LE 3: Approach to a Patient with Headache Flashcards
ushered in by an evident disturbance of nervous function, most often visual, followed in a few minutes by hemicranial or in about 1/3 of cases by bilateral headache, nausea, and sometimes vomiting, all of w/c last for hrs or as long as day or 2
Migraine w/ aura
“classic” or Neurologic migraine
familial d/o, periodic, unilateral, often pulsatile, begin with childhood or early adulthood and diminishing in frequency during advancing years
Migraine
unheralded onset over mins or longer of hemicranial headache or less often, by generalized headache w/ or w/o nausea and vomiting, w/c then follows the same temporal pattern as the migrain w/ aura
Migraine w/o aura
“common” migraine
1:5
male: 4-6%
female: 13-18%
asians: lower prevalence
Migraine
is an instrument often used for verbal assessment of pain
The McGill Pain Questionnaire
common clinical complaint w/c rivals backache as a reason to seek medical help
Headache
headache:
medical vs neurologic dses
medical > neurologic dses
epidemiology: young women w/ family hx of migraine
s/sx:
vertigo
incoordination
staggering
incoordination of limbs
dysarthria
visual phenomena: whole visual field of OU (temp. cortical blindness)
duration: 10-30mins followed by headache
Basilar Migraine
s/sx: recurrent unilateral headache assoc w/ weakness of EOM
CN affected w/ manifestion :
transient 3rd nerve palsy w/ ptosis w/ or w/o pupillary involvement
6th nerve rarely affected
duration: paresis often outlast the headache by days or weeks
Opthalmoplegic Migraine
most common variety of headache, frontal, temporal or occipitonuchal predominance, pain is dull and aching, sometimes described as fullness, tightness/pressure, does not interfere w/ ADL
middle age w/ anxiety, fatigue, and depression
Tension-Type Headache (TTH)
Frequency:
least 10 previous headaches fulfilling crit B-D
Frequent TTH
frequency:
ave. > or = to 15d/mo. (180d/yr) for > = 6 mos fulfilling crit. C-D
at least 2 pain char:
- Pressuring/tightening (nonpulsating) quality
- Mild-moderate intensity
- Bilateral location
- no aggravation by walking stairs or similar routine, physically activity
both of the ff:
- no vomiting
- no more than one of the ff:
a. nausea
b. photophobia
c. phonophobia - not attributed to any d/o
Chronic TTH
Paroxysmal hemicrania, short-acting unilateral neuralgiform headache attacks w/ conjunctival infection and tearing(SUNCT)
young adult men (20-50yo)
M:F 5:1
occur regularly each day for 6-12 weeks
Cluster headache and other trigeminal autonomic cephalgias
severe, chronic, intermittent
days or weeks
r/t injury
post-traumatic
headache w/: Drowsiness Confusion Stupor Hemiparesis
Post-traumatic:
Acute/Chronic
Headache is a prominent ft. complex syndrome: Giddiness Insomnia Fatigability Irritability Nervousness Inability to concentrate Trembling Tearfulness
Post-traumatic nervous instability
unilateral/bilateral retroauricular or occipital pain d/t stretching or tearing of the ligaments and muscles of occipitonuchal junxn
Post-traumatic:
whiplash injury
severe, episodic, throbbing, unilateral headache sometimes accompanied by ipsilateral mydriasis and excessive sweating of the face
Post-traumatic:
dysautonomic changes
infrequent headache deep seated non-throbbing aching nocturnal awakening inc. ICP dependent on tumor site
Brain tumor:
non specific features
Increasingly intense throbbing or non-throbbing, unilateral and localized to the affected artery, pain persistent throughout the day and severe at night, ESR >50mmH, elderly pt (60yo) Biopsy of affected vessel is granulomatous or giant cell arteritis, tx w/ steroids improvement in 1-2days. failure to improve will bring dx into question
Temporal Arteritis
headache assoc w/ greatly reduced pressure of CSF compartment and probably caused by traction of cranial blood vessels
Low pressure and spinal puncture headache
headache d/t drop in estradiol levels
Menstrual migraine
Generalized headache may occur in conjunxn w/ flushing of the face and hands and numbness of fingers
Erythrocyanotic
follows in initiating action within a second or two, last a few seconds to few minutes
Cough and exertional headache
headache w/ sexual excitement
- TTH
headache w/c occur at time of orgasm
- explosive, severe and throbbing type
Headache r/t sexual activity
danger signals on Examination
VSP RPM LART
VSP RPM LART abnormal V/s altered Sensorium Pupils unequal and/or poorly reactive Retinal hemorrhage or Papilledema signs of Meningeal irritation Lateralized deficits Ataxia of gait and/or mov'ts abnormal Reflexes Tender and poorly-pulsating cranial arteries
danger signals on Hx
SPF O MMS WFC
SPF O MMS WFC
Sudden onset of new severe headache Progressively worsening headache First headache in an adult Onset w/ exertion, coughing, straining and sexual activity Memory loss Myalgia Sensorium alteration Weakness Fever Clumsiness
pt. w/ serious headache
PACISSCHM
PACISSCHM
Pheochromocytoma Acute glaucoma Cns infexn, ischemia, hemorrhage Inc. icp Sah Secondary to metabolic disturbance Cranial arteritis Head trauma Malignant hpn
pt. w/ benign headache
TOMBC
TOMBC
Tth Orgasmic headache Migraine Benign exertional headache Cluster
what modality?
r/o structural d/o recurring or progressive headache focal slowing on EEG comorbid seizures persistent unilateral headache assure anxious pt or his relatives
Neuroimaging
what modality?
Loss of consciousness
Depressed sensorium or alertness
Seizure
Suspected metabolic encephalopathy
Electroencephalogram
what modality?
Cervical spine
Spine
Parasinuses
X-ray
what modality?
Vertebral
Intracranial
Carotid
Echogram
Ultrasound
what modality?
suspected MS, infiltrative or inflammatory process, inc or reduced icp
Lumbar Tap (CSF Analysis)
