Headaches Flashcards
features of SAH
S:diffuse O: reaches maximal intensity within a minute or two C: constant and throbbing R: usually to the neck A: photophobia, nausea, neck stiffness T: lasts at least an hour, usually for many, many hours E: non-specific S: 10/10!!
order of layers of the brain
brain–>pia mater–>arachnoid–>dura mater (2 layers)
SAH
85% caused by ruptured aneurysm 1/3 die immediately 1/3 present with coma, seizures or focal deficit 1/3 present with isolated headache 20-30% re-bleed within first month
only 25% of those with thunderclap headache have SAH
SAH investigation
CT head - only 95% sensitive in the first 48h
if CT negative, all require a LP (if no contraindications)
CSF findings in SAH
uniformly bloody early on
becomes xanthochromic (yellow) after several hours due to breakdown products of Hb (bilirubin)
xanthochromia confirms that the bleed was due to a SAH rather than a continuous bleed from a ‘bloody tap’
SAH management
secure aneurysm
evacuate haematoma
relieve hydrocephalus
features of Temporal/Giant cell arteritis
S: temporal O: gradual C: constant R: none A: malaise, weight loss, visual loss, diplopia, jaw claudication, proximal limb pain, temporal artery thickening and pulselessness T: subacute/chronic E: none (hair brushing) S: moderate
diagnosis can be difficult - requires urgent investigation
ESR traditionally used - normal in 5%, so also use CRP
temporal artery USS - only 40% sensitive, but very specific
temporal artery biopsy - gold standard, but still only 50-60% sensitive, especially if a small sample is taken
consider in anyone presenting with headache >50years old
GCA Tx
if suspicious, then treat! high risk of permanent visual loss
high dose oral steroids (prednisolone 60mg)
Sx should resolve within 2 days
after 1 month, slowly reduce dose
keep reducing until ESR starts to rise again, or Sx return
migraine diagnostic criteria
last between 3 and 72h
any 2 of - moderate or severe intensity; unilateral; aggravated with routine activity; throbbing in nature
either nausea/vomiting OR photophobia and phonophobia
these are often too strict however, for clinical practice
migraine aura
present in 25% caused by spreading cortical depression usually last 10-20mins usually precede migraine headache can occur without headache
location of aura and Sx
occipital lobe - visual distirbance
parietal lobe - marching sensory disturbance
frontal lobe - hemiparesis, dysphasia
these Sx come on gradually and spread over minutes, unlike stroke
migraine Tx
avoid dietary triggers (lacking in most) regular meals keep hydrated regular sleep pattern address anxiety and depression
avoid medication overuse!
regular analgesic use (10 time a month can be enough) leads to worsening of headaches. opiates and triptans are the worst, but paracetamol and NSAIDs also responsible
acute migraine Sx therapy
taken as soon as the headcahe starts
NSAIDs very effective in the majority
if not, triptans can be used
taken no more than twice weekly
triptans
e.g. sumatriptan
serotonin receptor agonist, leading to vasoconstriction in tyhe brain and reducing the subsequent neuropeptide release
