Neuroscience (Approach to Headaches) Flashcards
State the difference between primary and secondary headaches
PRIMARY HEADACHE = primary central pain due to dysregulation of pain-modulating pathways
- usually benign
- tension headache, migraine, cluster, hemicrania
SECONDARY HEADACHE = headache is a symptom of another primary pathology
- causes = infection, inflammation, brain tumour, trauma, bleed, raised ICP
For each demographic, state common headache conditions associated:
(1) Elderly
(2) Young adults
(1) ELDERLY = secondary headache (malignancies, giant cell arteritis)
(2) YOUNG PEOPLE = primary headache (migraine, tension headaches)
State the 5 common types of primary headache disorders
- episodic migraine
- tension-type
- cluster
- hemicrania continua
- SUNCT/SUNA
With regard to EPISODIC MIGRAINE, state
(1) Duration
(2) Location of headache
(3) Character of headache
(4) Associated symptoms
With regard to EPISODIC MIGRAINE, state
(1) Duration = 4-72 hours
(2) Location of headache = unilateral (can switch sides)
(3) Character of headache = pulsating / throbbing
(4) Associated symptoms = n/v, photophobia, phonophobia, aura (visual, sensory, speech disturbances)
With regard to TENSION-TYPE HEADACHE, state
(1) Duration
(2) Location of headache
(3) Character of headache
(4) Associated symptoms
With regard to TENSION-TYPE HEADACHE, state
(1) Duration = 30mins-7days
(2) Location of headache = bilateral (frontal / occipital)
(3) Character of headache = pressing + non-pulsating + tension sensation
(4) Associated symptoms = mild nausea, photophobia, phonophobia (rare)
With regard to CLUSTER HEADACHE, state
(1) Duration
(2) Location of headache
(3) Character of headache
(4) Associated symptoms
With regard to CLUSTER HEADACHE, state
(1) Duration = typically 1-2 hours
(2) Location of headache = unilateral (around one eye)
(3) Character of headache = severe + piercing + burning
(4) Associated symptoms = ipsilateral autonomic symptoms (tearing, nasal congestion, ptosis, miosis), agitation, restlessness
With regard to HEMICRANIA CONTINUA, state
(1) Duration
(2) Location of headache
(3) Character of headache
(4) Associated symptoms
With regard to HEMICRANIA CONTINUA, state
(1) Duration = continuous with exacerbations
(2) Location of headache = unilateral
(3) Character of headache = moderate + continuous with severe exacerbations
(4) Associated symptoms = ipsilateral autonomic symptoms (tearing, nasal congestion, ptosis, miosis), responsive to indomethacin
With regard to SUNCT/SUNA, state
(1) Duration
(2) Location of headache
(3) Character of headache
(4) Associated symptoms
With regard to SUNCT/SUNA, state
(1) Duration = seocnds to minutes, multiple times a day
(2) Location of headache = unilateral (around one eye)
(3) Character of headache = severe + stabbing + burning
(4) Associated symptoms = ipsilateral autonomic symptoms (tearing, nasal congestion, ptosis, miosis)
Meningoencephalitis = ____ and ____
(1) Presentation
(2) Common pathogens
(3) Management
(4) Diagnosis
Meningoencephalitis = MENINGITIS and ENCEPHALITIS
(1) Presentation = headache, neck stiffness, photophobia, fever, confusion (encephalitis)
(2) Common pathogens =
- meningitis (meningococcus, pneumococcus, TB, virus)
- encephalitis (viral - HSV, bacterial spread from meninges)
(3) Management
- ceftriaxone (gram), acyclovir (HSV, VZV)
- infants/old/pregnant - add ampicillin (listeria)
- mrsa - add vancomycin (mrsa)
- immunocompromised - swap ceftriaxone for meropenem (pseudomonas)
(4) Diagnosis
- lumbar puncture - high wcc, protein, low glucose
- positive kernig sign
- positive brudzinski sign
State the causes of raised ICP
- Increased cerebral volume - hematoma, tumour, abscess, cerebral edema
- Increased CSF production
- Decreased CSF drainage - obstructive hydrocephalus, meningeal inflammation or granulomas
- Increased blood volume - HTN
- Decreased blood outflow - increased cerebral blood flow during hypercarbia, venous stasis from venous sinus thrombosis, elevated central venous pressure
State the features of a headache associated with RAISED ICP
RAISED ICP
- worse on coughing/sneezing/straining
- worse on bending over
- visual obscurations on bending over
- headache worse in night than day
- headache upon waking and vomiting
- pulsatile tinnitus
- papilloedema
- CN VI palsy (nerve passes through lip of foramen magnum)
- CN II and CN III are vulnerable
State the investigations and treatment used for intracranial pressure abnormalities causing headaches.
INVESTIGATIONS
- lumbar puncture
- brain imaging (MRI)
TREATMENT
- treat underlying cause
- raised ICP - reduce ICP (acetazolamide + topiramate), surgery (optic nerve sheath fenestration - ONSF), CSF shunting to peritoneum, venous sinus stenting
- low ICP - blood patch + surgical repair
State the common causes and features of headache associated with low ICP
LOW ICP
(1) CAUSES
- spontaneous cause - spinal dural tear
- trauma or lumbar puncture (localise CSF leak)
(2) FEATURES
- headache worse in upright position
State the 3 possible causes of thunderclap headache
- subarachnoid haemorrhage
- cerebral venous thrombosis (CVT)
- carotid artery dissection
For each cause of thunderclap headache, state
(1) Features
(2) Investigations
(3) Causes
(4) Treatment (if any)
CAUSE 1: SUBARACHNOID HAEMORRHAGE
(1) Features - neck stiffness, neurolgoical deficit (blood enters parenchyma and irritates arteries causing vasospasm and secondary stroke), aleration of consciousness, raised ICP
(2) Investigations = CT of brain, lumbar puncture (observe biliruubin)
(3) Causes = SAH due to ruptured aneurysm, cerebral venous sinus thrombosi, cervical artery dissection, pituitary apoplexy
CAUSE 2: CEREBRAL VENOUS THROMBOSIS (CVT)
(1) Features - headache with focal signs, seizures, raised ICP
(2) Investigations = venography (CT or MRI)
(3) Causes = coagulation disorders, pregnancy, OCP
(4) Treatment - anticoagulants, endovascular thrombectomy, screen for thrombophilia
CAUSE 3: CAROTID ARTERY DISSECTION
(1) Features - tearing neck pain, focal neurological deficits, history of head manipulation
(2) Treatment - anticoagulants, antiplatelets, angioplast
