Headaches & Tumors Flashcards
Describe the origin points of headaches
- extracranially (skin, muscle, vessels, periosteum)
- intracranially (vessels, dura, falx cerebri)
- brain parenchyma is incapable of producing pain
Describe the red flags in headache eval
- first severe HA or worst HA of life with acute onset
- HA progressively worsening over days/weeks
- severe HA with fever
- nuchal rigidity
- decreased LOC or focal neuro signs
Describe the onset and epidemiology of migraines
- onset usually adolescence or young adulthood (childhood too)
- female 3:1 male
- most commonly without aura
Describe the 2 types of migraines
Common Migraine (without aura)
Classic Migraine (with aura before or after HA)
Describe some of the precipitating factors of migraines
- menstruation
- too much/little sleep
- red wine, cheese, chocolate, herring, processed meats, caffeine
- meds
Describe the symptoms of a migraine
+/- aura
- unilateral
- pulsating/throbbing
- nausea/vomiting
- moderate to severe
- worse with activity
- photo/phonophobia
Describe the types of migraine auras
- Visual (scotoma)
- Sensory (unilateral paresthesia, numbness)
- Motor (unilateral weakness, aphasia)
What is the diagnostic threshold for migraines
- 5+ attacks before diagnosis made
- photo/phonophobia, impairment, nausea
What is the potential pathophysiology of a migraine
- intense vasoconstriction of cranial vessels
- issue with serotonin
Describe some of the prophylactic treatment for migraines
- beta blockers (propranolol)
- calcium channel blockers
- SSRIs (fluoxetine)
- TCAs (amitriptyline)
- ASMs (valproic acid)
Describe some of the abortive therapies for migraine
- OTC analgesics
- vasoconstrictors (ergots)
- antiemetics
- serotonin agonists (sumatriptan)
- IV/IM NSAID (ketorolac/toradol)
Describe the characteristics and pathophys of a cluster headache
series/cluster of headaches over 2-3 months with clusters occurring every 1-2 years
dilation of retro orbital blood vessels and inflammation of trigeminal nerve branches
Describe the clinical presentation of cluster headaches
- excruciating penetrating unilateral non-throbbing pain in trigeminal nerve distribution
- usually behind an eye
Describe the treatment of cluster headaches
similar to migraines
- first line sumatriptan
- oxygen inhalation effective in 70%
- beta blockers not used
What might trigger cluster headaches
- alcohol
- histamines
- nitroglycerine
Describe the autonomic features associated with cluster headaches
- lacrimation
- conjunctival injection
- rhinorrhea
- ptosis/miosis
What is the most common type of headache
tension headache
What is the etiology of tension headaches
- episodic or chronic
- can last 30 mins to 7 days
Describe the clinical presentation of a tension headache
- bilateral occipital, nuchal, frontal, pressure/tightness/band like pain
- unaffected by activity
+/- photo/phonophobia - no n/v or throbbing
Describe the treatment for tension headaches
- OTC analgesics (ASA, APAP, NSAIDs)
- excedrin
- stress reduction
- prevention (antidepressants or ASMs)
Describe sinusitis
acute or chronic infection of sinus cavities
Describe a sinusitis headache
- usually stabbing or aching
- worse when bending forward, coughing
- better when supine
- pain to percussion over sinuses (diagnostic)
Describe acute glaucoma headaches
- orbital pain
- n/v
- cornea is edematous
- injected conjunctiva
- decreased vision
How is glaucoma diagnosed
measure intraocular pressure via tonometry device
Describe temporal arteritis
vasculitis involving branches of the external carotid arteries, usually the temporal artery
(>50, women 4:1 men)
Describe a temporal arteritis headache
jabbing, excruciating pain over temples, usually unilateral, may have vision loss
pain with palpation over temple
Describe diagnostics for temporal arteritis
- elevated ESR
- temporal artery biopsy
Describe the treatment for temporal arteritis
prompt tx with steroids to decrease chance of visual loss (high dose prednisone)
Describe the etiology of TMJ
usually due to spasms of muscles around the temporomandibular joint, may be due to overbite, previous dental work, grinding teeth
Describe the clinical presentation of TMJ
- unilateral/bilateral pain in TMJ, tender to palpation
- may feel clicking in joint
Describe trigeminal neuralgia etiology
Brief severe attacks of pain along the distribution of branches of the trigeminal nerve due in part to compression and demyelination
Describe the pain related to trigeminal neuralgia
- lancinating, stabbing, electric shock
Describe the treatment for trigeminal neuralgia
- analgesics
- carbamazepine
- phenytoin
- possible surgery (refer to ENT)
Describe meningitis presentation
viral or bacterial infection
- headache
- fever
- nuchal rigidity
- toxicity/sepsis
What is the diagnostic and treatment course for meningitis
lumbar puncture and gram stain
- IV abx and steroids if bacterial
- supportive if viral
Describe the presentation of a hypertensive headache
headache usually resulting from a diastolic BP >130
Describe the common types of brain tumors
-astrocytoma (glioma)
-meningioma
-acoustic neuroma
-metastasis
Describe headaches secondary to brain tumor
- worsening over days-weeks
- usually worse in the morning with nausea/vomiting
- weakness, paralysis, sensory deficits, cranial nerve palsies, visual disturbance, ataxia, AMS, seizure
Describe the etiology of astrocytomas
most common type of tumor (malignant)
- from astrocytes in the cerebral hemisphere
- 3 histopathological grades
Describe the etiology of meningiomas
2nd most common tumor (benign)
- from the meninges
Describe acoustic neuroma etiology
- benign, slow growing tumor, from Schwann cell sheath around the vestibulo-cochlear nerve (CN8)
- occupies the cerebellopontine angle
Describe metastatic brain tumors
secondary, more common than primary brain tumors
- commonly from the lungs (48%), breasts (15%), and others
Describe the grades of astrocytomas and survivability
- low grade: 6-8 years
- anaplastic astrocytoma: 5 yrs with surg/radiation
- glioblastoma multiforme: most malignant, <1yr
Describe the symptoms of acoustic neuromas
- unilateral hearing loss, tinnitus
- vertigo
- headache
- facial numbness/weakness
Describe the treatment of meningiomas
observation, surgical (not usually radiation or chemo)
Describe the treatment of acoustic neuromas
surgical excision, gamma knife, or observation
Describe the treatment of metastatic brain tumors
-systemic workup for primary source
-brain biopsy
-mainly palliative
- whole brain radiation therapy
- gamma knife
- chemo
Astrocytoma
glioblastoma multiforme
meningioma
acoustic neuroma
cerebral metastases
What are the diagnostic tests for brain tumors
- MRI: study of choice
- CT with contrast
- EEG if seizures present
