Headaches Flashcards
What is a good 3 step approach for taking a history of presenting complaint?
- ask questions about the symptoms, using SOCRATES
- ask questions about associated symptoms (symptoms review)
- ask questions about risk factors
What is the difference between primary and secondary headaches?
Primary headaches:
- there is NO clear underlying cause
- it is thought to be due to pain-sensitive structures in the head (nerves, muscles, vasculature) changing the way the brain processes external stimuli
Secondary headaches:
- the headache has a clear underlying cause
What are the 3 different types of primary headaches?
- tension headaches
- cluster headaches
- migraine
What is the definition of a tension headache?
Why does it occur?
the most common type of headache, which is considered a normal, everyday headache
it is not known why it occurs, but it is thought to be due to increased muscle contraction
Who tends to be affected by tension headaches?
it tends to affect younger people
more commonly affects females
What are the symptoms (SOCRATES) for a tension headache?
- S - generalised, bilateral
- O - gradual or acute onset
- C - dull - feels like a “tight band” across the forehead
- R - neck & shoulders
- T - lasts for 3-4 hours
- A - analgesics help to relieve pain
- S - moderate severity
there are NO associated symptoms
What are the 2 major risk factors for a tension headache?
- stress
- disturbed sleep
What is involved in the examination and investigations for tension headache?
- examination should be normal
- no investigations are carried out
What is involved in the conservative and medical management for tension headache?
What must special attention be pain to?
- conservative management involves headache diaries to find ways to relax and avoid triggers
- medical management involves simple analgesia (paracetamol, ibuprofen)
- be aware of medication-overuse headaches
- taking too many analgesics can also lead to headache
What is the definition of migraine?
What causes it?
migraine is a chronic condition that causes attacks of headaches
it is caused by inflammation of the trigeminal nerve, which changes the way in which the brain processes stimuli
e.g. the brain does not usually pay attention to light / sound, but now they are perceived differently as pain
Who is more likely to be affected by migraine?
- females are 3x more likely to be affected
- more common in young adult females
What acronym can be used to remember the triggers of migraine?
the acronym CHOCOLATE can be used:
- C - chocolate
- H - hangovers (alcohol, particularly wine)
- O - orgasms (hormonal changes)
- C - cheese / caffeine
- O - oral contraceptives
- L - lack of sleep
- A - alcohol
- T - travel
- E - exercise
also bright lights and stress
What are the symptoms of migraine (SOCRATES)?
- S - unilateral
- O - paroxysmal, comes on gradually
- C - pulsating / throbbing
- T - lasts for 4 - 72 hours
- E - physical activity / stress, noise, light
- S - moderate to severe (interferes with everyday activity)
- Relieving factors are lying in a quiet, dark room
What are the associated symptoms for migraine?
- aura - flashing lights, tingling
- photophobia & phonophobia
- nausea & vomiting
- visual changes
- tingling
- numbness
What are the risk factors for migraine?
How is it diagnosed?
- the only risk factor is family history
- it is a clinical diagnosis and investigations are not usually conducted
- investigations are only performed if something more sinister is suspected
What are the 3 stages in the management of migraine?
1 - Conservative:
- headache diary (relaxation techniques, good diet & sleep)
- avoiding triggers
2 - Acute Medical Treatment:
- 1 - paracetamol, ibuprofen, NSAIDs
- 2 - triptans are used if simple analgesics are not effective
3 - Preventative Treatments:
- 1 - propanolol (beta-blocker) or topiramate (antiepileptic)
- 2 - amitriptyline (antidepressant) if ^ does not work
Why is preventative treatment used for migraines?
What medication must be avoided in migraines?
preventative treatment is used for recurrent attacks that interfere with everyday activities
opiates (such as codeine) should be avoided in migraines as they cause dependence
What is the definition of a cluster headache?
a neurological disorder characterised by recurrent, severe headaches on one side of the head, which occur in a cyclical pattern
the headache comes on at the same time each day and is felt in the same place (usually behind the eye)
the person is then well for couple of months before another cycle of headaches begins
Who tends to be affected by cluster headaches?
- more common in men
- tends to affect them between the ages of 20 and 40
What are the symptoms of cluster headaches (SOCRATES)?
- S - unilateral, behind the eye
- O - acute onset, cyclical pattern, same time each day
- C - intense, sharp, penetrating
- T - lasts from 15 minutes to 3 hours
- E - triggered by alcohol and strong smells
- S - severe - can be disabling
What are the associated symptoms with cluster headaches?
Why do these occur?
there is activation of the hypothalamus, trigeminal nerve and autonomic nervous system
the associated symptoms are related to ANS activation
- watery, red eye
- facial flushing
- nasal congestion
- partial Horner’s (ptosis, miosis)
Where is the pain concentrated in each type of primary headache?
Cluster headaches:
- pain is in or around one eye
Tension headaches:
- pain is like a band squeezing the head
Migraine:
- pain, nausea & visual changes on one side of the head
What further investigations are conducted for primary headaches?
no further investigations are carried out for primary headaches as there is no clear underlying cause
What are the 6 different types of secondary headaches?
- trigeminal neuralgia
- meningitis
- encephalitis
- raised intracranial pressure (ICP)
- bleeds
- CNS tumours
What is the definition of trigeminal neuralgia?
What causes it and what condition is it associated with?
facial pain syndrome in the distribution of >1 divisions of the trigeminal nerve
it is caused by compression of the trigeminal nerve by a loop or artery or vein
it is associated with MS
What can trigger trigeminal neuralgia?
it is triggered by anything that can compress the trigeminal nerve, such as:
- cleaning teeth
- combing hair
- talking
- eating
- shaving
What are the symptoms of trigeminal neuralgia (SOCRATES)?
What investigations should be carried out?
- S - unilateral, along the trigeminal division
- O - paroxysmal, lasting for seconds
- C - stabbing, shooting
- A - associated symptoms are numbness
- E - brushing teeth, speaking, shaving, talking
there are no investigations for trigeminal neuralgia
What is the definition of meningitis?
What can cause it?
meningitis is inflammation of the meninges, which can be life threatening
it can be caused by bacteria, viruses or TB
What bacteria tend to cause bacterial meningitis in different age groups?
Babies:
- E. coli
- Group B streptococci
Children:
- H. influenzae
- Strep. pneumoniae
Adolescents / young adults:
- Neisseria meningitidis
Elderly:
- Strep pneumoniae
- Listeria monocytogenes
What viruses can cause meningitis?
What is more common and severe, bacterial or viral meningitis?
- enteroviruses
- herpes simplex virus
- varicella zoster virus
- HIV
- viral meningitis is MORE COMMON and LESS SEVERE than bacterial meningitis
What are the symptoms of meningitis?
Headache:
- O - acute onset
- S - severe pain
Associated symptoms:
- meningism
- fever
- rash
- vomiting
- seizures
What is meant by meningism?
this is a clinical syndrome of headache, neck stiffness and photophobia
it can be caused by other things, as well as meningitis
What are the risk factors for meningitis?
- it is transmitted through respiratory secretions so living in close communities / crowding is a risk
- age <5 and age >65 have more severe symptoms
What 2 signs will be present on examination for meningitis?
Kernig’s sign:
- there is an inability to straighten the leg when the hip is flexed to 90 degrees
Brudzinski’s sign:
- the patient’s hips and knees will flex when the neck is passively flexed
What type of rash might be present in meningitis?
a non-blanching petechial rash
when you press on this rash, it should not go white
What is involved in the investigations for meningitis?
CSF analysis is the most important investigation in meningitis
this is acheived through lumbar puncture
What is the main contraindication for lumbar puncture?
high intracranial pressure (ICP) is a contraindication for lumbar puncture
a CT-head should be done before LP to look for neurological deficit / reduced consciousness to make sure it is safe to continue with LP
What is the appearance, cells, glucose and protein like in bacterial, viral and TB CSF samples in meningitis?
Bacterial:
- CSF appears turbid (cloudy)
- increased neutrophils
- reduced glucose
- increased protein
Viral:
- CSF appears clear
- increased lymphocytes
- glucose is normal
- protein is normal or raised
TB:
- appears like a fibrin web
- increased lymphocytes
- reduced glucose
- increased protein
Why is glucose low in bacterial meningitis CSF samples?
glucose is low in bacterial infection as the bacteria in the CSF use the glucose for their own metabolism, whereas viruses do not
What is involved in the management of meningitis at the GP and in the hospital?
at the GP:
- IM benzylpenicillin is given and urgent referral to the hospital
at A&E:
-
broad spectrum antibiotics are given
- ceftriaxone IV
- benzylpenicillin IM
- acyclovir if infection is viral
- targeted antibiotics are then given depending on sensitivities
-
IV dexamethasone is considered
- this is a steroid that reduces the inflammation that occurs in the meninges
- it can reduce the risk of hearing loss
What are the possible complications of meningitis?
- hearing loss (this is the most common)
- sepsis
- impaired mental status
What is the definition of encephalitis?
What causes it?
inflammation of the brain parenchyma that can be fatal
- it is usually viral
- HSV 1-2
- CMV
- EBV
- HIV
- measles
- there are also non-viral causes
- bacterial meningitis
- TB
- malaria
- listeria
- Lyme disease
- legionella
Who tends to be affected by encephalitis?
it affects mostly the extremes of age - <1 and >65
What is the presentation of encephalitis like?
What symptoms are present?
it is an acute onset febrile illness with behavioural, cognitive and psychiatric manifestations
symptoms include:
- viral prodrome
- fever
- headache
-
altered mental state
- memory disturbances
- personality changes
- psychiatric manifestations
- impaired consciousness
What are the investigations for encephalitis?
- lumbar puncture is the investigation of choice
- bloods
- EEG
- CT / MRI to identify oedema / hyperintense lesions in the temporal lobes
How is location, aetiology and consciousness different in meningitis and encephalitis?
What is the definition of raised intracranial pressure?
What causes it?
this is an increase in the pressure of the skull
it is caused by:
- space occupying lesions (SOL) such as tumours, abscesses and haemorrhage
- hydrocephalus
What are the characteristics of the headache associated with a rise in ICP?
Are there other associated symptoms?
- S - bilateral
- O - gradual onset
- C - throbbing / bursting pain
- T - worse in the morning
- E - coughing and sneezing (these increase ICP anyway)
- associated symptoms are vomiting, seizures and altered GCS
What signs might be present in raised ICP?
- focal neurological symptoms
- papilloedema (swelling of the optic disc)
- Cheyne-stokes respiration (deep abnormal irregular breathing)
-
Cushing’s reflex demonstrated with Cushing’s triad
- increased systolic BP
- irregular breathing
- bradycardia
What is meant by focal neurological symptoms?
these are symptoms caused when there is damage in a specific part of the brain
e.g. a pituitary tumour pressing on the optic chiasma causes bitemporal hemianopia
What is the investigation performed in raised ICP?
What is contraindicated and why?
an URGENT CT-head is performed
- raised ICP is a contraindication for lumbar puncture
- high ICP changes the pressure gradient in the brain, so taking CSF and removing fluid from the system can further alter the pressure in the brain
- this leads to structures in the brain moving slightly
- this contributes to brainstem herniation, which can be life threatening
What are the 3 different types of bleed that can occur in the brain?
- extradural haemorrhage
- subdural haemorrhage
- subarachnoid haemorrhage
What is the definition of extradural (epidural) haemorrhage?
a collection of blood in the potential space between the dura and the bone
there is usually no space here as the dura is attached tightly to the skull
if there is a high force, the dura can strip away from the bone and blood can pool in the epidural space
What usually causes extradural haemorrhage?
Who tends to be affected?
- caused by head trauma
- common in young people (20-30 year old males)
- common cause is rupture to the pterion (where the sphenoid, parietal and temporal bones meet)
this is a weak point in the skull that is more prone to rupture
- the middle meningeal artery runs in close proximity to the skull under the pterion
What are the characteristics of the headache following extradural haemorrhage?
Why?
acute onset following a lucid interval
- it is commonly caused by rupture of the middle meningeal artery
- arteries carry blood at high pressure so the blood will accumulate quickly
- the lucid interval happens as the brain can initially compensate for the increase in pressure, then can no longer so the symptoms appear
What are the associated symptoms and risk factors associated with extradural haemorrhage?
- headache is acute following a lucid interval
- the headache is increasingly severe
- there is decreasing GCS and symptoms of raised ICP
- risk factors include head trauma
What investigations are carried out for extradural haemorrhage?
What results does this show?
- urgent non-contrast CT head-scan
- MRI (more specific, but takes longer)
- shows a lemon shape
- dura strips away from the bone, but at the sutures the dura is attached tightly and will not strip away
- there is a limited space where blood can collect and it is contained here
What is the definition of subdural haemorrhage?
What causes it and who is more susceptible?
a collection of blood between the dural and arachnoid covering of the brain
it is caused by rupture of the bridging veins
(susceptible in the elderly and alcoholics, due to brain atrophy)
Why are the elderly and alcoholics more susceptible to subdural haemorrhage?
this is due to brain atrophy
the bridging veins come from the cortex up to the bone
when the brain is smaller, but the size of the skull is the same, there is more space for the brain to move around
trauma (even a small one) can put pressure on the bridging veins, leading to their rupture
What are the symptoms of subdural haemorrhage?
Headache:
- O - gradual onset
- T - continuous
Associated symptoms:
- fluctuating consciousness
- confusion
- personality changes
- symptoms of raised ICP
What are the risk factors for subdural haemorrhage?
-
head trauma and falls
- often following minor trauma up to 9 weeks before which patients have forgotten
- old age
- alcoholics
-
anticoagulation
- this increases the tendency to bleed
How can subdural haemorrhages be classified?
Acute:
- occurring within 72 hours of trauma
- tends to occur in younger patients, trauma
Subacute:
- occurring 3 - 20 days after trauma
- tends to affect the elderly
- presents with a worsening headache
Chronic:
- occurs 3 weeks after the trauma
What investigations are performed for subdural haemorrhage and what signs do these show?
- urgent non-contrast CT-head
- this shows a banana shape
- unlike subdural haemorrhage, there are no suture lines so more space for the blood to expand
What is involved in the management of subdural haemorrhage?
ABCDE & neurosurgery referral
the treatment depends on the size and presentation
- if small (<10mm) and no significant neurological dysfunction, then it is observed
- if large or significant neurological dysfunction then Burr hole or craniotomy to drain blood from the brain
What is a subarachnoid haemorrhage and what causes it?
this involves bleeding into the subarachnoid space
it is most commonly due to rupture of a saccular aneurysm
the aneurysm is a bulging of a blood vessel which does not cause symptoms unless it ruptures
What are the symptoms of the headache present in subarachnoid haemorrhage (SOCRATES)?
- S - occipital (or diffuse)
- O - sudden (“thunderclap headache”)
- C - “worst headache ever” / “like being hit by a ball”
- T - continuous
- S - very severe, maximum intensity within minutes
What are the associated symptoms and risk factors for subarachnoid haemorrhage?
Associated symptoms:
- meningism
- symptoms of raised ICP
Risk factors:
-
polycystic kidney disease
- cysts on the kidneys and anerysms present which increases the risk of rupture of aneurysms
- alcohol
- smoking
- hypertension
What is the initial investigation performed for subarachnoid haemorrhage?
urgent non-contrast CT head
this has to be performed within 12 hours as the sensitivity of the CT decreases with time
When might a lumbar puncture be performed in suspected subarachnoid haemorrhage?
What would the results show?
- LP is performed if CT is normal
- This is to look for the presence of xanthochromia and oxyhaemoglobin
- these are the products of RBC breakdown that should not be outside the circulaton
- their presence in the CSF indicates that there has been a bleed
- this test can only be done from 12 hours after symptom onset
What is the definition of a CNS tumour?
primary brain tumours arising from any of the brain tissue types
- a primary tumour arises from the brain tissue
- a secondary tumour arises from metastases
- most commonly from the lung, skin or breast tissue
What is the epidemiology of CNS tumours like?
- in general, the incidence of brain cancers increases with age
- medulloblastoma is a paediatric brain tumour that is more common in children
What is the general presentation of a CNS tumour headache?
the symptoms depend on the tumour type and location
- S - bilateral
- O - gradual
- C - throbbing / bursting
- T - worse in the morning
- E - coughing / sneezing
What are the general associated symptoms of a CNS tumour?
-
FLAWS - symptoms of cancer
- fever
- lethargy
- appetite loss
- weight loss
- focal neurological signs
- weakness
- difficulty walking
- seizures
- personality changes
What are the risk factors for a CNS tumour?
- history of cancer
- family history of cancer
What investigations are performed for a CNS tumour?
- CT (quicker)
- MRI (better resolution)
- CXR / CT thorax, abdo & pelvis to check for metastases
- biopsy (definitive)
What is the treatment for a medication overuse headache?
- to withdraw all analgesics
- this will initially worsen the headache, but should alleviate it in the long-run
- once off the analgesia, it will be easier to discern the effects of other headaches (e.g. migraines)
What recommendation is given to headache patients when taking analgesia?
it is not advisable for headache patients to take simple analgesia for more than 2 days a week
