Secondary headache Flashcards
What presentations are indicators for sinister intracranial pathology?
Associated head trauma
First or worst
Sudden (thunderclap) onset
New daily persistent headache
Change in headache type/pattern
Returning patient
Long-standing episodic headaches are very likely to be caused by serious intracranial pathology
What symptoms are red flags for serious intracranial pathology?
Focal neurological symptoms
Non-focal neurological symptoms
Neck stiffness/fever - Meningitis
‘High pressure’ or ‘low pressure’ headaches
Symptoms of GCA
What signs are red flags when a patient presents with headache?
Activity of headache:
- New-onset or change in headache
- Over 50
- Immunosuppressed or cancer
- Change in frequency, characteristics, associated symptoms
Abnormal neurological examination
What is meant by a high-pressure headache?
Headache worse lying down
Headache wakening the patient up
Headache precipitated by physical exertion
Headache precipitated by Valsalva manoeuvre
Risk factors for cerebral venous sinus thrombosis
What is meant by a low-pressure headache?
Headache precipitated by sitting/standing up
This type of headache is caused by Low cerebrospinal fluid (CSF) pressure in the head due to a loss of CSF volume
This most commonly caused by CSF leakage after procedures such a Lumbar puncture
What is a thunderclap headache?
A high-intensity headache reaching maximum intensity in less than 1 minute
Majority peak instantaneously
It can be primary or secondary - difficult to tell the difference (probs just tell from history yeno)
What is a subarachnoid haemorrhage?
What causes them to happen?
Bleeding into the subarachnoid space—the area between the arachnoid membrane and the pia mater surrounding the brain
85% due to aneurysm
Describe the investigation protocol for someone with suspected SAH
1) History & Exam:
- Exam may be normal
- If other secondary causes ruled out then…
2) CT brain & Lumbar puncture
- LP must be done >12 hrs after onset
- CT +/- LP unreliable after 2 weeks…
3) If > 2 weeks then Angiography
How would a secondary headache due to meningitis or encephalitis present?
CNS infection should be considered in any patient with headache & fever
Meningitis:
- Nausea +/- vomiting
- Photophobia, phonophobia
- Neck stiffness
- Rash
Encephalitis:
- Altered mental state/consciousness (delirium)
- Focal symptoms/signs
- Seizures
Note that Meningoencephalitis (both together) is possible - and will have a combination of symptoms
What are causes of raised intracranial pressure?
Most common cause is Trauma
Other general causes - Infection, tumours, stroke, epilepsy
What are features suggestive of a space-occupying lesion and/or raised intracranial pressure?
Progressive headache - with associated Signs and symptoms
Warning features:
- Headache worse in morning
- Headache wakes patient at night
- Headache worse lying flat or brought on by Valsalva (cough, stooping, straining)
- Focal symptoms or signs
- Non-focal symptoms e.g. cognitive or personality change, drowsiness
- Seizures
- Visual obscurations and pulsatile tinnitus
What are the causes & signs of Intracranial hypotension (ie a low-pressure headache)?
Caused by dural CSF leakage - lower volume ∴ lower pressure:
- Leakage usually caused iatrogenically - post lumbar puncture
- Can be spontaneous though
Warning features:
- Clear postural component to headache
- Precipitates soon after assuming an upright posture and lessens or resolves shortly after lying down
- If chronic then may have lost postural component
How is intracranial hypotension investigated and treated?
Investigation:
- MRI brain and spine
Treatment:
- Bed rest, fluids, analgesia, caffeine (e.g. 1 can red bull 4x per day)
- IV caffeine
- Epidural blood patch if necessary
- Surgical procedure to patch up the holes in dura mater - would be done if post lumbar puncture etc
What is giant cell arteritis?
For which patients presenting with a headache - should GCA be considered?
Arteritis of large arteries - associated with polymyalgia rheumatica (autoimmune thing)
Should be considered in any patient over the age of 50 years presenting with new headache
What symptoms are seen in GCA?
New headache:
- diffuse
- persistent
- may be severe
Other features:
- Scalp tenderness
- Jaw claudication
- Visual disturbance
- Patient may be systemically unwell
