Headaches Flashcards
What are sinister causes of headache
VIVID
- Vascular (SAH/haematoma)
- Infection (meningitis/encephalitis)
- Vision threatening (temporal arteritis/acute glaucoma)
- Intracranial pressure (SOL, hydrocephalus)
- Dissection (carotid dissection)
In terms of SOCRATES how do tension headaches present
S: generalised + bilateral O: gradual or acute C: constant pressure, as if the head were squeezing by a vise R: can occur lower back of head, neck and eye A: usually none T: more than 30 mins. Usually 3-4 hours E: Analgesics help S: moderate
What causes tension headaches
- Stress
- Dehydration
- Lack of sleep
- Exertion
What is the management for tension headache
Simple analgesics
In terms of SOCRATES (SOCATES), how does migraine present
S: unilateral O: paroxysmal (sudden attack) C: pulsating/throbbing A: pre-monitoring phase (aura) T: 4-72 hours E: physical activity/stress/straining S: moderate to severe
What can migraine be proceeded by
- Irritability
- depression
- fatigue
- aura hallucinations
(strange smell, lights, visual disturbances)
What are the associated symptoms with migraine
- Nausea + vomiting
- photophobia
- phono-phobia
- osmo-phobia
In terms of SOCRATES, how does migraine present
S: unilateral O: paroxysmal (sudden attack) C: pulsating/throbbing A: pre-monitoring phase (aura) visual changes, aphasia, tingling numbness T: 4-72 hours E: physical activity/stress/straining S: moderate to severe
What acronym can be used to remember migraine symptoms
POUND Pulsating One day onset Unilateral Nausea Disabling
Who is more likely to have migraines, males or females
females
What are the possible triggers for migriaine
- Cheese
- OCP
- Caffeine
- alcohol
- stress
What are the investigations for migraine
None
unless other differentials suspected (meningitis/subarachnoid haemorrhage)
What is the conservative management for migraine
Headache diary: ask them to avoid precipitating factors
What is the acute medical treatment for migraine
- Sumatriptan (5HT-agonists)
- Analgesia (NSAID)
- Antiemetic (metoclopramide)
In terms of SOCRATES (SOATS), how do cluster headaches present
S: unilateral, behind the eye
O: acute onset, same time each day (alarm clock headaches)
C: shooting, stabbing
R:
A: swollen eyelid and forehead swelling, nasal congestion, Horner’s syndrome
T: 20-30 minutes
S: Severe: can be disabling and can wake individuals from sleep
What autonomic responses do people get in cluster headaches
- Swollen eyelid and forehead
- Red eye
- tearing
- Runny nose
- Horner’s syndrome
Who is affected by cluster headaches more, male or females
males
What is the pattern of symptoms in a cluster headache
Patients may have daily headaches for a 5-10 week cluster, and this repeats itself once a year
What are the investigations for cluster headaches
None
unless other differentials are suspected (meningitis, subarachnoid haemorrhage)
What is the acute medical treatment for cluster headaches
- 100% oxyegn via a non-rebreathable mask
2. Sumitriptan (5HT agonist) - subcut
What is the prophylactic medical treatment for cluster headaches
Verapamil
In terms of SOCRATES, how does raised intracranial pressure present (SOAE)
S: bilateral O: gradual, present in the morning A: Vomiting, drowsiness, irritability - seizures - bilateral papilloedema (disc swelling) - focal neurology E: worse when lying down, bending over and coughing
What are causes of raised intracranial pressure
- space occupying lesion (tumour, abscess, haemorrhage)
- hydrocephalus
- trauma
What are investigations for raised intracranial pressure
Urgent MRI (or CT) to determine underlying lesion
In terms of SOCRATES (SOATS), what is the presentation of subarachnoid haemorrhage
S: usually occipital
O: sudden onset, thunderclap headache
A: syncope, nausea, vomiting
Meningeal irritation can lead to meningism (triad: neck stiffness, nausea, headache)
Can present with signs of raised ICP
T: continuous
S: very severe - maximum intensity within minutes
What are the possible causes of subarachnoid haemorrhages
- berry aneurysm at the junction of the circle of Willis
Aneurysms risk increased with Hx or FHx of polycystic kidney disease - 20% idiopathic
- other risk factors include alcohol/smoking/hypertension
What are the investigations for a subarachnoid haemorrhage
- urgent CT scan within 12 hours
- Lumber puncture within 12 hours
- if CT is normal
- Xanthochromia oxyhaemoglobin
What is xanthochromia
Metabolised blood which is yellowish consisting of bilirubin
What is the surgical management for SAH
Refer immediately to neurosurgery
- surgical clipping
- endovascular coil embolization
What is the acute medical treatment for SAH
Cardiopulmonary support AB: maintain airway and breathing C: maintain cerebral perfusion keep well hydrated Maintain blood pressure
What are further supportive measures for SAH
- Reduce high ICP
- osmotic diuretic (mannitol) or hypertonic saline - Prevent cerebral artery vasospasm
- Nimodipine
What can be given to reduce cerebral artery vasospasm
Nimodipine
What causes cerebral artery vasospasm in subarachnoid haemorrhage
When the cerebral artery is bathed in blood from a subarachnoid haemorrhage, it causes vasospasm
In terms of SOCRATES (OAT), how does subdural haemorrhage present
O: gradual onset A: sleepiness, personality changes - diminished verbal and motor response - possible signs of raised ICP T: continuous
What are the risk factors for subdural haemorrhage
- Trauma
- coagulopathy, anti-coagulant use
- advanced age
What is a subdural haemorrhage
collection of blood between the dural and arachnoid coverings of the brain. the build up is gradual and is usually venous
In a subdural haemorrhage, what is the origin of the blood
Normally venous
What are the investigations for subdural haemorrhage
urgent non-contrast CT
In terms of SOCRATES (OA), how does an epidural haemorrhage present
O: acute onset ofter a lucid interval
A: deterioration of GCS + recent direct trauma
What is the definition of epidural haemorrhage
collection of blood between the dural and periosteum.
This build up is acute and the blood is arterial
What is the investigation for an epidural haemorrhage
urgent non-contrast CT
What is the difference between an epidural + sub dural haemorrhage
Epidural: between the dura and the periosteum
Subdural: between the dura matar and the arachnoid matar
Epidural: Arterial blood
Subdural: venous blood
Epidural: acute onset after lucid interval + history of direct trauma
Subdural: gradual + associated with sleepiness and personality changes
note that trauma is a cause of both
What is commonly found on examination of a patient with epidural haemorrhage
commonly there is scalp trauma
On CT, what is the difference in shape of a subdural or epidural haemorrhage
subdural: crescent shape
epidural: lenticular shape
What symptom might not be present in meningitis
A headache is not always present
In terms of SOCRATES (OAS), how does meningitis present
O: acute onset A: fever, meningism (neck stiffness, photophobia, headache) rash (very bad) confusion seizures S: severe
What is the aetiology of meningitis
Can be bacterial/viral/fungal
What are the investigations for meningitis
- Lumber puncture
CSF protein/glucose/M&C - Blood culture
- CT head
What is the treatment for meningitis?
Steroids then targeted antibiotic therapy
steroids protect the meningies before the antibiotics go and destroy the bacteria
What are the bacterial causes of meningitis in adults/elderly
- Streptococci pneumoniae,
Listeria monocytogenes
What are viral causes of meningitis
- enterovirus (coxsackie)
- herpes simplex virus
- HIV
What are the fungi causes of meningitis
- cryptococcus genuses
2. coccidioides genuses
What is a miscellaneous cause of meningitis
TB
What is Kernig’s sign
A way of diagnosing meningitis: Lay patient flat on their back flex their knee to 90 degrees Slowly lift patients leg upwards If this causes back pain that is a positive Kernig's sign
What is Brudzinski’s sign
A way of diagnosing meningitis:
flexing of the neck causing the patient to flex their knees is a positive Brudzinski’s sign
What is giant cell arteritis
Vasculitis affecting medium sized arteries in the head.
Abnormal ‘giant cells’ develop in the walls of these arteries. The presentation will vary based on which artery is affected
What is the most commonly affected artery in giant cell arteritis
Temporal artery
temporal arteritis is sometime synonymous with temporal arthritis
How does temporal arteritis present
Headache and scalp tenderness
How does ophthalmic arteritis present
Blindness
In terms of SOCRATES (SORAE), how does tempiral (giant cell) arteritis present
S: unilateral O: usually 1-2 days R: none - localised to the scalp A: signs due to other affected arteries: jaw pain when eating, visual disturbances E: scalp palpation (scalp tenderness)
What condition is temporal (giant cell) arteritis associated with
polymyalgia rheumatic
How does polymyalgia rheumatic present
Pain, tenderness and stiffness of the shoulders and upper arms
What investigations are done in order to diagnose temporal (giant cell) arteritis
- Bloods (ESR, CRP, FBC)
2. temporal artery USS, biopsy
What is the management of temporal (giant cell) arteritis
Urgent prednisolone
Prednisolone is a treatment or temporal (Giant cell) arteritis, what are the implications of delaying treatment
Any delay can lead to blindness
What is trigeminal neuralgia
Shooting facial pain in the distribution of the 5th nerve (manly V2). Mostly unilateral
What branch of the trigeminal nerve is usually affected in trigeminal neuralgia
V2
What are the risk factors for trigeminal neuralgia
60-80yrs of age
Multiple sclerosis
(+ female + hypertension)
What are the investigations for trigeminal neuralgia
usually none - can consider MRI
What is the management for trigeminal neuralgia
Anticonvulsants
carbamazepine
What are the presenting symptoms of sinusitis
7-10 days history or fever and headache with nasal congestion and discharge
What is the management for sinusitis
Mainly supportive
If bacterial cause suspected - antibiotics
What are the presenting symptoms of medication overuse
Rebound daily headaches which can occur in individuals who normally suffer from episodic tension headaches or migraines
What causes medication overuse
excessive use of analgesia (which can worsen existing headaches)
What is the management for medication overuse
withdraw medication
Headaches will worsen at first before they improve
What is acute glaucoma
Sudden blockage around the trabecular network
resulting in a sudden rise in intraocular pressure
What are the presenting symptoms of acute glaucoma
- Headache
- Painful eye
- visual changes
- vomiting
What is the management for acute glaucoma
- Acetazolamide (carbonic anhydrase inhibitor)
2. Timolol (beta-blocker)
Andromeda, a 32 year old female presents with recurrent headaches. They are severe, on the right side of her head and often continue for the rest of the day. Before the headaches start she gets tingling in her arms, and when the headaches start she goes to bed. She is worried they might affect her relationship with her new boyfriend.
Cluster headache Intracranial space-occupying lesion Medication overuse Migraine Tension headache
Migraine
Homer, a 45 year old male has had excruciating headaches for the last month. He gets them about 5 times a week and notices his eyes watering. He had a similar episode 6 months ago. They are very disruptive to his poetry.
Cluster headache Intracranial space-occupying lesion Migraine Subarachnoid haemorrhage Meningitis
Cluster headache
Atalanta, a 27 year old female athlete presents to the GP with early morning nausea and headaches which has been happening for at least a week. Both are worst when she wakes up and improve throughout the day. She notes that she has been getting tired over the last few weeks, she is late on her period, and is definitely more irritable with her boyfriend, who despite being an Olympian, keeps leaving apple cores scattered around the house.
Excessive excercise. Migraine Pituitary tumour Pregnancy associated tension headache Trigeminal neuralgia
Pituitary tumour (Causing raised ICP)
Aphrodite, a19 year old female sex-worker presents to A&E with a sudden onset headache that is the worst pain she has ever experienced. She occasionally gets mild headaches after sex, and has been given some medication by her GP for his. She has some neck stiffness and refuses to open her eyes wide or allow them to be examined.
Acute glaucoma Meningitis Migraine Subarachnoid haemorrhage Trigeminal neuralgia
Subarachnoid haemorrhage
Leonidas, a 24 year old male, was fencing and suffered and injury to the head when his rival, Xerxes hit him on the head with his shield. Leonidas recovered quickly and was able to continue to fight for the next 20 minutes. However he quickly developed an excruciating headache, started to lose consciousness and had to stop the fight to go to the nearest A&E. He has had a blocked nose for the last week.
Epidural haemorrhage Intraventricular haemorrhage Meningitis Subarachnoid haemorrhage Subdural haemorrhage
Epidural haemorrhage
Euclid is a 19 year old male currently studying Maths at university. He has been very unwell for the last few days with fever and headache and admits to becoming a little confused lately. He is very anxious about his upcoming exams. He has been taking caffeine pills to help him with revision, however this has affected his sleep and for the last couple of nights he has developed a stiff neck.
Medication overuse headache Meningitis Migraine Tension headache Sinusitis
Meningitis
Plutarch is a 77 year old male who has come in with a right sided headache. This started yesterday morning and have been getting progressively worse. His memory is a little off because of his dementia, but he says there is a possibility of trauma. His shoulders and neck also feel a little stiff. On examination, there is pain on palpation of the right forehead.
Intracranial space-occupying lesions Meningitis Subarachnoid haemorrhage Subdural haemorrhage Temporal arteritis
Temporal arteritis
Helen is a 40 year old woman with a history of multiple sclerosis. She has developed a headache over the last couple of days. She has travelled the world and rarely had headaches in the past. She has stopped eating, as chewing simply makes her feel worse.
Meningitis Migraine Temporal arteritis Tension headache Trigeminal neuralgia
Trigeminal neuralgia
70 year old Herodotus is brought in by his daughter to the GP. Over the last week he has developed a headache which lasts most of the day and rarely goes. He lives with his daughter and son-in-law as he is prone to falls due to his recent left hip replacement. The daughter also mentions that his father’s behavior has changed lately and tends to exaggerate some of his stories.
What do you think is the most important step in your management plan?
MRI scan Routine CT scan Sumitriptan + NSAIDs Urgent CT scan Watchful waiting
Urgent CT scan
Alexander, known to his mates as Alex the G, is a 32 year old soldier who has just returned from a tour in Iran. He tells you that he has been getting throbbing bilateral head pain, and puts this down to lack of sleep. As a general, he has multiple reports to write and is finding this difficult with his four friends constantly bickering about one thing or the other. He hasn’t tried any medication and asks that you prescribe some sleeping pills. What is the most appropriate management?
Diazepam Codeine NSAIDs Topiramate Refer to A&E
NSAIDs
Pythagoras is a 40 year old man who suffers from headaches. 3 weeks ago he was prescribed ibuprofen and has taken it religiously. Initially these worked really well, however now the headaches have returned and are worse than ever. He is very angry and does not think you are taking the right angle towards managing his issue. What is the next course of management?
Antibiotics Add a β-blocker Refer to A&E Switch medication to carbamazepine Ask to stop ibuprofen and see in 2 weeks
Ask to stop ibuprofen and see in 2 weeks
Hippocrates is a 71 year old homeopath who presents with a left sided headache which came on yesterday morning. He tried to tread it with a clever paste made of garlic, vinegar and honey. When he applied the paste he was in great pain, and so believed that his remedy was working. However, his skeptical son told him to see “another doctor” for treatment. What is the most important next step?
Prescribe prednisolone and refer patient to A&E
Prescribe sumitriptan and NSAIDs
Refer to A&E for urgent CT scan
Refer to A&E for urgent non-contrast CT scan
Refer to A&E for MRI
Prescribe prednisolone and refer patient to A&E
