16 - Headache Flashcards
Classification of headaches and incidence
- Primary headaches - headache and associated symptoms are due to disorder itself
- Tension-type (69%)
- Migraine (16%)
- Idiopathic stabbing (2%)
- Exertional (1%)
- Cluster (0.1%) - Secondary headaches - exogenous disorders
- Systemic infection (63%)
- Head injury (4%)
- Vascular disorders (1%)
- SAH (< 1%)
- Brain tumour (0.1%)
Red flags of headache
- Sudden onset
- First severe headache
- “Worst” headache ever
- Vomiting preceding headache
- Subacute worsening over days or weeks
- Pain induced by bending, lifting, coughing
- Pain disturbing sleep or immediately upon waking
- Known systemic illness
- Onset age > 55
- Fever or unexplained systemis signs
- Abnormal neurologic examination
- Pain with localised tenderness (region of temporal artery)
Pathophysiology of Headache
- Pain producing sites: scalp, meningeal arteries, dural sinuses, falx cerebri, proximal segments of large pial arteries
(contrary to belief: ventricular ependyma, choroid plexus, pial veins, brain parenchyma are not pain producing) - Production of pain and headache
A. Stimulation of pain nociceptors in response to tissue injury, visceral distention or other factors
B. Pain-producing pathways or peripheral or CNS damaged or activated inappropriately - Key structures in primary headaches:
A. large intracranial vessels and dura mater, peripheral terminals of CN5 innervates these structures
B. Caudal portion of trigeminal nucleus extending into dorsal horns of upper cervical spinal cord, receives input from 1st and 2nd cervical nerve roots
C. Rotal pain processing regions (ventroposteromedial thalamus and cortex)
D. Pain modulatory system - Cranial autonomic (parasympathetic pathway) activation
- Trigeminovascular system innervates via trigeminal nerve -> triggers autonomic response in headache
–> Lacrimation, conjunctival injection, nasal congestion, rhinorrhoea, periorbital swelling, aural fullness, ptosis
Trigeminal autonomic cephalalgias are due to ____, resulting in symptoms such as ___
Trigeminal autonomic cephalalgias are due to activation of cranial parasympathetic pathways, resulting in symptoms such as lacrimation, conjunctival injection, nasal congestion, rhinorrhoea, periorbital swelling, aural fullness, ptosis
Meningitis produces ___ headache with __ and __, pain accentuates on __. Signs of __, __, __. Lumbar puncture is required.
Migraine is often mistaken but contrasted for __ headache, photophobia, nausea and vomiting.
Meningitis produces acute, severe headache with neck stiffness and fever, pain accentuates on eye movement. Signs of neck stiffness, Kernig’s sign, Brudzinski’s sign. Lumbar puncture is required.
Migraine is often mistaken but contrasted for pounding headache, photophobia, nausea and vomiting.
Intracranial haemorrhage is __ and __ headache, maximal in onset within __, with __ but without fever. CT brain may be normal and may require LP sent for __ wrapped in aluminum foil and not exposed to light to diagnose small haemorrhage or haemorrhage below __
Intracranial haemorrhage is acute and severe headache, maximal in onset within < 5 mis, with neck stiffness but without fever. CT brain may be normal and may require LP sent for xanthochromia wrapped in aluminum foil and not exposed to light to diagnose small haemorrhage or haemorrhage below foramen magnum.
About __ of brain tumour patients has headache as chief complaint. Described as ____, worse with __ or __, associated with nausea and vomiting. Also disturbs sleep in 10% patients.
Vomiting __ headache by weeks is highly characteristic of ____
History of amenorrhoea or galactorrhoea suggests ___ or __
Headache arising de novo with known malignancy suggests __ or __.
Head pain abruptly after bending, lifting or coughing can be due to ____, ____ or ____.
About 30% of brain tumour patients has headache as chief complaint. Described as intermittent deep dull aching pain, worse with exertion or change in position, associated with nausea and vomiting. Also disturbs sleep in 10% patients.
Vomiting preceding headache by weeks is highly characteristic of posterior fossa brain tumour
History of amenorrhoea or galactorrhoea suggests prolactin-secreting pituitary adenoma or polycystic ovarian syndrome
Headache arising de novo with known malignancy suggests cerebral metastasis or carcinomatous meningitis.
Head pain abruptly after bending, lifting or coughing can be due to posterior fossa mass, Chiari malformation or low CSF volume.
Temporal/giant cell arteritis is an _____ involving ____. Commonly affects __, average age of onset __, with women accounting for __ of cases.
Typical presentation: (5)
Headache:
- Variable quality: __, ____, superimposed episodic __
- Unilateral or bilateral
- Located __ or any or all aspect of cranium, superficial and external to the skull with __ worse with brushing of hair or resting on pillow
- Gradually over few hours until peak intensity. Rarely __ in onset. Worse __(timing), aggravated by __(temperature).
- Affecting __ arteries or __ arteries, with appearance ____
Half of patients with untreated temporal arteritis develop __ due to __ involvement
ESR is __, but normal ESR does not exclude GCA
Temporal biopsy and immediate treatment with __ for 4-6 weeks and not unreasonably delayed.
Temporal/giant cell arteritis is an _inflammatory disorder of arteries involving external carotid circulation. Commonly affects elderly, average age of onset 70 years old, with women accounting for 65% of cases.
Typical presentation: headache, PMR, jaw claudication, fever, weight loss
Headache:
- Variable quality: throbbing, dull and boring, superimposed episodic stabbing pain
- Unilateral or bilateral
- Located temporally (50%) or any or all aspect of cranium, superficial and external to the skull with scalp tenderness worse with brushing of hair or resting on pillow
- Gradually over few hours until peak intensity. Rarely explosive in onset. Worse at night, aggravated by cold.
- Affecting temporal arteries or occipital arteries, with appearance of reddned, tender nodules or red streaking of the skin overlying arteries
Half of patients with untreated temporal arteritis develop blindness due to ophthalmic artery involvement
ESR is elevated, but normal ESR does not exclude GCA
Temporal biopsy and immediate treatment with high dose prednisolone 80mg OM for 4-6 weeks and not unreasonably delayed.
Glaucoma presents with preceding ____, with __headache, __ and __. The eyes are __, pupils __
Glaucoma presents with preceding severe eye pain, with prostrating headache, nausea and vomiting. The eyes are red, pupils fixed and moderately dilated
