Headaches Flashcards
What is the most common neurological outpatient referral?
Headaches
- 25% of new referrals
What is a primary headache?
The headache itself is the disorder (no underlying cause)
- e.g. migraine tension-type headache and cluster headache
What is a secondary headache?
Secondary to an underlying cause - e.g. Subarachnoid haemorrhage, space occupying lesion, meningitis, temporal arteries, high/low intracranial pressure, drug induced…
What is the most important question when assessing a patient?
Could this be a secondary headache?
When taking history of a headache, what are the most important features?
Onset (time to maximal symptoms and circumstances at onset)
Severity and quality of pain
Location/radiation of pain
Presence of an aura/prodrome
Periodicity
Associated features - photophobia, phonophobia, osmophobia, nausea, movement sensitivity and periorbital autonomic disturbance (common in cluster headaches)
Age at onset (migraine more common in childhood/early adulthood, whereas a secondary cause is more common in the over 50s)
Triggers/exacerbating/relieving factors
Family history
Social/employment history
Medication history
Co-morbid depression and sleep disturbance
What are the ‘red flag’ symptoms of a headache? (indicate a secondary cause)
Age >50
Thunderclap headache
Focal/non-focal neurological deficit
Worsening of symptoms with posture (high/low CSF pressure), valsalva (coughing, straining) or physical exertion
Early morning headaches
Systemic symptoms
Seizures
Temporal artery tenderness/jaw claudication
Specific situations
- cancer, pregnancy, post-partum, HIV/immunosupression
What acronym is used to remember red flag symptoms?
S - systemic symptoms
N - neurological signs or symptoms
O - older age at onset
O - acute onset (less than 5 minutes)
P - previous headache history is different
T - triggered headache (valsala or postural)
What clinical signs might you find on examination to suggest a secondary cause?
General/systemic - reduced consciousness - BP/pulse - pyrexia - meningism - skin rash - temporal artery tenderness Cranial nerve - pupillary responses - visual fields may have a blind spot - eye movements - fundoscopy
What abnormal findings might indicate a secondary cause on fundoscopy?
Papilloedema - raised ICP
Subhyaloid haemorrhage - raised ICP/SAH
What abnormal findings may indicate a secondary cause when assessing the cranial nerves of the eye?
3rd nerve palsy - eye droops down and out
6th nerve palsy - eye can’t move laterally
Horner’s syndrome
Which upper motor neurone signs may indicate a secondary cause?
Pronator drift
Increased tone
Brisk reflexes
Extensor plantar response
What cerebellar signs may indicate a secondary cause of the headache?
D - dysdiadochokinesis
A - ataxia
N - nystagmus
I - intention tremor (worse during voluntary movement)
S - scanning dysarthria (jerky, explosive, slurred speech)
H - heel-shin test positive
Describe the aetiology of a migraine.
More common in women than men
12-16% of population
25-55 years has highest prevalence
Positive family history is common
Give some examples of triggers of migraines.
Hormonal Weather Stress Hunger Sleep disturbance Exertion Alcohol excess Foods
What is the pathophysiology of a migraine?
Neurovascular hypothesis
- disorder of the endogenous pain modulating systems, particularly in subcortical structures (e.g. brainstem and diencephalic nuecli)
What are the phases of migraine?
Prodrome - sensation that a migraine is coming for 24/48 hours
Aura - 30% of migraine patients
Headache - persists from 4-48 hours
Postdrome - mild, non-specific headache lasting for 24/48 hours
What are the symptoms of a prodrome?
Mood disturbance Restlessness Hyperosmia Photophobia Diarrhoea
What is an aura?
Recurrent reversible focal neurological symptoms
- visual, sensory or motor (visual most common)
Develops over 5-20 minutes and lasts less than an hour
Describe visual and sensory auras.
Visual
- negative scotoma (blind spot)
- positive scotoma (dark spot)
- flashing lights
- fortification syndrome (halo effect around objects)
- visual field loss
Sensory - tingling starting in the thumb and fingers and spreading up the arm
Describe a normal headache.
Throbbing or pulsatile pain in the head of moderate to severe intensity
Gradual onset, lasting 4-72 hours
60% are unilateral
Aggravated by routine physical activity
Name some symptoms associated with a headache.
Nausea and vomiting Photophobia Phonophobia Osmophobia Mood disturbance Diarrhoea Autonomic disturbance - e.g. lacrimal, conjunctival, nasal stiffness
What investigations can you do if someone presents with a migraine?
Good history and normal clinical examination does not require further investigation
Cranial imaging advised if they have red flag symptoms or an aura lasting more than 24 hours
What is the most common complication associated with migraine management?
Medication overuse headache
- patient has a headache for at least 15 days of the month associated with frequent use of pain medication
- e.g. NSAIDs, paracetamol, opiods and triptans
- to avoid this, patients can’t take medication more than 2-3 times a week
What is a chronic migraine?
Headache on 15 or more days of a month
How can migraines be managed?
Lifestyle
- avoid triggers
- reduce caffeine and alcohol intake
- encourage regular meals and sleep patterns
Acute management
- simple analgesia
- triptans (e.g. Sumatiptan)
- anti-emetic (e.g. domperidone and metoclopramide)
Prophylaxis
- beta-blockers
- tricyclic antidepressants (amitriptyline, dosulepin)
- anti-epilepsy drugs (sodium valproate and topirmate)
What is the definition of a thunderclap headache?
Abrupt-onset of severe headache which reaches maximal intensity within 5 minutes and lasts for over an hour
What should you assume the underlying cause of a thunderclap headache is?
Subarachnoid haemorrhage
- 15% of tunderclap headaches
Name some of the possible causes of a thunderclap headache.
Intracranial haemorrhage Arterial dissection (vertebral or carotid) Cerebral venous sinus thrombosis Bacterial meningitis Spontaneous intracranial hypotension Pituitary apoplexy Primary headache - once no secondary cause can be found - migraine - exertional headache - cluster headache
If someone comes in with a thunderclap headache, what investigations can be done?
Primary aim is to identify a subarachnoid haemorrhage
- bloods (U&Es, LFTs, full blood count, coagulation screen and CRP)
- blood cultures
- 12-lead ECG
- urgent CT brain (over 95% of SAH have blood visible within the first 4 hours)
- lumbar puncture (performed after 12 hours to look for xanthochromia)
What is the normal intracranial pressure?
7-15mmHg
Why is raised ICP a problem?
1) CPP = mean arterial pressure - ICP
So if ICP increases, the global perfusion to the brain decreases, and cerebral metabolism is reduced
2) If the pressure is brain caused by a space-occupying lesion (haemorrhage), the space available in the brain decreases, and the brain herniates
What is CPP?
Cerebral perfusion pressure is the net pressure gradient causing blood flow into the brain
Name some types of brain herniation.
Uncal Central (transtentorial) Cingulate (subfalcine) Transcalvarial Upward transtentorial (upward cerebellar) Tonsillar (downward cerebellar)
What would you expect to find in the history, if the person has a raised ICP headache?
Worse lying flat (improved by sitting up or standing)
Worse in the morning
Persistent nausea/vomiting
Worse on valsalva (e.g. coughing, laughing, straining)
Worse with physical exertion
Transient visual obscurations with change in posture
What would you expect to find on clinical examination, if the patient has a raised ICP headache?
Optic disc swelling - papilloedema Impaired visual acuity/colour vision Restricted visual fields/enlarged blind spot 3rd nerve palsy 6th nerve palsy (false localising sign) Focal neurological signs
Name some causes of raised ICP.
Mass effect - tumour, infarction with oedema, abscess, subdural/extradural/intracerebral haematoma Increased venous pressure - cerebral venous sinus thrombosis, obstruction of the jugular venous system Obstruction to CSF flow/absorption - hydrocephalus, meningitis Idiopathic - idiopathic intracranial hypertension
What are the features of a low CSF pressure headache?
Headache is worse on sitting/standing and relieved by lying down
Results from a CSF leakage
- loss of CSF volume causes traction on meninges, cerebral/cerebellar veins and cranial nerves V, IX and X
What are some possible causes of a low CSF pressure headache?
Post-lumbar puncture - 1/3rd of cases - 90% develops within three days - most resolve spontaneously Spontaneous intracranial hypotension - results from spontaneous dural tear - can occur following valsalva
