Headaches Flashcards
Give some differentials for a headache…
Tension headaches Migraines Cluster headaches Secondary headaches Sinusitis Giant cell arteritis Glaucoma Intracranial haemorrhage Subarachnoid haemorrhage Analgesic headache Hormonal headache Cervical spondylosis Trigeminal neuralgia Raised intracranial pressure (brain tumours) Meningitis Encephalitis
What are the red flags in terms of headaches?
Fever, photophobia or neck stiffness (meningitis or encephalitis)
New neurological symptoms (haemorrhage, malignancy or stroke)
Dizziness (stroke)
Visual disturbance (temporal arteritis or glaucoma)
Sudden onset occipital headache (subarachnoid haemorrhage)
Worse on coughing or straining (raised intracranial pressure)
Postural, worse on standing, lying or bending over (raised intracranial pressure)
Severe enough to wake the patient from sleep
Vomiting (raised intracranial pressure or carbon monoxide poisoning)
History of trauma (intracranial haemorrhage)
Pregnancy (pre-eclampsia)
Why is fundoscopy an important part of examination when a patient presents with a headache?
Fundoscopy examination to look for papilloedema is an important part of an assessment of a headache. Papilloedema indicates raised intracranial pressure, which may be due to a brain tumour, benign intracranial hypertension or an intracranial bleed.
What is the classical presentation of a tension headache?
Classically they produce a mild ache across the forehead and in a band-like pattern around the head. This may be due to muscle ache in the frontalis, temporalis and occipitalis muscles. Tension headaches comes on and resolve gradually and don’t produce visual changes.
What are tension headaches associated with in terms of lifestyle factors…
Stress Depression Alcohol Skipping meals Dehydration
How do you treat tension headaches?
Reassurance
Basic analgesia
Relaxation techniques
Hot towels to local area
How do secondary headaches present and what are they due to?
Secondary headaches give a similar presentation to a tension headache but with a clear cause. They produce a non-specific headache secondary to:
Underlying medical conditions such as infection, obstructive sleep apnoea or pre-eclampsia
Alcohol
Head injury
Carbon monoxide poisoning
How does sinusitis present?
Sinusitis causes a headache associated with inflammation in the ethmoidal, maxillary, frontal or sphenoidal sinuses. This usually produces facial pain behind the nose, forehead and eyes. There is often tenderness over the affected sinus, which helps to establish the diagnosis.
How is sinusitis treated?
Sinusitis usually resolves within 2-3 weeks. Most sinusitis is viral. Nasal irrigation with saline can be helpful. Prolonged symptoms can be treated with steroid nasal spray. Antibiotics are occasionally required.
What is an analgesic headache?
An analgesic headache is a headache caused by long term analgesia use. It gives similar non-specific features to a tension headache. They are secondary to continuous or excessive use of analgesia. Withdrawal of analgesia important in treating the headache, although this can be challenging in patients with long term pain and those that believe the analgesia is necessary to treat the headache.
What is a hormonal headache?
Hormonal headaches are related to oestrogen. The produce a generic, non-specific, tension-like headache. They tend to be related to low oestrogen:
Two days before and first three days of the menstrual period
Around the menopause
Pregnancy. It is worse in the first few weeks and improves in the last 6 months. Headaches in the second half of pregnancy should prompt investigation for pre-eclampsia.
What is cervical spondylosis?
Cervical spondylosis is a common condition caused by degenerative changes in the cervical spine. It causes neck pain, usually made worse by movement. However, if often presents with headache.
What is the trigeminal nerve made up of?
The trigeminal nerve is made up of three branches:
Ophthalmic (V1)
Maxillary (V2)
Mandibular (V3)
Who does trigeminal neuralgia affect?
Trigeminal neuralgia can affect any combination of the branches. The cause is unclear but it is thought to be caused by compression of the nerve. 90% of cases are unilateral, 10% are bilateral. Around 5-10% of people with multiple sclerosis have trigeminal neuralgia.
What does trigeminal neuralgia present with?
It presents with intense facial pain that comes on spontaneously and last anywhere between a few seconds to hours. It is often described as an electricity-like shooting pain. Attacks often worsen over time.
