Week 11- headache Flashcards
1
Q
highest prevalence of headaches
A
25-40 yrs old, women
2
Q
how many % of headaches are life threatening
A
<1%
worry about tumors though
3
Q
troubles with headaches and tumors (rare)
A
- reassure and appropriately treat patients with benign headaches while
- finding the rare, life-threatening headache 3. without excessive evaluation
4
Q
how many headaches disorders in international classification of headaches disorders ICHDIII
A
200+
5
Q
main headaches types (3)
A
- Primary headache
- Secondary headache
- Neuropathies & facial pains and other headaches
6
Q
2 approaches to history taking for headaches
A
- Focus on serious causes
i. Learn the alarm features that should prompt consideration of a serious pathologies
ii. Know which aspects of the history predict a higher likelihood of abnormalities on neuroimaging (i.e. which represent a serious cause for headache) - Understand the typical features of common benign headache syndromes.
7
Q
physical examinations for headaches
A
- Rarely provides clues to the diagnosis
- Nevertheless, any abnormalities found on physical examination (especially visual, motor, reflex, sensory, speech or cognitive), warrant further investigations, since these abnormalities are one of the best predictors of CNS pathology
8
Q
most common physical exams fro headaches
A
- Neurological, including cranial nerve exams
- Head and neck exam
9
Q
which findings in physical exams are suggestive of secondary headaches
A
- focal neurological deficits, papilledema, bitemporal hemianopia, homonymous hemianopia, decreased visual acuity, or increased pain with Valsalva method.
10
Q
new headaches?
A
- Headaches of recent onset, or
- Chronic headaches that have changed in character/quality.
- Change in severity is less important than change in quality
11
Q
old headaches are most often
A
Though old headaches can be either primary or secondary, they are most often
due to migraine or tension-type headache (both of which are primary headaches)
12
Q
what to pay attention to in new headaches
A
alarm features
- Most new headaches are benign diagnoses, but almost all serious headaches are new headaches
13
Q
primary headaches
A
conditions themselves
- E.g. tension-type headache, migraine headache, cluster headache
14
Q
secondary headaches
A
symptoms of other illnesses.
- E.g., those caused by infection or vascular disease
15
Q
danger of primary vs secondary headaches?
A
- Primary headaches: no dangerous underlying cause, although can cause significant suffering and be disabling
- Secondary headaches: may be a sign of significant pathology (life threatening or significant disability)
16
Q
diagnostic testing and labs for primary vs secondary headaches
A
- Primary headaches: no labs or imaging that act as gold standard; diagnosed clinically
- Secondary headaches: diagnosis may require further diagnostic testing to identify the underlying disease of which the headache is a symptom
17
Q
most serious headaches are
A
recent onset or changed character
or sometimes secodnary
18
Q
old and new primary headaches
A
old: Tension headaches, Migraine headaches, Cluster headaches
new: Benign cough headache, Benign exertional headache
19
Q
old and new secondary headaches
A
old: Cervical degenerative joint disease, Temporomandibular joint syndrome
new:
Infectious:
* Upper respiratory tract
infection
* Sinusitis
Vascular:
* Temporal arteritis
Space-occupying lesions:
* Brain tumors
20
Q
secondary headaches benign or serious?
A
- Many conditions that cause headaches are benign, but some can lead to severe disability or mortality.
- Life-threatening headaches (e.g. meningitis, intracranial hemorrhage, brain tumor, temporal arteritis, and glaucoma) are rare but “must-not-miss”
21
Q
what’s more worrisome new or chronic seocndary headaches
A
new
22
Q
what to do in secondary headaches to see if dangerous
A
SNNOOP10, physical exam, image
23
Q
SNOOP10 is used for
A
red flags in secondary headaches
24
Q
SNOOP10 findings and related to secondary headaches
A
fever –> Headache attributed to infection or nonvascular intracranial disorders, carcinoid or pheochromocytoma
history of neoplasm –> brain neoplasm; metastasis
neruologic deficit or dysfunction –> Headaches attributed to vascular, nonvascular intracranial disorders; brain abscess and other infections
sudden headache –> hemorrhage
older age –> Giant cell arteritis and other headache attributed to cranial or cervical vascular disorders; neoplasms and other nonvascular intracranial disorders
positional headache –> hyper or hypotension
worse by sneezing, coughing–> Posterior fossa malformations; Chiari malformation
papilledema –> Neoplasms and other nonvascular intracranial disorders; intracranial hypertension
pregnancy –> Headaches attributed to cranial or cervical vascular disorders; postdural puncture headache; hypertension-related disorders (e.g., preeclampsia); cerebral sinus thrombosis; hypothyroidism; anemia; diabetes
immune sytem HIV –> opportunistic infectiin
drug overuse
postrrauamtic onset of headache
etc.
25
highest LR+ for red flags
1. dysequilibirum
2. headache causing awakening from sleeping
others are diplopia, hemiparesis, headache worse with valsava
26
neuroimaging for
patients with red falgs
27
use neuroimaging when
* Headaches with associated with any new neurologic deficits
* New and sudden-onset severe headaches
* HIV-positive patients with a new type of headache
* Patients older than 50 with a new headache
28
what has a high pretest probability for detecting severe intracranial pathology on neuroimaging
thunderclap headache
29
neuroimaging abnormalities with this highest LR+
cluster type headache
abnormal findings on neurological exam
headache difficult to classify and not clearly a primary headache
headache with aura
headache with focal neurologic symptoms
30
neuroimaging for dangeous headache causes
MRI or CT
31
is suspected emergent headache do what imaging
non-contrast head CT is the test of choice, but alternative/additional imaging is done as needed based on differentials
32
imaging for people with progressively worsening headache over weeks to moths
MRI with and without contrast
Reason: possibility of subdural hematoma, hydrocephalus, tumor, or another progressive intracranial lesion
33
what imaging for acute head trauma and if an intracranial hemorrhage is suspected
head CT without contrast media
MRI if smaller lesion
34
lumbar puncture to identify
Infection, red blood cells (suggests bleeding), xanthochromia (yellowing caused by bilirubin in the CSF), abnormal cells associated with some CNS malignancies
35
in patients with headaches when would you use a lumbar puncture
* Fever with altered mental status
* Meningeal signs
* Focal neurological deficits
* History of HIV or another immunocompromised state * Suspicion of idiopathic intracranial hypertension
36
in headaches: CBC for
infection
37
in headaches: ESR and CRP for
Giant cell (temporal) arteritis and other vasculitides
38
in headaches: metabolic panel
metabolic causes of headaches
39
in headaches endocrine testing for
pituitary gland abnormalities
40
rhinosinusitis - what is it? what's it caused by?
Inflammation of the sinuses and nasal mucosa, most often caused by viral infections, but may also be bacterial.
41
symptoms of rhinosinusitis
Leads to feelings of facial pain, pressure, or fullness
42
how often does rhinosinusitis develop in URTI
0.5-2%
43
acute vs subacute vs chronic rhinosinusitis
acute: <4 weeks
subacute: 4-12 weeks
chronic > 12 weeks
44
acute rhinosinusitis diagnosing
(up to 4 week)
* Acute bacterial rhinosinusitis diagnosis requires symptoms
for longer than 10 days or worsen after five to seven days
45
chronic rhinosinusitis diagnosis
(12 weeks or more)
* May be recurrent (at least 4 episodes per year, each episode lasting at least 7 days, with complete resolution between episodes)
46
what can lead to over diagnosis of rhinosinusitis
Overlapping symptoms between rhinosinusitis and prolonged viral upper respiratory infection
47
symptoms of rhinosinusitis
* Facial pain/pressure/fullness, maxillary toothache with accompanying nasal congestion/rhinorrhea after URTI
* There may be tenderness of overlying skin and bone on physical exam
48
highest LR+ for rhinosunusitis
-symptoms after URTI
-facial pain, pressure or fullness (pain bending forward)
49
imagine for rhinosinusitis
dont do....
Relatively uncommon exceptions:
* Sinus CT can define anatomic abnormalities and identify suspected complications
* MRI may be used if there is a suspected tumor or fungal sinusitis, (may involve local soft tissue)
50
how quickly does rhinosinusitis improve usually? with or without antibiotics?
* Viral rhinosinusitis usually improves in 7 - 10 d
* 70% clinically improve after seven days, with or without
antibiotic therapy
* Complete clinical cure without antibiotics:
* 8% in 3-5d
* 35% in 7-12d
* 45% in 14-15d
* Improved cure rates with antibiotics
51
when to consider antibiotics in rhinosinusitis
* Signs and symptoms acute rhinosinusitis that do not improve within seven days or that worsen at any time
* Moderate to severe pain
* Temperature of 38.3°C (101° F) or higher
* Immunocompromised
52
complications in x% of cases of rhinosinusititis
0.1%
53
refractory cases in rhinosinusisits? when to send to ER?
* Refractory cases:
* Reconsider diagnosis
* May warrant otolaryngologist referral
* Send to ER if
* Visual symptoms (including difficulty opening the eye)
* Severe headache
* Somnolence
* High fever
54
meningitis
Inflammation of the meninges caused by various pathogens which leads to acute headache and (classically) fever and a stiff neck
55
% of headache cases that present to emergency for meningitis
0.6%
56
bacterial or viral cause of meningitis more common
viral 3-4x more common
57
bacterial meningitis is most common in
neonates
58
risk factors for bacterial meningitis vs viral meminigitis
* Bacterial
* Immunocompromised state
* Functional or anatomical asplenia
* Cochlear implants
* Cerebrospinal fluid leaks
* Recent trauma or instrumentation
* Alcoholism
* Smoking
* Viral
* Exposure to enterovirus or arbovirus (mosquito-borne) infections (especially in summer and early fall)
59
risk factors for meningitis
* Travel to endemic areas (e.g., tuberculosis, fungal, or parasitic infections),
* Occupational or hobby-related contact with animals or soil (e.g., Listeria monocytogenes, Cryptococcus neoformans),
* Sexual activity (e.g., N. meningitidis, HSV),
* Injection drug use (e.g., S. aureus),
* Close contact with a person with meningitis (e.g., N. meningitidis, H. influenzae type b)
60
time course of meningitis
Acute, with rapid onset and progression, particularly for bacterial
61
median time to seek medical care in bacterial and viral meningitis
* Bacterial meningitis: 24 hours
* Viral meningitis: 2 days
62
meningitis symptoms classically
classic: fever, headache, neck stiffness, and altered mental status
Others: photophobia, phonophobia, nausea, vomiting, seizures
63
meningitis symptoms in older patients
* Older patients
* More likely: altered mental status, focal neurologic deficits
* Less likely: headache and neck stiffness
64
meningitis symptoms in kids
Vague symptoms e.g. irritability, lethargy, poor feeding
65
signs of meningeal irritation
not particularly good sensitivity or specificity; not reliable to rule out bacterial meningitis
* Kernig sign (resistance to knee extension with hip flexion)
* Brudzinski sign (involuntary hip flexion with neck flexion)
* Nuchal rigidity (resistance to neck flexion)
* Jolt accentuation of headache (worsening of headache by horizontal rotation of the head).
66
other signs of meningitis
* Others:
* Rash (especially in meningococcal disease), cranial nerve palsies (especially in tuberculous or fungal meningitis), papilledema (in increased intracranial pressure), focal neurologic deficits (in encephalitis or stroke).
67
sensitivity for community-aquried bacterial meningitis
-at least 2 of: headache, fever, stiff neck, mental status changes
-headache
-stiff neck
-temp >38c
-change in mental status
etc
68
diagnostic test for meningitis
CSF obtained from lumbar puncture (LP)
69
what to do instead of lumbar puncture in meningitis if contraindications
head CT
70
what is the execution of when not to do CSF lumbar puncture in meningitis
* Exception: contraindications or high-risk features for increased intracranial pressure or cerebral herniation
* e.g. focal neurologic signs, papilledema, immunocompromised state
* Head CT should be performed before LP in these patients
71
bacterial meningitis prognosis
* Rapidly fatal if untreated; 25% mortality rate (community-acquired)
* 7 to 21 days of treatment (i.e. antibiotics, corticosteroids)
* Complications: hearing loss, neurologic sequelae (e.g., cognitive impairment, seizure disorder, hydrocephalus, cerebral infarction), subdural effusion, empyema, abscess, endocarditis, septic arthritis, disseminated intravascular coagulation (DIC)
72
viral mengititis prognosis
* Generally self-limited with a good prognosis
* supportive care; may last over 2 wks
* Complications: hearing loss, developmental delay, seizure disorder
73
which has worse prognosis; bacterial or viral meningitis
bacterial
74
head trauma is the cause of % of beaches in emergency
9.3%
75
who Is head trauma more common in
-males
-kids
-elders
76
risk factors for head trauma
* Motor vehicle accidents
* Falls
* Assaultsandabuse
* Sports
* Alcohol or drug intoxication
* Coagulopathy
* Previous neurosurgical procedures
77
minor head trauma
* Head trauma is minor in 90% of cases
* Definition: Glasgow Coma Scale (GCS) score ≥ 13 and appear well on examination
* But, among those with minor head trauma, 7.1% had severe intracranial injury requiring prompt intervention (i.e. patient’s you’d want to have sent to the ER)
78
what is the Glasgow coma scale score for minor head trauma
>13
79
time course of head trauma
* May have acute, subacute, or chronic effects depending on the severity and type of injury
* Headaches after minor trauma are most likely to be chronic
* Some symptoms may appear immediately after the traumatic event, while others may appear days or weeks later
* Mild traumatic brain injury (TBI) may be temporary
* Moderate to severe TBI: may result in long-term complications or death
80
what type of headaches in head trauma
tension type headaches
81
highest frequency/ sensitivity for signs and symptoms in head trauma
-nausea
-vomit
-amnesia
-loss of consciousness
-decline in GCS score
etc
82
Among patients with minor head trauma, the following are associated with severe intracranial injury on CT: (high LR+)
-physical exam findings suggest skull fracture
-GCS score of 13
-2+ vomiting episodes
-GCS score <15 at 2 hours post injury
83
Physical examination findings suggestive of skull fracture
-periorbital ecchymosis (raccoon eyes)
-hemotympanum (ear drum)
-cerebrospinal fluid otorrhea
-postauricular ecchymosis (battle sign)
84
New Orleans criteria for head trauma
* Older than 60 years
* Intoxication
* Headache
* Any vomiting
* Seizure
* Amnesia
* Visible trauma above the
clavicle
85
Canadian CT head rule for head trauma
* 65 years or older
* Dangerous mechanism
(pedestrian struck by vehicle, occupant ejected from vehicle, fall >1m or 5 stairs)
* Vomiting more than 1 episode
* Amnesia longer than 30 minutes
* GCS score less than 15 at 2 hours
* Suspectedopen,depressed, or basilar skull fracture
86
nexus II fro head trauma
* Evidence of significant skull fracture
* Scalp hematoma
* Neurologic deficit
* Altered level of alertness * Abnormal behavior
* Coagulopathy
* Persistent vomiting
* Age65
87
more common vs less common symptoms for mild head trauma
early (mins to hours) common: Dizziness/poor balance, fatigue, headache, nausea
late (days to weeks) common: Anxiety/nervousness
irritability, difficulty concentrating, difficulty remembering, disorientation, drowsiness, increased sleep, headache, light sensitivity
early less common: confusion, vomiting
late less common: depression, decreased sleep, difficulty initiating sleep, light-headedness, tinnitus
88
other findings in head truama
more common: Feeling foggy, feeling slowed down, blurred vision, noise sensitivity
less common: Clinginess, emotional lability, personality changes, sadness, amnesia, delayed verbal and other responses, feeling stunned, inability to focus, loss of consciousness (<10%), slurred speech, vacant stare, convulsions, numbness and tingling
89
diagnostic test for head trauma- what does it detect
CT scan
Detects intracranial hemorrhage, contusion, edema, herniation, skull fracture, foreign body
90
mild vs moderate to severe traumatic brain injury prognosis
* Mild TBI: usually recover within weeks to months but may have persistent cognitive and/or emotional symptoms
* Symptoms usually last <72 hrs; most resolve spontaneously in 7-10 d
* Moderate to severe TBI: may have permanent neurological damage or disability that requires long-term rehabilitation
91
what is a subarachnoid hemorrhage
Blood vessel ruptures in the space between the brain and the skull, causing “the worst headache of their life” with associated vomiting, neck stiffness, and loss of consciousness
92
% of headaches in emergency are from subarachnoid hemorrhage
1-4%
93
who is subarachnoid hemorrhage most common in
40-60 years old
94
risk factors for subarachnoid hemorrhage
Most significant risk factors: cigarette smoking, hypertension
* Other risk factors: heavy alcohol use, personal or family history of aneurysm, or cerebrovascular disease, cocaine, type IV Ehlers-Danlos syndrome
* People with autosomal dominant polycystic kidney disease have elevated risk of intracranial aneurysm: screen to prevent subarachnoid hemorrhage (SAH)
95
2 headache types in subarachnoid hemorrhage
thunderclap headache and warning "sentinel" headache
96
thunderclap and warning headaches in subarachnoid hemorrhage
* Thunderclap headache
* Sudden onset at maximum intensity
* May last from hours to weeks
* Warning (“sentinel”) headaches
* Rapid onset
* May precede a major ruptured aneurysm by days to weeks
97
what type of headache in subarachnoid hemorrhage
* Sudden severe headache, often “the worst headache of their lives”
* I.e. Thunderclap headache
98
symptoms in subarachnoid hemorrhage? type of headache? localized or diffuse?
* Sudden severe headache, often “the worst headache of their lives”
* I.e. Thunderclap headache
* Starts abruptly at maximum intensity within minutes
* Often accompanied by vomiting
* Headache may be localized or diffuse
* Occipital location is more common in SAH than in other causes of sudden severe headache
99
symptoms in subarachnoid hemorrhage
* Nausea and vomiting (~75%), dizziness
* Transient loss of consciousness, transient motor deficits (e.g. buckling of legs), impaired consciousness (>50%)
* Neck pain, nuchal rigidity
* Orbital pain, vision changes, cranial nerve palsies, ptosis, motor or sensory disturbance, dysphasia, bruit, lightheadedness, back pain, seizure
* Retinal hemorrhages: rare but may be visible on physical examination
100
high sensitivity for subarachnoid hemorrhage
-headache
-thundeclap headache
-worst headache of their life
-stiff neck
-altered mental status
101
Ottawa subarachnoid hemorrhage rule? when to not rule out?
* For alert patients ≥15 years old with new, severe, atraumatic headache reaching
maximum intensity within 1 hour
* Sensitivity: 100%
* Do not rule out subarachnoid hemorrhage if one or more of the following (i.e. rule out if none of the following)
* Age ≥40
* Neck pain or stiffness
* Witnessed loss of consciousness
* Onset during exertion
* Thunderclap headache (instantly peaking pain) * Limited neck flexion on examination
102
further testing for subarachnoid hemorrhage
noncontrast head CT (even if neuro exam normal)
if negative, do lumbar puncture
--> Xanthochromia
103
Xanthochromia
bilirubin (from blood) causes yellow discoloration of CSF
seen in subarachnoid hemorrhage in lumbar puncture
104
prognosis of subarachnoid hemorrhage
* Often results in death or disability
* Mortality rates up to 50%
105
quick diagnosis in subarachnoid hemorrhage
* Quick diagnosis is important; misdiagnosis and treatment delays are common (~25% of patients with SAH are initially misdiagnosed)
* Misdiagnosis: 4x increase in death at 1 year, worse functional recovery, worse quality of life
* Correctly diagnosed: 91% achieve an overall good or excellent outcome
* Incorrectly diagnosed: 53% achieve this
106
complications in subarachnoid hemorrhage
rebleeding, vasospasm, hydrocephalus, seizures
107
idiopathic intracranial hypertension
Severe daily headaches typically in young women who are obese, that may awaken them from sleep. Associated with visual disturbance
* aka pseudotumor cerebri
108
pseudotumor cerebri aka
Idiopathic Intracranial Hypertension
109
who does Idiopathic Intracranial Hypertension happen in most
* Prevalence 0.5-2/100,000 of the general population
* Mean age ~30
* >90% women
* 94% obese
* Also, rapid weight gain or loss, female sex hormones
110
medications that can cause idiopathic intracranial hypertesnion
tetracyclines, vitamin A derivatives, corticosteroid withdrawal.
111
time course of idiopathic intracranial hypertension
chronic- months to years
* Variable course, with periods of remission and exacerbation
* Some patients experience spontaneous resolution, while others may have persistent or progressive symptoms that require long-term treatment
112
2 most prominent symptoms in idiopathic intracranial hypertesnion
1. chronic headache
2. progressive visual deterioration
* Chronic headache
* Often the first and most common symptom
* Frequently migraine-like with nausea, photophobia, and phonophobia
* Progressive visual deterioration
* Vision loss, transient visual obscurations (TVOs), diplopia, enlarged blind spot
113
other features of idiopathic intracranial hypertension
cranial nerve palsies (especially CN6 – 12% of cases), cognitive deficits, olfactory dysfunction, and pulsatile tinnitus
114
which cranial nerve in idiopathic intracranial hypertension
CN 6
115
most valuable findings in idiopathic intracranial hypertension
* Papilledema (~90%)
* TVOs
* elevated intracranial pressure (ICP) on lumbar puncture (diagnostic)
116
papilledema in how many cases of idiopathic intracranial hypertension
90%
117
testing for idiopathic intracranial hypertension
1. modified dandy criteria
2. visual function tests (e.g. visual acuity, visual field, color vision, contrast sensitivity) used to monitor progression and severity of visual impairment
118
modified dandy criteria for idiopathic intracranial hypertension
* Signs and symptoms of increased ICP
* No localizing neurological signs (except for CN6 palsy)
* Normal neuroimaging studies (except for findings related to increased ICP)
* MRI or CT
* Cerebrospinal fluid (CSF) opening pressure of more than 25 cm H2O with normal CSF composition
* Lumbar puncture to measure CSF opening pressure and composition
* No other cause of increased ICP identified
119
prognosis of idiopathic intracranial hypertension
Untreated, can lead to irreversible visual loss due to optic atrophy
120
risk factors for poor visual outcomes in idiopathic intracranial hypertension
male sex, black race, severe papilledema at presentation, fulminant disease course, and lack of weight loss
121
poor prognosis if have persistent or recurrent headaches in idiopathic intracranial hypertension despite normalization of inctracranial pressure;; risk factors for chronic headache
* medication overuse, comorbid migraine, psychological factors
122
temporomandibular disorder headache
Temporomandibular joint dysfunction causes headache or facial pain that comes on with chewing
123
who does temporomandibular disorder headache occur in
* 10% to 15% of adults, peak ages 20 to 40 years
* Twice as common in women than in men.
124
what is temporomandibular disorder headache associated with
other pain conditions (such as chronic headache), fibromyalgia, autoimmune disorders, sleep apnea, and psychiatric illness
125
time course of Temporomandibular Disorder Headache? how long is chronic?
* Can be acute or chronic
* Chronic TMD is defined by pain of more than three months’ duration
126
signs and symptoms of Temporomandibular Disorder Headache
* Often associated with jaw movement (e.g., opening and closing the mouth, chewing)
* Pain is in the preauricular, masseter, or temple region, with severity ranging from mild to debilitating
* May be limited of jaw mobility
* Adventitious jaw sounds (e.g., clicking, popping, grating, crepitus) may be present, but also occur in up to 50% of asymptomatic patients (i.e. low specificity)
127
symptoms in Temporomandibular Disorder Headache with high sensitivity
-facial pain
-ear discomfrot
-headache
-jaw discomfort or dysfucntion
* Other symptoms: dizziness, neck, eye, arm, or back pain.
128
testing for Temporomandibular Disorder Headache
* None; a clinical diagnosis based on history and physical examination
129
prognosis/ clinical course of Temporomandibular Disorder Headache
* Symptoms resolve within two weeks with treatment
* Most patients improve with a combination of noninvasive therapies
130
what's more common to cause headache; primary tumor or metastatic tumor
metastatic is 7x more common
primary is 1.4% of all cancers
131
primary brain tumors
* Rare; 1.4% of all cancers
* 0.8% of headaches presenting to the emergency department * Peak prevalence between 55 and 64 years
* Slightly more common in men
132
metastatic brain tumors
* ~7 times as common as primary
* Brain metastases are the most common
neurologic complication of systemic cancer (20-40% adult patients)
* May be the first manifestation of
cancer in some patients
133
what are the 3 most common tumors for metastasis to thebrain
lung
breast
melanoma
134
time course for primary and metastatic tumors
* Classically, progressive headache
* Primary
* Variable, depending on tumor type, location, and grade; may be chronic or acute
* Metastatic
* Varies depending on the type and aggressiveness of the primary tumor.
135
1/3 of patients with brain tumors have what as the primary complaint
headache
136
classic symptoms of brain tumor
* Classically: severe, worse in the morning, and occurring with nausea and vomiting
* Actually, patients with brain tumors more often report a bifrontal, tension-type headache.
* Relatively common: Headache, altered mental status and focal weakness, seizures
137
neurologic exam for brain tumor shows
hemiparesis, impaired cognition, sensory loss, gait abnormalities
138
primary brain tumor symptoms with high sensitivity
headache
generalized seizures
unilateral weakness
unsteadiness
139
metastatic brain tumor symptoms with high sensitivity
hemiparesis
impaired cogntion
headache
focal weakness
alerted mental staus
sensory loss
papilledema
140
neurologic deficits if primary brain tumor is in frontal lobe
Dementia, personality changes, gait disturbances, generalized or focal seizures, expressive aphasia Parietal lobe Receptive aphasia, sensory loss, hemianopia, spatial disorientation
141
neurologic deficits if primary brain tumor is in temporal lobe
Complex partial or generalized seizures, quadrantanopia, behavioral alterations
142
neurologic deficits if primary brain tumor is in occipital lobe
Contralateral hemianopia
143
neurologic deficits if primary brain tumor is in thalamus
contralateral sensory loss, behavioral changes, language disorder
144
neurologic deficits if primary brain tumor is in cerebellum
Ataxia, dysmetria, nystagmus
145
neurologic deficits if primary brain tumor is in brain stem
Cranial nerve dysfunction, ataxia, papillary abnormalities, nystagmus, hemiparesis, autonomic dysfunction
146
testing for primary brain tumor
MRI
* Brain MRI with gadolinium contrast
* Biopsy is required for definitive diagnosis
* Chest and abdomen CT if suspected metastatic disease
147
testing for secondary brain tumor
* Enhanced CT scanning or brain MRI
* Rounded, well-circumscribed, non-infiltrative masses surrounded by edema and enhanced by contrast
* Surgical biopsy may be necessary for definitive diagnosis
148
prognosis is better or worse for primary or secondary brain tumor
secondary has worst prognosis
149
primary brain tumor prognosis
* Depends on tumor type, grade, location, and patient factors; * Five-year survival rate is 33.4%
* Glioblastoma has the worst prognosis (1.2%)
150
secondary brain tumor prognosis
* Median survival: 3-6mo
* Depends on a number of factors, such as the number and location of lesions, the type and extent of systemic disease
151
medication overuse headaches is aka
rebound headache
152
Medication Overuse Headache (MOH) is from
* Refractory daily or near-daily headache that can result from overuse of analgesic medication
* Overuse can increase headache frequency, reduced efficacy of preventive or abortive medications
* I.e. Patients inadvertently increase headache frequency by overuse of analgesics, and tolerance develops to headache analgesia
* Headache, no longer responsive to treatment, worsens when analgesic is abruptly stopped
153
one of the most common secondary headache disorders is
Medication Overuse Headache (MOH)
* Prevalence: ~1%
* Frequent cause of headache in patients referred to specialized headache clinics
* 30% to 50% of patients who develop chronic headaches have MOH
154
who is Medication Overuse Headache (MOH) most common in
More common in women, lower socioeconomic status
155
what is medication overuse headache often associated wit
chronic migraine or tension type headache
* Hence, a complication of treating chronic primary headaches
* Analgesics are broadly available without healthcare professional intervention and people are often unaware of the potential consequences of progressively increased use
156
medication classes for medication overuse headaches- what has the highest risk?
* Non-steroidal anti-inflammatory drugs (NSAIDs) * Acetaminophen
* Triptans
* Ergotamines
* Opioids
* Highest risk: opioids, followed by triptans, ergotamines, and nonopioid analgesics
157
what are other pre existing conditions in medication overuse headaches
pre-existing sleep disturbances and psychiatric disorders (particularly depression, anxiety, obsessive-compulsive disorder)
158
how many headaches per month and for how long in medication overuse headache
* ≥15 headache days per month in patients who have had >3 months of excessive use of abortive medications
159
how many days per month do you have to take medications for medication overuse headache
* Intake must be 10 d/mo for ergotamines, triptans, opioids, combinations or multiple drug classes
* Intake must be 15 d/mo for NSAIDs, ASA, acetaminophen
160
when do medication overuse headaches occur
* May be episodic or persistent
* Typically starts in the morning
161
signs and symptoms of medication overuse headache
* Depends on the type and frequency of medication used
* No classic signs and symptoms
* Neck pain, sleep disturbance, autonomic (rhinorrhea, lacrimation) and gastrointestinal (nausea, vomiting, diarrhea) symptoms, comorbid anxiety and depression
* Often overlap with other acute and chronic headache types
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high LR+ for medication overuse headaches
ask question of do you take treatments for frequent migraines more than 10 days per month?
how many times have you used illegal drug or prescription medication for no medical reason?
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further testing for medication overuse headache
none
clinical history + physical exam
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prognosis of medication overuse headache
* Initial worsening of headache and withdrawal symptoms are common during medication weaning
* After appropriate treatment (gradual withdrawal), residual symptoms likely due to underlying primary headache disorder
* In ~75% of patients, discontinuing the overused medication results in reversion
* Relapse rate is high (about 30% per year; about 50% at 5 years)
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temporal arteritis is aka
giant cell arteritis
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what other condition is temporal arteritis common to go wiwth
polymyalgia rheumatica
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temporal arteritis is
Headache essentially exclusive to patients over 50 often accompanied by jaw claudication. More common in patients with polymyalgia rheumatica
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who is temporal arteritis more common in
* >50 yoa, women>men
* Among those over 50: 0.02%
* Among those with polymyalgia rheumatica (PMR): 15%
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what % of patients with temporal arteritis are referred for biopsy
30-40%
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timing of temporal arteritis
* Chronic and of varying duration
* Usually, headache onset is gradually over a few hours, but can have a rapid onset
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symptoms of temporal arteritis
* Headache may be unilateral or bilateral
* Temporal location in 50% of patients (may involve any location on the head)
* Pain almost always described as dull and boring
* Scalp tenderness
* Jaw claudication
* Other nonspecific manifestations of a chronic inflammatory disorder:
* Fever, fatigue, weight loss
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high LR+ in temporal arteritis
scalp tenderness and jaw claudication
headaches and jaw claudifcation
jaw claudication
beaded temporal artery
enlarged temporal artery
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gold standard test for temporal arteritis
temporal artery biopsy
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other testing for temporal arteritis
ESR (or CRP)
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what may be present but not helpful at diagnosing temporal arteritis
Anemia and thrombocytopenia
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prognosis of temporal arteritis
* Untreated, blindness in 50%
* Treatment should be initiated prior to the biopsy and then discontinued if necessary
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if temporal arteritis is untreated what % go blind
50%
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what are the main types of primary headaches
Mostly tension-type headaches, migraines, and cluster headaches (though there are
many others)
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short vs long primary headaches
* Fewer than 4 hours: ‘short headache.’
* Cluster headaches, neuralgiform headache attacks, primary stabbing headaches.
* More than 4 hours: ‘long headache.’
* Migraine, tension headaches, persistent daily headaches, hemicrania continua.
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when can you diagnose a primary headache
If there are no red flags, history and physical examination
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when do primary headaches require neuroimaging?
Some primary headaches, (e.g. benign cough, sexual, or primary exercise headache) strongly resemble serious headaches
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prognosis of primary headaches
excellent; benign
even though can impact quality of life
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short lasting primary headaches (3)
1. Cluster Headaches
2. Short-lasting Unilateral Neuralgiform Headaches
* Short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA)
* Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT)
3. Primary Stabbing Headaches
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2 types of short lasting unilateral neuralgiform headaches
* Short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA)
* Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT)
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cluster headaches are
Severe unilateral headaches that cluster in time. Typically in young men and associated with autonomic symptoms and restlessness.
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prevalence of cluster headaches? who in more? precipitating factor?
* Relatively rare
* Prevalence ~0.1%
* 4-6 times more common in men than in women
* 70% of patients reporting onset before 30 years of age
* May be precipitated by alcohol
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time course of cluster headache?
* Characterized by brief (15 to 180 minutes) episodes of severe head pain with associated autonomic symptoms
* Several (up to 8) episodes per day
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what is more common; episodic type or chronic type of cluster headache
* Episodic type (80-90%)
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episodic type of cluster headache
Periods of weeks to months (average 6-12 wks), followed by remission for at least one month (up to 12 months)
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chronic type of cluster headache
* No remission or remission of less than one month
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signs and symptoms of cluster headaches
* Pain is rapid onset and most commonly occurs in the retro- orbital area, followed by the temporal region, upper teeth, jaw, cheek, lower teeth, and neck, and is usually unilateral; most often sharp, but may be pulsating/pressure-like
* Ipsilateral autonomic symptoms such as eyelid edema, nasal congestion, lacrimation, or forehead sweating usually accompany the pain
* Restlessness/agitation in 80-90% of cases
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further testing for cluster headaches
neuroimaging
192
prognosis of cluster headaches
* Significant socioeconomic impact and associated morbidity
* ~80% of patients report restricting daily activities
* Only 25% of patients with cluster headaches are diagnosed correctly within one year of symptom onset
* >40% report a delay in diagnosis of five years or more
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comorbidities with cluster headaches
depression (24%), sleep apnea (14%), restless legs syndrome (11%), and asthma (9%).
* Many with cluster headaches report suicidal thoughts * 2% of patients in one study had attempted suicide
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onset age of short-lasting unilateral neuralgiform headaches? do men or women get SUNCT or SUNCA more?
35-65 years old
men= SUNCT
women= SUNA
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what triggers short-lasting unilateral neuralgiform headaches
stimulus to the trigeminal nerve (simple or a noxious)
196
how long do short-lasting unilateral neuralgiform headaches
1s – 10min (SUNA tends to last longer than SUNCT)
At least one a day (at least half the times they occur)
Tend to occur during the day
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primary stabbing headache epidemiology
Up to 35% of patients with headaches 42-45% of people with migraines
In these cases stabs tend to be at the site typically affected by migraines Mean age of onset: 28
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female or male more for primary stabbing headache
female : 5:1
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cause of primary stabbing headaches
no clear trigger
200
what is the shorting lasting headache i.e. 3 seocnds or less
primary stabbing headache
201
time line of primary stabbing headaches
Usually one or a few attacks per day
Rarely, repetitively over days
Months-long intervals between attacks in 76% of cases
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symptoms of primary stabbing headaches
Sharp, sudden stabbing, non- pulsatile. pain of moderate to severe intensity in the temporal (42%) or peri-orbital regions.
Changes locations in ~2/3 of patients (same or opposite hemicranium)
No cranial autonomic symptoms
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symptoms of short lasting unilateral neuraligiform headache
Moderate to severe unilateral pain with orbital, supraorbital, temporal and/or other trigeminal distribution occurring as single stabs, series of stabs or in a throbbing/saw-tooth pattern
At least one of the following (autonomic) findings ipsilateral to the pain:
1. conjunctival injection and/or lacrimation
2. nasalcongestionand/orrhinorrhoea
3. eyelidoedema
4. foreheadandfacialsweating
5. foreheadandfacialflushing
6. sensation of fullness in the ear
7. miosis and/or ptosis
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what is found in short lasting unilateral neuraligiform headache
autonomic findings i.e. eyelid oedema, facial sweating, conjunctival injection etc
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2 types of short lasting unilateral neuraligiform headache? what's the difference in presentation
SUNA
either lacrimation or conjunctival injection but not both
SUNCT
both lacrimation and conjunctival injection
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syndrome of primary stabbing headaches
Occasional extracephalic jabs in the facial area or randomly distributed throughout the body (including e.g. “jabs in the heart”)
Conjunctival hemorrhage and monocular vision loss have occurred
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further testing for short lasting unilateral neuraligiform headache
Diagnosis is mostly clinical
However, because these symptoms can suggest an underlying structural pathology a brain (MRI) with pituitary views and blood tests for pituitary function are suggested work-up
208
further testing for priamry stabbing headaches
Diagnosis is mostly clinical
However, because these symptoms can suggest an underlying structural pathology imaging may be recommended
209
prognosis fro short lasting unilateral neuraligiform headaches
Has been known to last for up to 46yrs
No known complications or increased mortality
Prognosis is improving as more treatments become available
210
primary stabbing headaches prognosis
Because of the mildness of the attacks and the benign course, treatment is rarely necessary and reassurance is usually sufficient (and in any case, the erratic pattern would make assessing treatment effectiveness challenging)
211
2 eyes of long lasting primary headaches
1. migraine
2. tension type headache
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migraine definition
Chronic, often disabling, unilateral pulsating headaches accompanied by symptoms such as nausea, photophobia, phonophobia. Can be associated with aura.
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what is the second most common primary headache disorder
migraine
214
men or women for migraine
approximately 15% among women and 6% among men
215
when do migraines begin
tend to start in adolescence
216
symptoms of migraine
* Pain often described as pulsating or throbbing; bilateral in 60-70% of cases
* Common associations: nausea, photophobia (sensitivity to light), and phonophobia (sensitivity to sound). Physical activity often exacerbates migraine headache. Aura may be present
* Aura: visual, sensory, or speech symptoms that are completely reversible
* In children and adolescents: pain that is moderate to severe, more often bilateral until late adolescence, throbbing (can also present as non-throbbing), frontotemporal and aggravated by activity. Photophobia and phonophobia, nausea, and/or vomiting are often present.
216
how long does a migraine last
* 4-72 hours
* In children and adolescents: 2–72 hours
* Aura: appear gradually, last no longer than 60 minutes
217
what may exacerbate a migraine?
by emotional stress, fatigue, menstrual period (though this is not unique to migraine), foods containing nitrite or tyramine
218
how often do auras occur in migraines
1/3
219
what type of aura is most common in migraine
* Typically visual, precede the headache, and last for about 20 minutes
* Common: blind spot that is later accompanied by flashing lights, spots of light, zigzag lines, or squiggles (“scintillating scotoma”)
* Usually involve 1 portion of the visual field.
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types of auras in migraine most common
stars or flashes 83%
zigzags 56%
duration <30 mins is 70%
221
ID migraine screening tool (3 questions)
1. Nausea: “Did you ever feel nauseous when you had headache pain?”
2. Photophobia: “Did light trouble you when you had headache pain (much more than when there was no headache)?”
3. Disabling Intensity: “Did your headache ever limit your ability to work, study or do something you needed to, for at least 1 day?”
222
which LR+ for ID migraine screening tool has high LR and icnrease migraine suspicion
you feel nauseated or sick to stomach
223
which LR- are low and if absent decrease suspicion of migrain (i.e. if present will liekly have migraine?)
functionally impaired by headache for any day in last 3months
sounds bother you
224
further testing for migraines
do not typically require imaging unless there are neurological abnormalities, worsening severity or unusual presentations
* Decisions about imaging in patients with increasingly frequent migraine can be challenging
225
migraine prognosis
3-4%/year probability of escalation from episodic to chronic form
* Pulsating quality, severe pain, photophobia, phonophobia, and attacks longer than 72 hours predict this escalation
226
risk factors for escalation from episodic to chronic migraine
- if occur 10-15 times a month
-if overuse medications like opiods
-obese
-diabetes
-arthritis
-head or neck injurt
227
most common headache dirsoger globally
tension type headahce
prevalence of 25-25%
228
duration of tension type headache (its a long lasting headache)
Duration of 30 minutes to 7 days
229
what makes tension type headache worse
stress or end of day
230
what does pain tend to do in tension type headache
wax and wane
231
signs and symptoms of tension type headache
* Characterized by bilateral mild to moderate pressure without other associated symptoms
* Pain is mild to moderate, bilateral and pressing/non-pulsing
232
further testing for tension type headache
* Individuals who meet the criteria for tension-type headache but who have normal neurologic examination results require no additional laboratory testing or neuroimaging
* Decisions about imaging in patients with increasingly frequent TTH can be challenging
233
prognosis of tension type headache
* 3-4%/year probability of escalation from episodic to chronic form
* Long attack duration and nausea are predictive factors for this progression
234
migraine vs tention type headache
LR+
nausea
photophobia
phonophobia
exacerbated by physical actiity
chocolate and cheese as headache trigger
etc
235
POUND for migraine vs tension type headache
if have 4-5 of these its an LR+ of 24
* Pulsatile quality
* Duration of 4 - 72 hours
* Unilateral location
* Nausea or vomiting
* Disabling intensity
236
chronic headaches ? how many headaches for how long?
* Not a specific headache type and not an official class in the ICHD per se
* >15 of the headache episodes per month for >3 months
237
chronic headaches are more in what gender
women
238
most chronic primary headaches are
migraines or tension type headaches
Nevertheless, about 30% to 50% of patients who develop chronic headaches have medication overuse headache (MOH)
239
risk factors for progression from episodic to chronic headaches
* Frequent headache episodes at baseline
* Medication overuse
* Others:
* Chronic pain, especially musculoskeletal pain
* Cutaneous allodynia
* Sleep disorders
* Obesity
* High caffeine consumption
* Stressful life events, especially in middle age
240
poor prognosis for chronic headaches associated with
psychosocial factors, anxiety, mood disorders, poor sleep, stress, and low headache management self-efficacy
241
chronic migraines
* May evolve from episodic migraine
* Patient typically report progressively frequent bilateral frontotemporal TTH-type symptoms with superimposed full- blown migraine attacks
242
comorbidities in chronic migraines
obesity, obstructive sleep apnea, depression, chronic pain disorders, cardiovascular disease, sleep and emotional disturbances
243
chronic tension type headaches
* Long attack duration and nausea are predictive of development of chronic TTH
* Bilateral, non-pulsatile, absence of associated symptoms * Pericranial tenderness is often found on palpation
244
headache impact test
* “This questionnaire was designed to help you describe and communicate the way you feel and what you cannot do because of headaches”
245
headache diary
* Document date, duration, symptoms, treatment, and outcome, suspected triggers or other observations
246
PHQ9 and CAGE (alcohol) questionarire
to assess impact of frequent headaches
247
referral and follow up
* Neurologist is recommended if:
* Not clearly a primary headache
* Red flag symptoms are detected
* Headaches do not improve with appropriate treatment
* Problems are too complex or require a multidisciplinary approach
* Monitor the headache pattern with regularly scheduled follow-up
* Patients should be educated to report the following:
* Signs of re-escalation of primary headaches
* Development of medication overuse headaches (MOH) * Red flags related to serious secondary headaches
