Headaches and Meningitis Flashcards
What are some causes of headaches?
- Traction or dilation of intracranial or extracranial arteries
- Traction or distension of large extra-cranial veins, dural venous sinuses
- Compression, traction or inflammation of cranial and spinal nerves
- Spasm and trauma to cranial and cervical muscles
- Meningeal irritation and raised ICP
- Disturbance of intra-cerebral serotonergic projections
What are primary headaches vs secondary headaches?
Primary:
- Symptom based
- No organic causes
Secondary:
- Aetiology based
What are the primary headaches?
- Migraine:
- Migraine with aura
- Migraine without aura
- Hemiplegic migraine
- Basilar migraine - Tension type headache
- Trigeminal autonomic cephalgias TACs:
- Cluster headache `
What are some secondary causes of headache?
Head/neck trauma
Cervical or cranial vascular disorders
Substance misuse or withdrawal
Psychiatric disorder related
Arterial HTN related
Non-vascular intra-cranial disorders
Infection
What does a headache worse with standing up and relieved by lying down indicate?
Intracranial hypotension
What does a headache worse with coughing, straining or valsalva indicate?
Raised ICP
What associated symptoms should you ask about?
N/V
Photophobia
Phonophobia
Fever
Blurred vision/loss of vision
Visual scintillation
Double vision
What are the headache red flags?
S2NOOP5/SNOOP
- Systemic symptoms: fever, weight loss
- Secondary risk factors: cancer, HIV, immunocompromised
- Neurological symptoms
- Onset: new onset, worst ever, abrupt
- Older patient: new over 50 (GCA)
- Previous headache different
- Position component (e.g. increases when upright)
- Pulsatile tinnitus (diplopia, transient visual changes)
- Provocative factors (coughing, exercise, sex)
- Pregnancy
When would you do neuro-imaging in a headache presentation?
- Thunderclap or sudden, severe headaches
- New onset of headache
- New pattern of headache
- Headache >50
- Focal signs or symptoms occurring with the headache
- Headache worse with valsalva
- Postural headache
- Headaches associated with fever, vomiting, meningism
- Headache associated with another systemic disease (HIC, vasculitis)
What are some cranial/cervical intravascular causes of secondary headache?
Arterial Dissection
Arteritis
Stroke
ICH
What are some arterial hypertension causes of secondary headache?
Eclampsia
Hypertensive Encephalopathy
What are some non-vascular intracranial causes of secondary headache?
Chiari malformation
Intracranial hypetension
Neoplasms
What are some infectious causes of secondary headache?
Meningitis
Encephalitis
Pain location, character, severity, aggravators and duration: Migraine
Usually unilateral (only 30% are bilateral)
Throbbing/pulsating
Moderate to severe
4hrs to 72 hours
Aggravated by exercise/worse on exertion
Pain location, character, severity and duration: Tension Headache
Bilateral
Pressure/tightening band across the head
Only moderately bad at most
30 mins
Pain location, character, severity, and duration: Cluster headache
Unilateral, peri/retro-orbital
Deep, excruciating
Horribly severe
15 minutes to 3 hours
Associated symptoms: Migraine
Photophobia/phonophobia
Nausea and vomiting
Aura!!
- Precedes the headache
- Starts over 5 minutes, with at least 2 symptoms in succession
- Aura lasts 5-60 minutes
- Headache starts within 60 mins after
- Visual, sensor, speech, motor, retinal
Associated symptoms: Tension headace
None
Associated symptoms: Cluster Headache
Autonomic Symptoms: watery, red, grumpy eye
- Ipsilateral but unilateral
- Lacrimation, conjunctival irritation
- Rhinorrhoea or congestion
- Partial Horner’s syndrome: ptosis and mitosis of the eye
When would you consider imaging for a migraine?
Unusual clinical presentation
When would you consider imaging for tension headaches?
When there’s risk factors suggesting the headache is actually secondary headache
Would you ever image a cluster headache?
Unlikely- clinical diagnosis
What is the Mx of a migraine?
Paracetamol, NSAIDs, Triptans (SC, buccal)
Prophylaxis:
- Propanolol
- TCA?
What is the Mx of a tension headache?
Paracetamol, NSAIDs
What is the Mx of a cluster headache?
Acute attack:
- Paracetamol, NSAIDs, triptan (nasal or SC)
Prophylaxis
- verapamil
- Steroids
What is the ICHD diagnostic criteria for migraine?
What is the ICHD diagnostic criteria for migraine with aura?
What is meningitis?
Inflammation of the meninges
Classify meningitis based on onset and temporal profile
Acute- bacterial
Subacute- viral or partially treated bacterial
Chronic
Recurrent
What are common infectious causes of meningitis?
Viral
Bac
TB
Fungal Parasitis
What are common non-infectious causes of meningitis?
Carcinomas
Autoimmune: sarcoidosis, beckets, SLE
Drug/chemical induced
What is a common infectious cause of meningitis in newborns?
Group B strep- s.agalactiae
What is a common infectious cause of meningitis in infants?
H. influenzae
Group A strep- s.pneumonia
N.meningitidis
What is a common infectious cause of meningitis in children?
N.meningitidis
H.influenza
Group A strep
What is a common cause of meningitis in adults?
N.meningitidis
Group A strep
What is a common cause of meningitis in the elderly?
Listeria monocytogenes
Group A strep
What are common viral causes of meningitis?
Enterovirus
EBV (remember cheeky glandular)
CMV
Mumps
What are the symptoms of meningitis?
TRIAD: fever, headache, neck stiffness
Photophobia
Phonophobia
Nausea and vomiting
Petechiae (meningococcus)
Seizures
Focal neurological signs
What are the symptoms of encephalitis?
Altered conscious state
Confusion
Coma
What overall Ix do you do for meningitis?
Blood culture!!
FBC, CRP
LFTs, UECs, COags
Imaging:
CTB
MRI
MRA( if concerned for vascular?)
LP
EEG
What do you look at with the LP and meningitis?
Pressure
Glucose
CSF proteins
Cell count
Cytology- malignant cells
Gram stain, AFB, indian ink stain
Cultures
Viral PCR
What are the CSF features of bacterial infection?
Turbid colour
Lots of polymorph cells
Cell count +++
<1/2 plasma glucose
>1.5 protein
Bacteria in smear, culture
What are the CSF features of viral infection?
Clear
Lots of mononuclear cells
Cell count ++
>1/2 plasma glucose
<1 protein
Nil bacteria
What is the management of meningitis?
- Treat underlying cause
- Usually ASAP empirical antibiotics
- Anti-virals, anti-fungals etc
- Inflammatory/AI cause: steroids - Supportive care- ICU
- Mx the complications
- Never forget prophylaxis for contacts!
