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
