Secondary Headache Flashcards
secondary headache
-caused by exogenous disorders
-can be mild secondary or life threatening
-SAH
-meningitis
-temporal arteritis
-posttraumatic headache
-glaucoma
-COVID-19 headache
-medication overuse headache (analgesic rebound)h
-increased intracranial mass lesion/pressure
-activity triggered headaches
-facial pain and headache
headache
-primary headache- trigeminal nerve that innervates: large intracranial vessels, dura mater (pia has no pain), pain processing pathways -> parasympathetic activation
-migraine and other primary headache types are not vascular headaches
-acute vs. recurrent, new, psychiatric hx
-neurological exam
-investigation- blood tests, dx imaging, lumbar puncture
-causes of headache is on a cellular level not really vasodilation
primary vs secondary headache
-primary diagnosed through history
-secondary diagnosed through investigation using blood test, imaging, LP
symptoms suggesting underling disorder for headaches
-sudden onset
-first severe headache or different type
-worst headache ever
-vomiting that precedes (can be tumor)
-subacute worsening over days or weeks
-pain induced by bending, lifting, coughing
-disturbs sleep or presents immediately upon awakening
-known systemic illness
-onset after age 55
-fever, systemic signs
-abnormal neurologic exam
-pain associated with local tenderness, e.g. temporal artery
SNNOOP10
- red flags for secondary causes of headache
-Systemic symptoms including fever- attributed to infection, nonvascular intracranial disorders, carcinoid, or pheochromocytoma
-Neoplasm Hx- neoplasms of the brain, metastasis
-Neurologic deficit- attributed to vascular, nonvascular intracranial disorders, brain abscess and other infections
-Onset is sudden- subarachnoid hemorrhage and other headache attributed to cranial or cervical vascular disorders
-Older age- giant cell arteritis (older women) and other headache attributed to cranial or cervical vascular disorders; neoplasms and other nonvascular intracranial disorders
-Pattern change- neoplasms, headache attributed to vascular, nonvascular intracranial disorders
-Positional headache- intracranial hypertension or hypotension
-Precipitated by sneezing, coughing, or exercise- posterior fossa malformations, chiari malformation
-Papilledema- neoplasms and other nonvascular intracranial disorders intracranial hypertension
-Progressive headache and atypical presentations- neoplasms and other nonvascular intracranial disorders
-Pregnancy or puerperium- headaches attributed to cranial or cervical vascular disorders, postdural puncture headache, hypertension related disorders (preeclampsia), cerebral sinus thrombosis, hypothyroidism, anemia, diabetes mellitus
-Painful eye with autonomic features- pathology in posterior fossa, pituitary region, cavernous sinus, tolosa hunt syndrome (severe, unilateral headaches with orbital pain and ophthalmoplegia due to extraocular palsies; other ophthalmic causes
-Posttraumatic onset of headache- acute and chronic posttraumatic headache; subdural hematoma and other headache attributed to vascular disorders
-Immune system pathology- opportunistic infections
-Painkiller overuse or new drug at onset of headache- medication overuse headache, drug incompatibility
SNNOOP10 condensed
-Systemic symptoms including fever
-Neoplasm hx
-Neurologic deficit
-Onset is sudden abrupt
-Older age
-Pattern change or recent onset of new headache
-Positional headache
-Precipitated by sneezing, coughing, or exercise
-Papilledema
-Progressive headache and atypical presentations
-Pregnancy or puerperium
-Painful eye with autonomic features
-Post traumatic onset of headache
-Pathology of the immune system such as HIV
-Painkiller (analgesic) overuse
subarachnoid hemorrhage
-sudden onset
-thunderclap headache
-sometimes followed by impaired consciousness
-often associated with meningismus- neck pain
-etiology- trauma, spontaneous (nontraumatic) SAH -> sentinel bleed (leak) - berry aneurysm or ateriovenous malformation
-dx confirmed by CT scan and/or LP
-cerebral arteriography usually needed to identify source of hemorrhage
-approx 50% have sentinel bleed
-50% with sentinel bleed will bleed again within 2-6 weeks
-re-bleed- 50% mortality, 50% of survivors have significant neurologic deficits
-head CT negative in 1-10% of cases- sensitivity decreases with time from onset of sx
-CT may not show bleed within the first 24 hours
-if head CT negative- repeat CT in 2 weeks or LP
-arteriography if + CT Or LP
prior to a lumbar puncture
-imaging required prior to LP if papillaedema
-check abnormal neurologic exam, mental status
-check abnormal funduscopic exam (papilledema, loss of venous pulsations)
-check meningeal sings
-do not do lumbar puncture- if infection, mass, or deformity in the area of puncture
emergent acute headache
-conduct imaging prior to leaving office/ED
-if abnormal neurologic exam/mental status
-thunderclap headache
urgent acute headache
-scheduled imaging prior to leaving office/ed
-HIV positive pt
-age > 50 years (normal neurologic exam)
subarachnoid hemorrhage: complications/concerns
-most immediate complications - cardiac arrhythmias and pulmonary edema
-concerns- re-bleed and development of hydrocephalus
subarachnoid hemorrhage: mortality and morbidity
-high morbidity and mortality
-10% of patients will die before they reach hospital
-40% will due in the hospital within one month of the hemorrhage
-a ruptured aneurysm needs to be secured (clipping/coiling) urgently to prevent re-bleeding
giant cell arteritis
-temporal arteritis
-rare before age 50
-temporal artery tenderness, swelling, redness, nodularity
-visual disturbance- visual loss in 7-60% if untreated - urgent
-jaw claudication (muscle pain)
-systemic symptoms- fever, wt loss, anorexia, malaise
-can be confused with meningitis- check for infection, age, ESR
-polymyalgia rheumatica (prox. muscle pain/tend/stiffness
-ESR (erythrocyte sedimentation rate) usually > 50(mm/hr)- nonspecific blood test -> shows inflammation does not dx specific things
-temporal artery biopsy- multinucleated giant cells/inflammation- can be skip lesions (not consistent along the artery) -> confirms dx
-therapy- high dose steroids (prednisone) -> decrease inflammation to prevent blindness
meningitis
-inflammatory response of the meninges and the CSF of the subarachnoid space to bacterial invasion (or viral)- can be various diff types of bacteria or virus
-often infectious (varies)
-1 of the most common CNS infections
-meningoencephalitis- meninges and brain parenchyma are infected
-acute- hours or days- often
-subacute/chronic
meningitis risk factors
-very young age
-asplenia- sickle cell disease and other chronic hemolytic anemias
-immunodeficiency’s (HIV infection, long term use of corticosteriods)
-malignancy
-diabetes mellitus
-homelessness/overcrowding
-being at risk for infective endocarditis
-recent visit to endemic areas
-refugee status (drought, famine, war)
-recent neurosurgery, head trauma, ear or sinus infection, invasive medical procedures, CSF Dural leaks, CSF rhinorrhea
acute bacterial meningitis
-severe illness
-purulent (pus) CSF
-rapidly progressive
-without treatment -> fatal
aseptic meningitis
-milder
-typically self limited
-usually caused by viruses
-bacteria, fungi, parasites, or noninfectious inflammation
Meningitis- Symptoms
-vague pro-drome of viral symptoms
-classic triad- fever, headache, nuchal rigidity
-passive flexion of the neck is restricted and painful
-rotation and extension are typically not as painful
-fever or chills in more than 85% of pts
-lethargy or coma
-photophobia
-rashes (especially Neisseria meningitis)
-seizures
meningitis signs
-fever or hypothermia
-meningismus- assess neck rigidity by flexing the neck forward while the pt is lying in bed
-kernigs sign in older children- supine, knees bent, try to extend legs, pain in hamstrings or inability -> +
-brudzinskis sign- neck flexion -> knees/hips flex up
-tripod position- severe meningitis, knees and hips flexed, back arched lordotically, neck extended, arm brought back to support thorax
-rash/petechiae (in pts with bacteremia)
-purpuric lesion on the skin (gunmetal or slate gray)
meningitis work up
-strong clinical suspicion- demands immediate action
-blood cultures- empiric antibiotic treatment
-CSF -> LP
-CT scan
-MRI
diagnosis of meningitis
-medical emergency
-if suspicion of neiserria meningitis- place pt in isolation pending definitive dx
-requires rapid dx and treatment- after IV access and blood cultures
-lumbar puncture- gram stain, culture, cell count and differential, and glucose (decreased) and protein (increased) content
-glucose and protein may stay the same with viral
-patient with signs compatible with mass lesion (focal deficits, papilledema, deterioration in consciousness, seizures) -> head CT prior to lumbar puncture -> cerebral herniation
take home message for B. meningitis
-true medical emergency
-speed of intervention to prevent neurological injury is key to successful management
-early diagnosis is important
-early intervention with appropriate antimicrobial treatment is essential
-do not delay therapy while awaiting results of diagnostic testing (collect cultures first)
posttraumatic headache
-nonspecific symptoms may follow closed head injury, regardless of whether consciousness is lost
-headache is often conspicuous feature
-usually appears within a day or so following injury, may worsen over the ensuing weeks, and gradually subsides
-usually a constant dull ache with throbbing that may be localized, lateralized, or generalized
-nausea, vomiting, scintillating scotomas
-simple analgesics
-severe headache may need preventative treatment
-concussion possible
COVID-19 headaches
-often experience pressure or throbbing that dominates their entire head
-resembles tension type or migraine
-often worse when bending over
-can be accompanied by fever, body aches, fatigue
-nasal congestion and sore throat common symptoms
-long-haulers may experience COVID-19 headache that persists for months, or never resolves
medication overuse headache
-chronic daily headache leads to medication overuse, pain unresponsive to medication
-usually opioids (10), but can also be simple drugs (15)
-CRITERIA:
-occurring on 15 days/months in a pt with preexisting headache disorder
-regular overuse for >3 months of one or more drugs that can be taken for acute and/or symptomatic treatment
-not better accounted for by another ICHD-3 dx
-management:
-withdrawal of the offending medication
-use a different analgesic
-early initiation of a migraine preventive therapy
-education
intracranial lesions
-subacute progression of a focal neurologic deficit- focal meaning specific to the part of the brain its pressing on
-space occupying
-seizure
-non focal neurologic disorder such as headache, dementia, personality change, or gait disorder
-presence of systemic symptoms like malaise, weight loss, anorexia, fever suggests metastatic rather than primary brain tumor
-may be IITCH
-may result from focal irritation or displacement of pain-sensitive structures
-from generalized increase in ICP
-headache that worsens with recumbency, is suggestive of a mass lesion
-nausea/vomiting before headache
activity triggered headaches
-primary cough headache- severe head pain due to coughing (straining, sneezing, laughing)- lasts for only a few mins or less
-similar presentation- intracranial lesions -> posterior fossa - arnold-chiari malformation)
-symptoms sometimes clear completely after lumbar puncture
-other activity triggered headache syndromes: primary exertional headache, primary headache associated with sexual activity
trigeminal neuralgia
-aka Tic Douloureux
-idiopathic, multiple sclerosis (MS); neoplasia
-brief episodic lancinating stabbing facial pain
-maxillary and mandibular divisions of CN V triggered (trigeminal)
-features:
-women>men
-mid to later life
-touch, movement, drafts or eating
-exam usually negative
-CT/MRI etc.-usually negative, posterior fossa exploration
-treatment: (seizure medications)
-oxarbazepine
-carbamazepine (most well studied, effective)
-NSAID combinations
acute glaucoma
-group of eye diseases- second most common cause of vision loss in US
-about 3 mill americans have, only half are aware
-fluid forms within the anterior part of eye
-common feature- damage to the optic nerve
-raised intraocular pressure IOP is the most important risk factor
-can present with prostrating headache associated with nausea and vomiting
-headache starts with severe eye pain
-ocular and facial pain
-unilateral blurring of vision
-colored haloes around lights
-upon physical exam the eye is often red with a fixed (doesnt dilate) steamy moderately dilated pupil (usually unilateral)
-Lower IOP quickly- carbonic anhydrase inhibitor (acetazolamide)
-beta blocker (timolol)
-pilocarpine
other causes of facial pain
-postherpetic neuralgia (shingles)- treatment is acyclovir
-glossopharyngeal neuralgia
-TMJ joint dysfunction- worsening pain, continuing pain f undiagnosed cause, surgical treatment -> refer to dentist
when to refer
-acute onset
-increasing headache unresponsive to simple measure
-hx of trauma, hypertension, fever, visual changes
-presence of neurologic signs or of scalp tenderness
-thunderclap
when to admit
-suspected subarachnoid hemorrhage
-structural intracranial lesion
papilledema
-swelling around optic nerve
-shows ICP
-check before lumbar puncture
-
lithium
prevention
botox
-migraine
