Flashcards in 8. Headache Deck (72)
define a primary headache
a head pain syndrome occurring in the absence of cranial or systemic pathology (sui generis)
define a secondary headache
occurs in temporal association with cranial, extracranial, or systemic pathology
headache: symptom or diagnosis?
headache: goal of assessment?
determine if primary or secondary, then specify what type it is!
most headaches: primary or secondary?
qualities of a primary headache?
benign, few in number
qualities of a secondary headache? possible underlying disease states?
symptom of many possible underlying disease states (infection, hemorrhage, incr ICP, brain tumor)
what two types of headaches account for over 90% of primary headaches?
general approach to a headache?
figure out if there are warning signs that point to a secondary headache. if not, dx primary headache. if non-responsive to therapy, may need to re-assess. remember that pts can have 2 kinds of headaches!
acronym for red flags of headaches? these warrant aggressive workup including imaging
-Systemic symptoms (fever, wt loss) or secondary risk factors (cancer, HIV)
-Older patient with new onset or progressive HA
-Prior HA history: if this HA is first, different, or changing
what will be seen with meningitis/encephalitis?
mental status changes
focal neuro deficites
may have seizures
headache most often diffuse, may be pulsatile.
may have N/V
classic example: HSV encephalitis
HSV encephalitis: what will be s/s?
fever, stiff neck, cog changes (loss of smell?), neuro deficits due to necrotizing progression
HSV encephalitis: labs? treatment?
MRI abnl early
EEG with periodic complexes
Treat with acyclovir
Brain tumor: signs/sx?
-HA often not initial symptom. May be progressive, worse with recumbency.
-deficits, seizures, diplopia (6th nerve palsy), papilledema on fundoscopy
what is the difference between a stroke and an Transient Ischemic Attack (TIA)?
stroke means the brain has already been damaged. TIA is a warning sign. if you catch TIA (maybe with sign of headache) may be able to prevent stroke
N/V likely if hemorrhagic stroke
HA may be localized or holocranial
why are older patients of particular concern when they come in with HA?
most patients with migraine and tension-type will have onset before 40.
stroke/TIA moves up in your DDx with what types of patients?
older and have risk factors for stroke
presentation of subarachnoid hemorrhage?
sudden, dramatic. N/V, worse headache of someone's life. most dramatic presentation of all the headaches.
mental status changes, neck stiffness, fever, coma
subarachnoid hemorrhage: workup?
CT, lumbar puncture with presence of red cells, elevated protein, incr ICP.
why N/V with subarachnoid hemorrhage?
blood is irritating to the meninges
cause of subarachnoid hemorrhage?
ruptured aneurysm (arterial)
subarachnoid hemorrhage: sentinal event?
possible that there will be a leak of blood, leading to headache/seizure prior to hemorrhage.
epidural hematoma: presentation?
often post-trauma or concussion. rapid arterial bleeding (often MMA) leads to rapid incr in ICP. may have a lucid interval and then deteriorate so we keep them under observation.
subdural hematoma: presentation?
slow/venous bleeding as opposed to rapid arterial (like epidural). blood can accumulate in the potential space of the subdura. mental status changes, headache, evolving neuro deficits
subdural hematoma: paralysis/ headache? where will these be present?
Contralateral hemipareisis, ipsalateral headache.
Giant cell arteritis: what is the first thing to think? why?
50! age 50, or ESR >50.
Giant cell arteritis: presentation of headache?
new headache, or worsening of pre-existing HA.
Giant cell arteritis: treatable? what if you don't treat?
yes, with steroids. if you don't treat, half of pts will go blind.
giant cell arteritis: wtf is it?
inflammatory process of blood vessels, typically of the head.
what is intracranial hypertension?
increased ICP, idiopathic.
intracranial hypertension: presentation?
papilledema, bilateral 6th nerve palsy, elevated pressure with lumbar puncture. holocranial headache, blurry vision/diplopia
intracranial hypertension: risk?
risk of damage to vision
intracranial HTN: work up
image first to see if mass, then LP to see if elevated opening pressure
why might patients have a lucid interval following trauma to the head?
epidural hematoma: initial loss of consciousness from concussion, then recover, then second deterioration due to accumulation of arterial blood in epidural space. (no potential space there!)
what may be seen on imaging with intracranial HTN?
venous sinus thrombosis
main three types of primary headache?
migraine, tension-type, cluster
definition of migraine?
5 or more attacks lasting 5-72 hrs
2 or more of: unilateral pain, pulsating pain, worse with activity, moderate to severe pain
N/V or photo/phonophobia
definition of tension-type headache?
defined as what migraine is not.
presentation of tension-type headache?
lasts 30 min to 7 days, can be bilateral, non-pulsating, not worse with activity.
can be photo or phonophobic (doesn't need to be)
migraine: prevalence of aura?
what is an aura?
neurologic perturbation, occurs before or during migraine, usually lasts less than an hour. can be visual, aphasia, numbness.
migraine: what is diagnosis based on?
history and a NORMAL neuro eval
migraine: neuro cause?
may be related to disordered serotonergic neurotransmission, and activation of the trigeminovascular system.
why does migraine often occur with neck pain?
pain comes from trigeminal, ends up in medulla - therefore easy to have neck pain.
why would migraine be mistaken for sinus headache?
pain for both conditions may localize over frontal sinuses. with migraine, this is thought to be referred from V1 pathways. with migraine, might also be autonomic sx like sinus sx (congestion, tearing)
cluster headache: presentation?
most severe pain known in people. can be up to 8 per day. ipsilateral autonomic signs.
two types of cluster headaches?
episodic and chronic cluster
episodic cluster headache: presentation?
periods of susceptibility to cluster headaches, followed by memissions
chronic cluster headaches: presentation?
a year or longer of cluster headaches with no remission.
what type of headache is associated with being woken from sleep?
cluster, tumor (incr ICP)
what can cause a drug-induced headache? what kinds of drugs?
can result from drug abuse, but also from prescription meds. especially vasodilator, IVIG.
what is analgesic rebound?
occurs in ppl with migraines. due to chronic taking of short term pain relief.
pathophys: up-regulation of serotonin receptors, pts have chronic daily headache and are refractory to other medications until they go off the analgesics for several months, "analgesic washout"
temporomandibular joint dysfunction may mimic what kind of headache
in an adult, most sinus headaches are actually what?
sinus headache: presentation?
bifrontal or bimaxilary, throb, related to sinus disease.
occipital neuralgia: presentation? tx?
pain, numbness, tingling over scalp that is served by greater occipital nerve. tx = local anesthetic
trigeminal neuralgia: presentation?
lancinating pain, often over V2 area. pts may avoid shaving, makeup due to trigger point. usually a blood vessel sitting on trigemina.
trigeminal neuralgia: tx?
rule out MS especially in younger pts. rule out lesion. carmazapine or microvascular decompression of errant vessel.
trigeminal neuralgia: dx?
trigger pain, there may be a refractory period afterward. rule out MS, tumor
what is the definitive test to identify an aneurysm
sudden onset, worst headache of life: what type?
sudden onset, focal neuro deficit: what type?
new/different headache in patient >50yrs: what type?
giant cell/temporal arteritis
headache that awakes from sound sleep: what type?
could be mass lesion, sagittal sinus thrombosis, migraine, cluster
escalating headache that is always in same location: what type?
headache associated with focal neurological deficit: what type?
neck stiffness: what type?
behavioral or personality change: what type?
what can trigger a migraine?
food, drink, stress, errativ schedule, lights, smells
cluster headache: pattern of onset?
unilateral pain starting in orbital area, often with predictable schedule, may awaken patient at night