Headaches Flashcards
What are the categories of sinister causes of headaches
Vascular Infection Vision-threatening Intracranial pressure Dissection
What are the sinister vascular causes of headaches
SAH, haematoma, cerebral venous sinus thrombosis, cerebellar infarct
What are the sinister infectious causes of headaches
Meningitis and encephalitis
What are the sinister vision-threatening causes of headaches
temporal arteritis, acute glaucoma, cavernous sinus thrombosis, pituitary apoplexy, posterior leucoencephalopathy
What are the sinister intracranial pressure causes of headaches
SOL (tumour, abscess cyst), cerebral oedema (trauma, altitiude), hydrocephalus, malignant hypertension, idiopathic intracranial hypertension.
What are the sinister dissection causes of headaches
Carotid dissection
What can a decreased level of consciousness with a headache suggest
SAH, Subdural (after head injury, fluctuating) or extradural haematoma (after head injury, altered after lucid interval), encephalitis, meningitis
What can cause a sudden onset “worst headache” ever (and why)
SAH (blood enters the CSF and causes irritation to the meninges)
What can a seizure or focal neurological deficit with a headache suggest
Intracranial pathology
At what age group is temporal arteritis more common
A new headache in those over 50
What does a persistent headache that is worse when lying down suggest (and what is it normally coupled with)
Coupled with early morning nausea
Raised intracranial pressure, pain can also occur when bending over
What does a headache that is worse when standing up suggest
Reduced intracranial pressure, often occurs after LP
What does a progressive, persistent headache suggest
Expanding SOL
What does weight loss, night sweats and fever suggest with a headache
Malignancy, chronic infection, or chronic inflammation
What in the PMC might be significant to a headache
Previous malignancy (lung or breast) HIV or immunosuppression
What basic Obs do you look at for headache presentations
Temperature (infection)
BP and pulse (malignant hypertension)
Consciousness (GCS)
What does a focal limb deficit with headache suggest
Intracranial pathology
What does a 3rd nerve palsy with headache suggest
SAH due to rupture of the posterior communicating artery
What would be seen in a 3rd nerve palsy
Mydriasis
Eye is down and out
Ptosis
What does a 6th nerve palsy with headache suggest
Malignancy or raised intracranial pressure
What does a 12th nerve palsy with headache suggest
Carotid artery dissection
How does Horner’s syndrome present and what does it suggest on BG of headache
Partial ptosis, miosis, anhydrosis
Carotid artery dissection or cavernous sinus lesion
What are some causes of non-sinister headache
Tension-type Migraine Sinusitis Medication overuse Temperomandibular joint dysfunction syndrome Trigeminal neuralgia Cluster headaches
What is the difference between primary and secondary headaches
Primary = if headache was removed, there is no harmful pathology Secondary = headache results from a harmful pathology
How can you characterise non sinister headaches
Ask if they suffer from other types
Are there predisposing factors
How disablingn are they
Is there an aura before headache
How does a tension type headache
Bifrontal pain (band around the head), episodic, variable frequency
NO other features
lasts a couple hours, not severely disabling
Triggered by fatigue and stress
How does a migraine present
Typically unilateral with aura (1/3). Pain is throbbing or pulsatile.
Sensitivity to light, sound and smell + nausea
Lasts 4-72 hours
How does sinusitis present
Tight facial pain coming on over hours to days in conjunction, with coryzal symptoms. Often exacerbated by movement.
Lasts several days (infection)
Moderate but not disabling
How does medication overuse headache present
Common in women, migraine medication and analgesics
Resembles migraine and tension type headache
How does temperomandibular joint dysfunction syndrome present
20-40yrs, common in women, dull ache in the muscles of mastication that can radiate to the jaw and ear. They hear a click of grinding noise when they move their jaw
How does trigeminal neuralgia present
Common in women 60-70yrs
Unilateral stabbing , sharp facial pain involving one or more divisions of the trigeminal nerve
Lasts seconds, triggered by eating, laughing, talking or touching the area.
Rarely occurs during sleep (unlike migraine or cluster)
How does cluster headaches present
Common in men. Occurs in clusters for 6-12 weeks every 1-2 years.
Attacks tend to occur at exactly the same time every day or night (alarm clock)
Intense pain focused over one eye, pain diminishes 20-30mins later
Red, watery eye, rhinorrhoea and Horners
What are some treatments for migraine
triptans (5HT agonists - sumatriptan), analgesics (aspirin, paracetamol), antiemetics (metoclopramide)
What investigations should you do in a suspected SAH
CT (within 6 hours is best)
LP after 12 hours -> look for xanthochromia (remains 12 days post headache)
What is the management for SAH
Refer to neurosurgical unit
Nimodipine (CCB that reduces spasm and therefore ischaemia)
Cerebral angiopathy to find the source
Platinum coil insertion
How do you differentiate between epilepsy and migraine with aura
Epilepsy produces positive gain of function symptoms (flashing lights, convulsions, odd skin sensation)
Migraine produces a mix of negative and positive
Epileptic seizures are often followed by a postictal phase where the patient is exhausted and sometimes confused.
