Symptom To Diagnosis - Headache Flashcards
Headaches are classified into ?
Primary and secondary.
Primary headaches:
Syndromes unto themselves rather than signs of other diseases.
Although potentially disabling they are reliably NOT life threatening.
Secondary headaches:
Symptoms of other illnesses –> Potentially dangerous.
Single most important question when developing a DDX for a headache?
Is this headache new or old?
Chronic headaches tend to be?
Primary.
New-onset headaches tend to be?
Secondary.
Old headaches - 2 categories:
- Primary.
2. Secondary.
Old headaches - Primary:
- Tension headaches.
- Migraine headaches.
- Cluster headaches.
Old headaches - Secondary:
- Cervical degenerative joint disease.
- Temporomandibular joint syndrome.
- Headaches associated with substances or their withdrawal –> Caffeine, nitrates, analgesics, ergotamine.
New headaches - 2 categories:
- Primary.
2. Secondary.
New headaches - Primary:
- Benign cough headache.
- Benign exertional headache.
- Headache associated with sexual activity.
- Benign thunderclap headache.
- Idiopathic intracranial HTN (pseudotumor cerebri).
New headaches - Secondary:
- Infectious.
- Vascular.
- Space-occupying lesions.
- Medical morning headaches.
New headaches - Secondary - Infectious:
- URI.
- Sinusitis.
- Meningitis.
New headaches - Secondary - Vascular:
- Temporal arteritis.
- SAH.
- Parenchymal hemorrhage.
- Malignant HTN.
- Cavernous sinus thrombosis.
New headaches - Secondary - Space-occupying lesions:
- Brain Tumors.
2. Subdural hematoma.
New headaches - Secondary - Medical morning headaches:
- Sleep disturbance.
2. Night-time hypoglycemia.
Severe or quality is more important in distinguishing a new from an old headache?
Quality.
–> Severe headache that is identical in quality to chronic headaches is less worrisome than a mild headache that is dissimilar to any previous headaches.
Migraine headache - Textbook presentation:
- Women in their teens or 20s.
- Unilateral, throbbing, severe enough to make it impossible to do work during an attack.
- Occasionally preceded by about 20 min of flickering lights in a visual field (aura). Patients usually find it necessary to lie in a dark, quiet room.
Auras in migraines:
33-75% of patients with migraines have auras.
Of ALL people with migraine:
18% –> ALWAYS have auras.
13% –> SOMETIMES have auras.
8 –> Have auras WITHOUT headaches.
Auras are usually?
Visual, precede the headache, and last for about 20 min.
Descriptions of auras:
- Frequently, patients will initially describe a blind spot.
- Auras usually involve one part of the visual field.
- Scintillating scotoma often occur –> Flashing lights, spots of light, zigzag lights, or squiggles.
Criteria for migraines without aura:
- A patient must have at least 5 attacks that last 4-72hrs.
- Headache must have 2 of the following qualities:
a. Unilateral pain.
b. Pulsating pain.
c. Moderate to severe pain (must limit activity).
d. Aggravated by routine physical activity. - And have 1 of the following associated symptoms:
a. Nausea and/or vomiting.
b. Photophobia or phonophobia.
Criteria for migraines with aura:
- DEFINITION: Recurrent disorder manifesting in attacks of reversible focal neurologic symptoms that usually develop gradually over 5-20min and lasting less that 60min.
- Usually follow the aura symptoms.
- Must have at least 2 attacks.
…% of patients with migraine headaches have NON pulsatile headaches.
50%.
…% of patients with migraine headaches have BILATERAL headaches.
40%.
A recent systematic review suggested the mnemonic POUNDing as a diagnostic test for migraines:
- Is the headache Pulsatile.
- Does it last between 4 and 72hOurs without medications?
- Is it Unilateral?
- Is there Nausea?
- Is it Disabling?
If 4/5 is YES –> LR+ 24.
When differentiating migraines from tension headaches, … is an important clue to migraines.
NAUSEA.
9 Indications for imaging in people with headaches:
- Abnormal neurologic exam or symptoms that are atypical for aura, especially dizziness, lack of coordination, numbness or tingling, or worsening of headache with the Valsalva maneuver.
- Increasing frequency of headaches or a change in headache quality or pattern.
- Headaches that awaken the patient from sleep.
- New headaches in patients over 50.
- 1st headache, worst headache, or abrupt-onset headache.
- New headache in patients with cancer, immunosuppression, or pregnancy.
- Headache associated with loss of consciousness.
- Headache triggered by exertion.
- Special consideration should be given to a person who is receiving warfarin therapy.
MC headaches?
Tension headaches.
Tension headache - Textbook presentation:
Generally occur a few times each month and are described as bilateral and squeezing.
–> Usually relieved with OTC analgesics and are seldom severe enough to cause real disability.
IHS definition of episodic tension headache?
- Recurrent episodes of headache lasting minutes to days.
- Pain is typically pressing/tightening in quality, of mild/moderate intensity, bilateral in location and does NOT worsen with routine physical activity.
- Nausea is ABSENT.
- Photophobia/phonophobia may be present.
1-year prevalence of tension headaches is?
63% –> Men.
86% –> Women.
IHS criteria differentiate headaches as?
- Episodic or chronic.
2. With or without associated tenderness of pericranial muscles.
EBD of tension headaches - Common?
MC –> It is the default diagnosis in almost every patient with a mild to moderate headache syndrome.
EBD of tension headaches - IHS diagnostic criteria:
- At least 10 previous headaches.
- Duration of 30min to 7 days.
- 2 of the following:
a. Pressing or tightening (non pulsating) quality.
b. Mild/moderate in severity (inhibits but does not prevent activity).
c. Bilateral.
d. Not aggravated by routine activity. - No nausea or vomiting.
- Photophobia/phonophobia may be present, but not both.
Headache due to unruptured CNS aneurysm?
Classic presentation of a headache caused by a CNS aneurysm is a unilateral and throbbing headache that is NEW in a middle-aged patients.
CNS aneurysm may present in 3 ways:
- Asymptomatic detection.
- Acute rupture or acute expansion.
- Chronic headache.
EBD of unruptured CNS aneurysms:
111 patients referred for therapy of unruptured aneurysms –> 54 had symptoms at diagnosis.
Of the 54 with symptoms –> 35 (64%) had chronic symptoms.
In 18 of these 35 –> Symptom was chronic headache without neurologic signs.
EBD of unruptured CNS aneurysms - Headache bilateral/unilateral?
Divided equally between unilateral and bilateral.
EBD of unruptured CNS aneurysms - Neuroimaging:
Contrast-enhanced CT and MRA –> Very sensitive means of detecting CNS aneurysms.
- -> Aneurysms >1cm –> 100%.
- -> Aneurysms Lower.
EBD of unruptured CNS aneurysms - Traditional angiography:
- GOLD STANDARD.
- Usually required prior to repair.
- There are case reports of small aneurysms being missed on traditional angiography and being seen on CT and MRA.
Morning headache?
Edema forms around the CNS lesion while the patient is supine at night leading to headaches from increased intracranial pressure in the morning.
MC substances of which the withdrawal may cause morning headaches?
- Caffeine.
- Alcohol.
- Carbon monoxide.
Intracranial neoplasms - Textbook presentation:
Brain tumors classically present with progressive morning headaches associated with focal neurologic deficits.
Brain tumors are classified as?
- Metastatic.
- Primary extra-axial.
- Primary intra-axial.
Metastatic brain tumor from?
37% –> Lung.
19% –> Breast.
16% –> Melanoma.
Primary extra-axial brain tumors:
80% –> Meningioma.
10% –> Acoustic neuroma.
7% –> Pituitary adenoma.
Primary intra-axial brain tumors:
47% –> Glioblastoma.
39% –> Astrocytoma.
Metastatic brain tumors are about … times more common than primary ones.
7
Intracranial neoplasms generally present with …?
Focal signs –> Seizure, signs of increased intracranial pressure (headache).
Although the presenting symptoms of an intracranial neoplasm vary with type of tumor, the MC symptoms are:
50% –> Headache.
Seizure.
Hemiparesis.
Change in mental status.
EBD of intracranial neoplasms - Role of history?
NOT particularly helpful in making a diagnosis of intracranial neoplasms.
EBD of intracranial neoplasms - One very good report retrospectively studied 111 patients with brain tumors. Symptoms were NON SPECIFIC:
48% --> Headaches. 17% --> Classic brain tumor headache (severe, worse in the morning, associated with nausea/vomiting). 77% --> Met the criteria for tension headaches. 9% --> Migraine-like headaches. MC qualities were: 67% --> Intermittent. 68% --> Frontal. 72% --> Bilateral.
EBD of brain tumors - Neuroimaging - Contrast-enhanced CT:
- Reasonable choice for screening in low suspicion patients.
- Sens is around 90%.
EBD of brain tumors - MRI with contrast?
PROCEDURE OF CHOICE –> Sens is around 100% and the detail provided often suggests a likely pathology.
Medical morning headaches - Textbook presentation:
- Various diseases can cause headaches that occur predominantly in the morning.
- Headaches are generally worse upon awekening and then improve as the day progresses.
- More common symptoms of the underlying disease (daytime HYPOGLYCEMIA with overly controlled DM or daytime somnolence with OSA) are present.
Medical morning headaches - Most rigorously defined morning headaches are?
Those caused by disturbed sleep. The sleep disturbance can be of almost any etiology.
Primary sleep disturbance:
- OSA.
2. Periodic leg movement of sleep (PLMS).
Abnormal sleep duration:
- Excessive sleep.
- Interrupted sleep.
- Sleep deprivation.
Secondary to another disease:
- Chronic pain.
2. Depression.
EBD of medical morning headaches:
- Recognition of the OSA and nighttime hypoglycemia can be difficult since the clinical clues are NON SPECIFIC.
- Nighttime hypoglycemia –> DM.
- OSA –> Diagnosis with polysomnography - ALSO info about PLMS.
Headaches associated with substances or their withdrawal - Textbook presentation:
These are headaches that occur in close temporal relation to substance exposure or substance withdrawal.
–> They resolve when culprit substance is no longer used.
Many substances can cause headaches acutely, with long-term use, or after their withdrawal:
- Acute exposure –> Nitrites (“hot dog headache”), MSG (“Chinese restaurant syndrome”), carbon monoxide.
- Long term exposure –> Analgesics.
- Withdrawal from acute exposure (alcohol).
- Withdrawal from chronic exposure (caffeine, opioids).
EBD of caffeine withdrawal headaches - IHS criteria:
- Bilateral or pulsating (or both) headache.
- > 200mg caffeine daily for >2wks.
- Headaches within 24h of the last caffeine intake and are relieved within 1h by 100mg caffeine.
- Headache resolves within 7d of total caffeine withdrawal.
An average cup of coffee contains?
About 100mg of caffeine.
Premium coffees may contain more. A 12oz coffee at Starbucks contains 375mg of caffeine.
The average adult American ingests approx. …mg of caffeine daily.
280mg.
Headaches when patients sleep later than usual or mainly on weekends or vacations?
Caffeine withdrawal headache should be considered.
EBD of substance withdrawal headaches - Carbon monoxide poisoning presentation:
Runs the spectrum from mild headache to headache with nausea, vomiting, and anxiety to coma and cardiovascular collapse.
EBD of carbon monoxide - Various aspects of patient’s history that increase suspicion of this diagnosis?
- Headache occurs only in a single location and resolves when the patient is removed from this setting.
- Multiple family members/roommates have similar symptoms.
- Carbon monoxide poisoning is MC in the WINTER.
EBD of carbon monoxide poisoning - Diagnosis:
An elevated carboxyHb level makes the diagnosis.
ABG measurements and pulse ox do NOT detect CO poisoning.
What is a thunderclap headache?
Headache that begins at its peak intensity.
Rare diseases that can occasionally present with a thunderclap headache:
- Cerebral venous sinus thrombosis.
- Pituitary apoplexy.
- Carotid dissection.
- Spontaneous intracranial hypotension from CSF.
Bottom line about thunderclap headaches:
Assume to be caused by a sunarachnoid hemorrhage (SAH) until proven otherwise.
SAH - Textbook presentation:
- Midde-aged with worst headache of his life.
- Vomiting soon after beginning of headache.
- Then focal neurologic symptoms.
- Soon patient loses consciousness.
- If patient is alert at the time of medical assessment –> Focal neurlogic signs and meningismus on physical exam.
SAH is primarily caused by?
Rupture of a saccular aneurysm in or near the circle of Willis (=85%).
Saccular aneurysms are present in about …% of the population.
4%.
Largest saccular aneurysms (>1cm) rupture at a rate of about …%/year.
0.5
Vast majority of saccular aneurysm ruptures occur in persons …-… yo.
40-65yo.
SAH carries a mortality of about …%.
50%.
It is generally accepted that anywhere from …%-…% of patients will have a warning or sentinel headache in the weeks preceding the SAH.
10% to 50%.
Warning or sentinel headaches is caused by?
- Likely caused by expansion or small leak from an aneurysm.
- This headaches is usually thunderclap as SAH but resolves within 24hr.
- About 50% of patients with warning headaches actually seek medical care.
EBD of SAH - SAH accounts for …-…% of headaches presenting to the ED.
1-4%.
EBD of SAH - Among headaches presenting to the ED, SAH accounts for?
12% –> Worst headache of life.
25% –> Worst headache of life + neurologic findings.
EBD of SAH - Prevalence of various symptoms of SAH:
90% –> Headache.
74% –> Stiff neck.
60% –> Change in mental status.
27% –> Stupor or coma.
EBD of SAH - Initial diagnostic test:
NON contrast head CT. Sens varies with the time since the onset of symptoms: First 12h --> 97%. 12-24h --> 93%. Falls as low as 80% after 2 weeks.
EBD of SAH - Next to angiography?
CSF exam for RBC and XANTHOCROMIA (result of oxyHb and later bilirubin) –> Most accurate diagnostic method.
EBD of SAH - Importance of correct diagnosis:
- About 25% with SAH are initially MISDIAGNOSED.
- Patients with less severe clinical presentations are most commonly misdiagnosed.
- Patients who are initially misdiagnosed are only ABOUT HALF as likely to have a good or excellent outcome.
EBD of SAH - Bottom line:
All patients in whom SAH is suspected should undergo a NON CONTRAST head CT.
LP should be done in a patient with a normal head CT and even only minimal suspicion of SAH.
Cough headaches:
- MC in men 3:1.
- More common in older patients (mean age 67).
- Last <1min.
Exertional headache:
- MC in men (90%).
- Mean age 24.
- Bilateral + throbbing.
- Sometimes related to migraines - some patients may induce migraines with physical activity.
- Lasts from 5min to 24h.
Sexual headache:
- MC in men (85%).
- Mean age 41.
- Lasts <3h.