Neurology - Headaches Flashcards
Headaches DDx
Sinister vs Non-sinister
Sinister: VIVID
Vascular (Sub-arachnoid haemorrhage, Haematoma)
Infection (meningitis/encephalitis)
Vision threatening (temporal arteritis/acute glaucoma)
Intracranial pressure (Space-occupying-lesion, hydrocephalus)
Dissection (carotid dissection)
Non-sinister: Tension headache Migraine Cluster headaches Trigeminal neuralgia Sinusitis Medication overuse headache
Tension Headache Presentation/Ix/Rx
S: Generalised. Usually frontal or occipital O: Gradual or acute onset C: Dull A: Usually none T: Lasts 3-4 hrs E: Analgesics help S: Moderate
Usually in times of stress, exertion, lack of sleep
Ix: None
Management: Simple analgesics
Migraine Presentation/Ix/Triggers
S: Usually unilateral O: Paroxysmal C: Pulsating/throbbing A: Premonitory phase (aura) - visual changes, aphasia, tingling, numbness. Not essential T: 4-72hrs E: Physical activity/stress/straining S: Moderate to severe
Affects F>M. Aetiology unclear
Triggers: Cheese, Oral contraceptive pill, Caffeine, Alcohol, Stress
Ix: None - unless other differentials suspected e.g. meningitis/subarachnoid haemorrhage
Migraine Management
Conservative: Headache diary. Ask them to avoid precipitating factors.
Acute medical treatment:
Sumitriptan
+ Analgesia (NSAIDs)
+ Antiemetic (metoclopramide)
Prophylactic medical treatment:
1st: Propranolol or topiramirate
2nd: Amitriptyline
Beware of medication overuse headaches.
Andromeda, a 32 year old female presents with recurrent headaches. They are severe, on the right side of her head and often continue for the rest of the day. Before the headaches start she gets tingling in her arms, and when the headaches start she goes to bed. She is worried they might affect her relationship with her new boyfriend.
Cluster headache Intracranial mass lesion Medication overuse Migraine Tension headache
Migraine
Recurrent headaches Right side of her head Rest of the day Tingling She goes to bed
Cluster headaches presentation/Ix
S: Unilateral, behind the eye O: Acute onset, same time each day A: Not essential... Swollen eyelid and forehead swelling Nasal congestion Horner's syndrome T: Last 20-30mins S: Severe - can be disabling
Affects M>F. Aetiology unclear.
Occurs in a ‘cluster’. For example, a patient may have daily headaches for a 5-10 week cluster, then this repeats itself once a year.
Ix: None unless other differentials suspected.
Cluster headaches management
Acute medical treatment:
100% O2 via non-rebreathable mask
Sumitriptan (subcut) - needs to act faster than oral
Prophylactic medical treatment:
Verapamil
Homer, a 45 year old male has had excruciating headaches for the last month. He gets them about 5 times a week and notices his eyes watering. He had a similar episode 6 months ago. They are very disruptive to his poetry.
Cluster headache Intracranial space-occupying lesion Migraine Subarachnoid haemorrhage Meningitis
Cluster headache
Excruciating
5 times a week
Eyes watering
Similar episode 6 months ago
Raised ICP Presentation/Aetiology/Ix/Rx
S: Bilateral O: Gradual; present in the morning A: Vomiting, drowsiness, irritability... Red Flags: Seizures Papilloedema Focal neurology E: Worst when lying down or bneding over and coughing
Aetiology:
Space occupying lesion - tumour, abscess, haemorrhage
Hydrocephalus
Trauma
Ix:
Urgent CT/MRI to determine an underlying lesion
Rx: Treat based on underlying cause
Atalanta, a 27 year old female athlete presents to the GP with early morning nausea and headaches which has been happening for at least a week. Both are worst when she wakes up and improve throughout the day. She notes that she has been getting tired over the last few weeks, she is late on her period, and is definitely more irritable with her boyfriend, who despite being an Olympian, keeps leaving apple cores scattered around the house.
Excessive exercise. Migraine Pituitary tumour Pregnancy associated tension headache Trigeminal neuralgia
Pituitary tumour (Causing raised ICP)
Early morning nausea At least a week When she wakes up Been getting tired over last few weeks More irritable
Subarachnoid haemorrhage presentation/aetiology/Ix
S: Usually occipital
O: Sudden onset, “thunderclap”
A: Syncope, nausea, vomiting
Meningeal irritation can lead to meningism
Can present with signs of raise ICP
T: Continuous
S: Very severe - max intensity within mins.
Aetiology:
Usually due to a berry aneurysm at a junction of the circle of Willis. Aneurysms risk increases with a Hx or FHx of polycystic kidney disease.
20% are idiopathic
Other risk factors include alcohol/smoking/hypertension
Ix:
- Urgent CT scan within 12 hrs
- Lumbar puncture within 12 hrs - bloody CSF (xanthochromia)
Subarachnoid –> …
A ruptured aneurysm can lead to build up of blood (a haematoma) in the subarachnoid space between the
arachnoid and pia mater.
Subarachnoid haemorrhage management
SAH has a 50% mortality
Refer immediately to neurosurgery
Acute medical treatment -
cardiopulmonary support:
AB - maintain airway and breathing
C: Maintain cerebral perfusion. Keep well hydrated (oral/IV). Maintain blood pressure.
Further supportive measures:
Reduce ICP. Osmotic diuretic (mannitol) or hypertonic saline
Prevent cerebral artery vasospasm -
Nimodipine
Definitive surgical treatment:
Surgical clipping or endovascular coil embolization
Aphrodite, a 19 year old female sex-worker presents to AandE with a sudden onset headache that is the worst pain she has ever experienced. She occasionally gets mild headaches after sex, and has been given some medication by her GP for his. She has some neck stiffness and refuses to open her eyes wide or allow them to be examined.
Acute glaucoma Meningitis Migraine Subarachnoid haemorrhage Trigeminal neuralgia
Subarachnoid haemorrhage
Sudden onset
Worst pain
Neck stiffness and refuses to open her eyes wide - meningism
Subdural haemorrhage presentation/RF/definition/Ix/Rx
O: Gradual
A: Sleepiness, personality change - diminished verbal and motor response, possible signs of raised ICP
T: Continuous
Risk Factors:
Trauma
Coagulopathy/anti-coagulant use
Advanced age
Definition:
Collection of blood between the dural and arachnoid coverings of the brain. this build up is gradual and the blood is usually venous.
Ix: Urgent non-contrast CT scan
Rx: Neurosurgery referral
Epidural haemorrhage presentation/examination/definition/Ix/Rx
O: Acute onset after a lucid interval
A: Deterioration of GCS and Hx of recent direct trauma
Ex: Commonly scalp trauma
Definition: Collection of blood between the dural and periosteum. Build up is acute and blood is arterial.
Ix: Urgent non-contrast CT scan
Rx: Neurosurgery referral
Why non-contrast CT scan
The CT scan is non contrast as the blood is not contained, and consequently this will result in a leak of contrast into surrounding tissues.
Shape of subdural haemorrhage on CT scan
Crescent shaped
Shape of epidural haemorrhage on CT scan
Biconvex lens shaped
Leonidas, a 24 year old male, was fencing and suffered and injury to the head when his rival, Xerxes hit him on the head with his shield. Leonidas recovered quickly and was able to continue to fight for the next hour. However he quickly developed an excruciating headache, started to lose consciousness and had to stop the fight to go to the nearest A&E. He has had a blocked nose for the last week.
Epidural haemorrhage Intraventricular haemorrhage Meningitis Subarachnoid haemorrhage Subdural haemorrhage
Epidural haemorrhage
Injury to the head Shield Next hour Excruciating headache Lose consciousness
Meningitis Presentation/Aetiology/Ix/Rx
NB; headache is not always present in meningitis
O: Acute onset A: Fever Meningism (neck stiffness and photophobia) Rash (v bad) Confusion Seizures S: Severe
Aetiology - can be viral/bacterial/fungal
Ix: Lumbar Puncture –> CSF protein/glucose/microscopy and culture
Rx: Targeted antibiotic therapy
Euclid is a 19 year old male currently studying Maths at university. He has been very unwell for the last few days with fever and headache and admits to becoming a little confused lately. He is very anxious about his upcoming exams. He has been taking caffeine pills to help him with revision, however this has affected his sleep and for the last couple of nights he has developed a stiff neck.
Medication overuse headache Meningitis Migraine Tension headache Sinusitis
Meningitis
University Fever Headache Confused Stiff neck
Giant cell arteritis
Vasculitis affecting medium sized arteries in the head.
Abnormal “giant cells” develop in the walls of these arteries.
The presentation will vary based on which artery is affected.
Temporal artery (temporal arteritis): Headache and scalp tenderness. This is the most commonly affected artery and hence GCA is often synonymous with temporal arteritis.
Opthalmic artery:
Blindness
Temporal (Giant Cell) Arteritis Presentation/Ix/Rx
If the temporal artery is affected there will be headache…
S: Unilaterally, localised to scalp
O: Usually 1-2 days
A: Signs due to other affected arteries…
Jaw pain when eating
Visual disturbance
E: Scalp palpation (scalp tenderness)
Associated with polymyalgia rheumatica - pain, tenderness and stiffness of the shoulders and upper arms.
Ix: ESR
CRP
FBC
Temporal artery USS and biopsy
Rx: Urgent prednisolone
Any delay can lead to blindness
Plutarch is a 77 year old male who has come in with a right sided headache. This started yesterday morning and have been getting progressively worse. His memory is a little off because of his dementia, but
he says there is a possibility of trauma. His shoulders and neck also feel a little stiff. On examination, there is pain on palpation of the right forehead.
Intracranial space-occupying lesions Meningitis Subarachnoid haemorrhage Subdural haemorrhage Temporal arteritis
Temporal arteritis
Right sided
Progressively worse
Shoulders and neck also feel a little stiff
Pain on palpation of right forehead
Trigeminal Neuralgia presentation/RF/Ix/Rx
Shooting facial pain in the distribution of the Vth Nerve - usually V2, mostly unilateral. Provoked by washing, shaving, chewing.
RF: 60-80yrs of age Multiple sclerosis Female HTN
Ix: Usually none - can consider MRI
Rx: Anticonvulsants (carbamazepine)
V-2 function
V2 is purely sensory.
Helen is a 40 year old woman with a history of multiple sclerosis. She has developed a headache over the last couple of days. She has travelled the world and rarely had headaches in the past. She has stopped eating, as chewing simply makes her feel worse.
Meningitis Migraine Temporal arteritis Tension headache Trigeminal neuralgia
Trigeminal Neuralgia
Multiple sclerosis
Chewing
Acute glaucoma presentation/Rx
Sudden blockage around the travecular meshwork, resulting in a sudden rise in intraocular pressure.
Headache, painful eye, visual changes, vomiting.
Rx: Acetazolamide (carbonic anhydrase inhibitor)
Timolol (beta blocker)
70 year old Herodotus is brought in by his daughter to the GP. Over the last week he has developed a headache which lasts most of the day and rarely goes. He lives with his daughter and son-in-law as he is prone to falls due to his recent left hip replacement. The daughter also mentions that his father’s behavior has changed lately and tends to exaggerate some of his stories.
What do you think is the most important step in your management plan?
MRI scan Routine CT scan Sumitriptan + NSAIDs Urgent CT scan – Exclude possible subdural haematoma Watchful waiting
Urgent CT scan
Over the last week
Rarely goes
Prone to falls
Behaviour has changed lately
Alexander, known to his mates as Alex the G, is a 32 year old soldier who has just returned from a tour in Iran. He tells you that he has been getting throbbing bilateral head pain, and puts this down to lack of sleep. As a general, he has multiple reports to write and is finding this difficult with his four friends constantly bickering about one thing or the other. He hasn’t tried any medication and asks that you prescribe some sleeping pills. What is the most appropriate management?
Diazepam Codeine NSAIDs Topiramate Refer to A&E
NSAIDs
Throbbing bilateral head pain
Multiple reports to write
Friends constantly bickering
Hasn’t tried any medication
40 year old man who suffers from headaches. 3 weeks ago he was prescribed ibuprofen and has taken it religiously. Initially these worked really well, however now the headaches have returned and are worse than ever. He is very angry and does not think you are taking the right angle towards managing his issue. What is the next course of management?
Antibiotics Add a β-blocker Refer to A&E Switch medication to carbamazepine Ask to stop ibuprofen and see in 2 weeks
Ask to stop ibuprofen and see in 2 weeks
Taken it religiously
Headaches have returned
Hippocrates is a 71 yr old homeopath who presents with a left sided headache which came on yesterday morning. He tried to tread it with a clever paste made of garlic, vinegar and honey. When he applied the paste he was in great pain, and so believed that his remedy was working. However, his skeptical son told him to see “another doctor” for treatment. What is the most important next step?
Prescribe prednisolone and refer patient to AandE
Prescribe sumitriptan and send home
Refer to AandE for urgent CT scan
Refer to AandE for urgent non-contrast CT scan
Refer to AandE for MRI
Prescribe prednisolone and refer patient to AandE
Left sided
Applied the paste
Great pain
