DDx: Headache Flashcards Preview

08 NEUROLOGY > DDx: Headache > Flashcards

Flashcards in DDx: Headache Deck (13):
1

Differential Diagnosis of Headache:

Primary Headaches:

Tension-type headache

Migraine

Trigeminal autonomic cephalalgias

Cluster headache

Secondary Headaches:

Frontal sinusitis

Medication-overuse headache

Subarachnoid hemorrhage

Meningitis or encephalitis (see Approach to Meningitis and Encephalitis)

Benign intracranial hypertension (pseudotumor cerebri)

Intracranial neoplasm

Temporal arteritis

Toxoplasmosis

2

Tension-type headache

Hx: Bilateral, pressing (or tightening) pain of mild to moderate intensity not aggravated by physical activities and without nausea.

Tx: Drug treatment usually begins with NSAIDs. The addition of caffeine to aspirin or NSAIDs increases treatment efficacy.  Prophylaxis, often with a tricyclic antidepressant, may be needed. 

 

 

3

Migraine

Hx: May be unilateral, pulsating in quality, and moderate to severe in intensity; associated with nausea or vomiting, photophobia, and phonophobia.  Fifteen percent to 20% of patients with migraine experience an aura. In >90% of these patients, the aura may consist of such visual symptoms as photopsia (sparks or flashes of light), fortification spectra (arcs of flashing light that often form a zigzag pattern), or a scotoma (an area of loss of vision surrounded by a normal field of vision).  

Common dietary triggers include caffeine; nitrates or nitrite preservatives; phenylethylamine, tyramine, and xanthine in aged cheese, red wine, beer, champagne, and chocolate; monosodium glutamate (food additive); dairy products; and fatty foods. 

POUND: Pulsatile quality (headache described as pounding or throbbing), One-day duration (episode may last 4-72 hours if untreated), Unilateral in location, Nausea or vomiting, and Disabling intensity (altered usual daily activities during headache episode). 

Tx: Mild attacks are effectively treated with nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen; more severe attacks are treated with a triptan (selective serotonin receptor agonist) [contraindicated in the presence of ischemic vascular disease and uncontrolled hypertension].  Dihydroergotamine is an alternative (contraindicated in CAD and pregnancy).

The major medications shown to be effective for migraine prevention include β-blockers (such as propranolol, metoprolol, or timolol), tricyclic antidepressants (such as amitriptyline), and anticonvulsants (such as valproate, topiramate, or gabapentin).

Some herbal products such as feverfew, butterbur root, the mineral magnesium, the vitamin riboflavin, and the antioxidant coenzyme Q10 may have some efficacy in migraine prevention.

4

Trigeminal autonomic cephalalgias

Rare. Group of primary headache disorders characterized by excruciating unilateral headache that occurs in association with prominent cranial autonomic features (lacrimation, nasal congestion, rhinorrhea, and conjunctival injection). Disorders include cluster headache, paroxysmal hemicrania, and SUNCT syndrome.

5

Cluster headache

Hx: Cluster headaches are characterized by unilateral, severe, boring pain that is usually orbital, supraorbital, and/or temporal in location

The time from onset to peak intensity is usually minutes, with the pain lasting 15 minutes to 3 hours.

Accompanying autonomic symptoms include lacrimation, nasal congestion, rhinorrhea, miosis, ptosis, and conjunctival injection. The attacks occur in clusters that last weeks to months, with remissions lasting months to years. 

Often associated with unilateral tearing and nasal congestion or rhinitis. Pain is severe, unilateral, and periorbital. More common in men but relatively uncommon overall.

Tx: Oxygen inhalation delivered via a non-rebreather face mask at a flow rate of 6 to 12 L/min for 10 minutes is often effective in terminating the attack. Subcutaneous sumatriptan and nasal zolmitriptan are also effective in treating a cluster headache. Verapamil can be effective in preventing cluster headaches.

6

Secondary Headaches:

Frontal sinusitis

Usually worse when lying down. Associated with nasal congestion. Tenderness overlies affected sinus.

7

Medication-overuse headache

Chronic headache with few features of migraine. Tends to occur daily in patients who frequently use headache medications.

8

Subarachnoid hemorrhage

Sudden, explosive onset of severe headache (“worst headache of my life”). Preceded by “sentinel” headache in 10%.

Dx: In a minority of patients with a small amount of blood in the subarachnoid space, computed tomography (CT) of the head may initially be normal.

When this occurs, a lumbar puncture is required to detect erythrocytes or xanthochromia (a yellowish discoloration caused by the breakdown of erythrocytes) in the cerebrospinal fluid (CSF).

9

Meningitis or encephalitis (see Approach to Meningitis and Encephalitis)

Meningitis is associated with fever and meningeal signs. Encephalitis is associated with neurologic abnormalities, confusion, altered mental state, or change in level of consciousness.

10

Benign intracranial hypertension (pseudotumor cerebri)

Often abrupt onset. Associated with nausea, vomiting, dizziness, blurred vision, and papilledema. Neurologic examination is normal but may reveal sixth cranial nerve palsy. Headache aggravated by coughing, straining, or changing position. Cerebrospinal fluid pressure is elevated.

11

Intracranial neoplasm

Worse on awakening; generally progressive. Headache aggravated by coughing, straining, or changing position.

"Red flag" symptoms: Awakening from sleep due to headache; focal neurologic findings; more general neurologic findings such as dizziness, lack of coordination, or tingling; fever; neck stiffness or meningeal signs; tenderness or diminished pulse over the temporal artery; diastolic blood pressure >120 mm Hg; or papilledema or decreased visual acuity. 

Dx: MRI of the brain is preferable to computed tomography of the head in the evaluation of subacute or chronic headache because of improved sensitivity resulting from superior anatomic resolution.

12

Temporal arteritis (see Systemic Vasculitis)

Occurs almost exclusively in patients aged >50 y. Associated with tenderness of the scalp and temporal artery, jaw claudication, and visual changes.

13

Toxoplasmosis

Fever, headache, focal neurologic deficits; multiple ring-enhancing lesions on CNS imaging; positive toxoplasma serology

All patients newly diagnosed with HIV should be tested for latent infection with serology for T gondii IgG antibody.  If serology is positive and CD4 count is <100/mm3, primary prophylaxis with trimethoprim-sulfamethoxazole (TMP-SMX) reduces the risk of toxoplasmosis dramatically (to 0%-2%).

Patients on antiretroviral treatment can discontinue TMP-SMX when CD4 count is >200/mm3 for 3 months (and there is adequate viral suppression).  TMP-SMX is also used for primary prophylaxis against Pneumocystis pneumonia.