear send to lab for cell count, gram stain, glucose, protein and culture
Rule out meningitis
Signs and symptoms of meningism
The symptoms and signs of meningitis associated with an acute febrile illness or dehydration
There is no actual infection of the meninges
Also called meningismus or pseudomeningitis
If papilldema is found with headache in a physical what would you see?
Brain Tumor
Meningitis
Idiopathic Intracranial Hypertension (Pseudotumor Cerebri)
If papilledema is suspected in a physical for a headache what imaging and exams are required?
Neuroimaging
Lumbar Puncture for Pressure & CSF Analysis
Idiopathic Intracranial Hypertension
Aka Pseudotumor cerebri
Caused by cerebral edem Papilledema Elevated intervranial pressure Normal CSF on lumbar puncture Headache Nausea/Vomiting Normal Neurologic Examination
What are some etiologies of idiopathic intracranial hypertension?
Cerebral Venous Sinus Thrombosis Jugular Vein Thrombosis Addison’s Disease Chronic Obstructive Pulmonary Disease Hypoparathyroidism Severe Iron Deficiency Anemia
What is the most worrisome vital sign you can find in a headache and why?
Fever
Meningitis
Encephalitis
Upper respiratory infection (most common)
What could you find in vital signs of blood pressure in a headache?
Hypertension
Hypotension
In the EENT exam what should you look for if there is a headache?
Infection or neoplasm
Visually inspect the rtina for evidence of papilledema
If present it most likely represents increased intracranial pressure
If you have an abnormal finding in a neurological exam, what is the first things to expect?
Intracranial pathology
What are the 4 big headache issues?
Migraine
Muscle contraction headache
Cluster headache
Secondary headache disorders
Hemicrania Histroy
A lateralized headache Typical migraine pattern Cluster headaches Paroxysmal hemicrania If the headache is throbbing maybe associated with nausea, vomiting, photophobia, sonophobia Normal cause is migraine
In physical examination of Hemicrania what should you look for unilaterally?
Conjunctival injection Nasal congestion Rhinorrhae Normal neuro exam Cluster headache
If no other symptomology appears in Hemicrania, what can be assumed?
Muscle contraction headache
Cluster headache
A type of vascular headache that occurs in series of groups
Can last several weeks to several months at the same time each year
Spring and fall with pain free intervals
Onset age 20 to 30
When do cluster headaches tend to occur?
At night generally lasting 1-3 in 24 hours lasting 15 min to 3 hours
How is the pain in a cluster headache described?
Excruciating, boring pain behind or around eyes
What are some cluster headache manifestations?
Pain affecting one side of the head but can spread
Tends to switch sides
Pain so terrible some try to kill themselves
Patient prefers upright and moving rather than still and laying
What are some associated symptoms to cluster manifestations?
Conjunctival Injection Tearing Nasal Congestion Rhinorrhea Partial Horner Syndrome Sweating and Flushing (all occurring just on the side of the headache)
What are the signs of Horner syndrome?
Ptosis of upper eyelid Meiosis (pupil constriction) Anhydrosis and flushing on same side of face Narrowing of the palpebral fissure Retraction of eyeball
What is the etiology of horner’s syndrome?
Ipsilateral brain stem lesion interrupting descending sympathetic pathways
What are the cluster headache variants?
Atypical pain location
Multiple sharp jabbing pains (ice pick headaches)
SUNCT
Chronic continuous, sharply localized and unilateral pain
What are cluster headache triggers?
Alcohol consumption
Smoking
Sublingual nitroglycerin
What is the pathogenesis of a cluster headache?
Nucleus of trigeminal nerve descending to the spinal cord level becomes hyperactive unilaterally
Internal and external carotid arteries dilate and are principle pain sources
Horner syndrome - stretch/compression of sympathetic plexus around carotids
Serum serotonin and histamine levels inc
Why should you not use OMT during a cluster headache?
During he headache it can exacerbate or prlong the pain
What could cervical somatic dysfunction secondarily cause in a cluster headache?
Hyperactivity of the sensory nucleus of the trigeminal nerve may be due to spinal cord facilitation
When should OMT be done for a cluster headache?
Between attacks:
Treat cervical segments
Treat any dysfunctions occurring in the upper 6 horacic segments and ribs
Normalized sympathetic outflow to head and neck
What should you use to treat a cluster headache?
100% Oxygen by face mask for 15-20 min
SubQ sumatriptan injection (6 mg)
IM or IV dihydroergotamine (1 mg)
Intranasal lidocaine (4-6% drops)
What is the short term prevention for a short term cluster headache?
Prednisolone and Trednisone (60-100 mg a day) slowly tapered over a period of a month
Only can be used once a year
Ergotamine tartrate (up to 4 mg a day in divided doses) risk of rebound headache
How does methysergide work to provide short term cluster headache prevention?
Effective 65-70%
Only cluster
Fibrotic syndrome in prolonged use
-retroperitoneal, pleural, pulmonary, cardiac valvular fibrosis
What are the long term prevention for cluster headaches?
Verapmil - calcium channel blocker
- (240-960 mg/day) used for hypertension or cardiac disease
- ECG needed priot to use then 10 days after dose change
Lithium carbonate
- Takes a week to reach steady state
Effective at blood lvl of 0.4-0.8 mol/liter
Can be combined with others
Describe chronic paroxysmal hemicrania.
Similar to cluster headache Mostly female, occurs 10-30 times a day Short duration (2-25 min) with unilateral pain No nausea or vomiting Responds to Idomecthacin (NSAID)
