Headaches Flashcards
what is headache and what are the overaching causes of it.
- is a symptom
- very common (half to three quarters of adults aged 18–65 years in the world have had headache in the last year and, among those individuals, 30% or more have reported migraine)
Causes:
> structural
> pharmacological (GTN for angina)
> psychological
Give some features and causes of acute onset single headache
Acute single headache
> Febrile illness, sinusitis
> First attack of migraine
> Following a head injury
> Subarachnoid haemorrhage
> Meningitis, tumour, drugs, toxins, stroke
> Thunderclap (sudden onset), low pressure
What are some red flags for headaches?
Onset
> thunderclap
> acute
> subacute
Meningism
> photophobia
> phonophobia
> stiff neck
> vomiting
Systemic symptoms
> fever
> rash
> weight loss
Neurological symptoms or focal signs
> visual loss
> confusion
> seizures
> hemiparesis
> double vision
> 3rd nerve palsy (ptosis)
> Horner syndrome (droopy, enopthalmos, constricted pupil)
> papilloedema
Orthostatic (better lying down)
Strictly unilateral
Mnemonic: NOS MOS
What is the pathology and presentation of a subarachnoid haemorrhage?
- sudden generalised headache (blow to the back of the head)
- meningism: stiff neck and photophobia
pathology/causes
- most caused by ruptured aneurysm
- some from arteriovenous malformations
- some are unexplained
What is the treatment and investigations for a subarachnoid haemorrhage?
give relevant details
Around 50% are instantly fatal.
- Vasospasms- may stop the leak
- Early treatment:
- Nimodipine and BP control
- -High risk of a further bleed
- Early neurosurgical assessment will confirm the bleed and establish the cause.
Investigations
- CT brain
- Lumbar puncture (RBC and xanthochromia) and MRA
- angiogram
How are aneurysms treated?
- clipped, wrapped in the past
- Now filled with platinum coils
- aneurysms sclerose and close up
What is the pathology of an acute intracerebral bleed?
- causes fatal haemorrhage due to coning
- bleeding fills the ventricles
What is the danger of an intracerebral bleed? ICP?
raised intracranial pressure (ICP)
- brain can tolerate a growing mass to a certain point
- when volume rises above a certain limit brain is no longer compliant
- pressure rises dramatically
- brain starts to seep into areas of weakness: coning
> brainstem death
What is papilledema?
swelling of the optic disc due to raised ICP
Describe how headache can arise from blood vessels.
give symptoms for each artery
Pathology in the large arteries of the neck; carotid and/or vertebral artery dissection.
> layers of tissue in arteries can split
> blood collects here
> turbulent flow in lumen
> common cause of headache
vertebral arteries:
- occipital and neck pain
carotid arteries:
- ‘phantom of the opera mask’ distribution
- eye and forhead
Describe the pathology of arterial dissections. GIVE causes, investigations and treatment
Split in arterial wall, and creates a false lumen (less blood comes through the main lumen)
- 20% of ischaemic strokes <45 years (young stroke).
- Causes: Traumatic vs. Spontaneous (eg. EDS)
- Diagnosis: MRI/MRA, Doppler, Angiography
- Treatment: Aspirin or anticoagulation
Describe a subdural hemorrhage
- common in elderly people due to falls and anticoagulation
- chronic subdural blood will appear dark (begins to degrade)
Describe the pathology of temporal arteritis. give signs and symptoms and treatment.
- most common in females over 55
Symptoms
- constant unilateral headache, scalp tenderness and jaw claudication
- 25% polymyalgia rheumatica-proximal muscle tenderness
- involvement of the posterior ciliary arteries causes blindness
Signs
- elevated ESR and CRP
- temporal artery are usually inflamed and tortuous
- visible on ultrasound
- biopsy shows inflammation and Giant Cells.
treatment
- high dose steroids (anti-inflammatory) and aspirin
Describe cerebral venous thrombosis.
Give causes, signs and symptoms.
- thrombosis in dural venous sinus or cerebral vein
Signs and symptoms
- unusual amount of headache due to raised ICP
- non-territorial ischaemia “venous infarcts”
- haemorrhage
Causes
- thrombophilia
- pregnancy
- dehydration
- Behcets disease (too much inflammation in ther vessels)
Describe the pathology of meningitis
Causes:
- Viral - Coxsackie, ECHO, Mumps, EBV
- Bacterial - Meningococci, Pneumococci, Haemophilus (vaccines)
- Tuberculous
- Fungal - Cryptococci
- Granulomatous- Sarcoid, Lyme, Brucella, Behçet’s, Syphilis
- Carcinomatous
Symptoms:
- Malaise
- Headache
- Fever (septic)
- Neck stiffness
- Photophobia
- Confusion
- Alteration of consciousness
How is meningitis treated?
Antibiotics FIRST
then diagnose:
- Blood and urine culture
- Lumbar puncture
> Increased White Cell Count, decreased glucose
> Antigens
> Cytology
- Bacterial Culture
- CT or MRI Scan BEFORE (needle in lumbar could cause coning IF there’s ICP
What does herpes simplex encephalitis do to the brain?
classic haemorrhagic changes in the temporal lobe
How does bacterial meningitis alter the brain?
- cerebral oedema
- effacement of ventricles and sulci and inflamed meninges
What are the symptoms of sinusitis?
paranasal.
Symptoms:
- Malaise, headache, fever.
- Blocked nasal passages.
- Loss of vocal resonance.
- Anosmia.
- Nasal or postnasal catarrh.
- Local pain and tenderness
- Frontal pain characteristically starts 1-2 hours after rising and clears up during the afternoon.
Describe headaches caused by brain tumours
- swelling around the tumour
- generates a lot of pressure
- eg Glioblastoma multiforme
What is idiopathic intracranial hypertension.
Give causes, symptoms and treatments
Pseudotumor Cerebri
- Often young obese women
Symptoms:
- Headache, visual obscurations, diplopia, tinnitus
- Papilloedema, +/- visual field loss
Causes:
Drugs: hormones, steroids, antibiotics, vitamin E
Treatment:
- weight loss,
- diuretics,
- optic nerve sheath decompression,
- lumboperitoneal shunt,
- stenting of stenosed venous sinuses.
Describe a low pressure headache
give treatment and causes
orthostatic
- CSF leak due to tear in dura
- Causes: Traumatic post lumbar puncture or spontaneous
- Treatment: rehydration, caffeine, blood patch
What is a Chiari malformation?
Give details and treatments
herniation of the cerebellum more than 5 mm beyond the margin of the foramen magnum
- brain sits very low in the skull
- cerebellar tonsils descend
- descend further when patient cough and tug on the meninges causing cough headache
Treatment:
treat cough/cold,
operation- remodel base of skull by taking away some of the bone
Describe the pathology of obstructive sleep apnoea
Give treatments
often characteristic physique, history of loud snoring and apnoeic spells
- signs: hypoxia, CO2 retention, non-refreshing sleep
- symptoms: depression, impotence, poor performance at work
Treatment:
- require sleep study
- nocturnal Non Invasive Ventilation
- Surgery
Describe trigeminal neuralgia
give treatments
Electric shock like pain in the distribution of a sensory nerve
Causes:
- Often triggered by innocuous stimuli (chewing, touching teeth)
- Any division of the trigeminal can be affected
- Neurovascular conflict at the point of entry of the nerve into the pons
- Can be a symptom of M.S.
Treatment:
- anti-convulsants
- Carbamazepine
- lamotrigine
- gabapentin
- Posterior fossa decompression.
Describe atypical face pain
give epidemiology, symptoms and treatments
- Most commonly in middle aged women
Symptoms:
- Depressed or anxious.
- Daily, constant, poorly localised deep aching or burning.
- Facial or jaw bones, but may extend to the neck, ear or throat
- Not lancinating (shooting)
- Not conforming to the strict anatomical distribution of any nerve
- No sensory loss
- Pathology in teeth, temporomandibular joints, eye, nasopharynx and sinuses must be excluded
Treatment:
- Unresponsive to conventional analgesics, opiates and nerve blocks
- Mainstay of management tricyclics
Describe post traumatic headaches
- Of people admitted with head injury, headache is present in:
> 36% at discharge
> 24% at 6 months
> 16% at 12 months - Correlates with previous history of headache
- Unrelated to duration of post-traumatic amnesia
Depends on the nature of the head injury
> High in victims of car accidents
> Low in perpetrators of car accidents
> Low in sports injuries
Multiple mechanisms.
> Neck injury
> Scalp injury
> Vasodilation ? autonomic damage
> Depression - often delayed
How is post traumatic headache treated?
- Explanation that it will take years to go away
- Prevent analgesic abuse (use pain modulators)
- Non-steroidal anti-inflammatories: ibuprofen, naproxen
- Tricyclic antidepressants: Amitriptyline (3-4 yrs)
Describe cervical spondylosis
give presentation and treatments
- Commonest cause of new headache in older patients
Presentation:
- Usually bilateral
- Occipital pain can radiate forwards to the frontal region
- Steady pain
- No nausea or vomiting
- Worsened by moving the neck
Management:
- Rest, deep heat, massage
- Anti-inflammatory analgesics
- Over-manipulation may be harmful
summaise session review
draw the 3 forms of attack of migraine and explain how they can present
State the overall disorders (features) for migraine
Tendency for repeated attacks
it has triggers
- You can become easily hungover
- visual vertigo
- motion sickness
Explain the phases of migraine
Prodrome- include one or more of the following:
- Changes in mood
- Urination
- fluid retention
- food craving
- yawning
Aura- can present visually, or as weakness, speech arrest and numbness
Headcahe- head and body pain, nausea and photophobia
Resolution- rest and sleep; with a sweer type of pain
Recovery - mood is disturbed during this perios and you can feel hungover and have food intolerance.
This takes around 48hr but can be varied
what do you see when there’s positve and negative symptoms together in.migraine aura?
draw if possible
Scintillations and blindspot.
You also see expanding C’s with elemental visual distubances. It moves towards the periphery
State the treatment options for acute attacks of migraine
T A S A T O
- Triptan tablets (melts, nasal sprays)- synergise wiht NSAIDS for better therapeutic effects.
- Aspirin/Ibuprofen AND anti-emetics like metoclopramide which stimulate peristalsis (they have gastric parersis)
- Soluble preparations to aid absorption.
- A short nap
- Opiates given with caution
- TMS- interrupts networks that can perpetuate migraines
HIT THE HEADACHE HARD AND FAST
What are the lifestyle issues those with persistent migraine have?
- Sensitive head even in between attacks
- Over react ton any sort of stimulation. Hence they cannot ignore the world around them as it overstimulates them.
What can people with migraine possibly do to avoid triggers, i.e. give me examples of triggers for migraine
- dietary, environmental, hormonal, dehydration, stress
- Avoid caffenated drinks
- Dont skip meals and eat fresh food
- Don’t oversleep or have late nights. Don’t overuse electronics
- Analgesic abuse- avoid this
What are the major prophylaxis of Migraine.
- TCAs
- Over the counter preparations like Mg or nicotinamide.
- Beta-blockers
- Serotonin antagonist- Pizotifen very effective.
- CCBs
- Anticonvulsants- valproate- very teratogenic
- botox
- Greater occipital nerve block
- suppress ovulation using POP/implants- dont using OCP as oestrogen can cause headaches
what condition do pts with migraine have to fulfil to have prophylaxis.
what is the latest migraine drug and what does it do?
Migraine for more than 14 times in a month
New drug: Erenumab (Injectable)
cuts number of migraines in half
it is a monoclonal antibody that disables calcitonin gene- related peptide or it’s receptor
Can be used for episodic migraine, chronic migraine orcluster headache.
What happens in tension type headache and how can you treat it?
There are tight muscles around head and neck bilaterally, as though head is in a vice.
Treatment
- NSAIDS preferred
- Paracetamol
- TCAs
- SSRI- less effective
- Biofeedback and relaxation unproven but anecdote seems to say it helps
what is a cluster headache and describe it’s main features.
Severe ipsilateral pain that lasts for aroud 3hrs untreated. normally in the face- phantom of the opera
Classified as a trigeminal autonomic cephalgia.
It MUST HAVE atleast one of the following IPSILATERALLY:
- Conjuctival redness, and /or redness
- nasal congestion and/or rhinorrhea
- Eyelid oedema.
What are the associated features of the cluster headaches
- Forehead and facial sweating
- Miosis and /or ptosis
- A sense of restlesness or agitation
- symptoms appear diurnally
- not associated with brain lesion on MRI
what are the acute treatment for cluster headches
- Inhaled 100% oxygen- it inhibits neuronal activation in the trigeminocervical complex.
- Subcutaneous or Nasal Sumatriptan
Give the preventative treatments for cluster headaches
- Verapamil
- Prednisolone
- Lithium
- Valproate
- Gabapentin
- Topiramate
- Pizotifen
what are the difference between migraine and clusters
what are the causes of recurrent and triggered (pattern of) headaches
Recurrent headaches:
> Migraine
> Cluster headache
> Episodic tension headache
> Trigeminal or post-herpetic neuralgia
Triggered headache
> Coughing, straining, exertion
> Coitus
> Food and drink
There are two progression of dull headaches, what are they and give possible causes
Dull headache, increasing in severity
> Usually benign
> Overuse of medication (e.g. codeine)
> Contraceptive pill, hormone replacement therapy
> Neck disease
> Temporal arteritis
> Benign intracranial hypertension
> Cerebral tumour
> Cerebral venous sinus thrombosis
Dull headache, unchanged over months
> Chronic tension headache
> Depressive, atypical facial pain
