Headache Flashcards by Hannah Meiklejohn

List 8 important DDx for headache

Tension-type

Migraine

SAH

Meningitis/encephalitis

Subdural haematoma

Space-occupying lesion

GCA

Glaucoma

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Describe the characteristics of a tension-type headache

Bilateral “band-like” pressure

Gradual onset

Common, associated with stress

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Describe the characteristics of migraine

Unilateral

Gradual onset

May be associated with nausea and accompanying or preceding visual or sensory aura

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Describe the characteristics of headache due to SAH

Severe

Sudden onset

“Warning headache” beforehand

+ive FHx

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Describe the characteristics of headache due to meningitis/encephalitis

May be associated with fever, neck stiffness or photophobia

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List the typical clinical vignette seen in subdural haematoma

Age

Alcoholics

Anticoagulants

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Describe the characteristics of headache due to a space-occupying lesion

Morning headaches

May be associated with new-onset seizures and other neurological deficits

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What clinical features also accompany GCA?

Unilateral headache

Visual disturbances

Jaw and tongue claudication

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Describe the characteristics of headache due to GCA

Unilateral

Usually in over 50s

May be accompanied by visual disturbance and jaw and tongue claudication

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Describe the characteristics of headache due to glaucoma

Unilateral with visual disturbance

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How does SAH present clinically?

Sudden onset, severe headache (not previously experienced, sometimes with preceding sentinel headache)

Reduced conscious state with decline (30% present deeply comatose or with sudden death)

Meningism (headache, neck stiffness, photophobia, fever, vomiting), due to blood in the subarachnoid space

Focal neurological signs

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What are the possible mechanisms of focal neurological signs in SAH and what signs are commonly seen?

Intracerebral component of bleeding may cause frontal or temporal haematoma and related signs

Local pressure effects of aneurysm (particularly of PCommA) may cause 3rd nerve palsy

Cerebral vasospasm may cause symptoms and signs 2-7 days post-initial presentation

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List 5 DDx for severe, sudden onset headache

Meningitis

Intracerebral haematoma (HTNive or amyloid haematoma, trauma)

Migraine or cluster headache

Headache with orgasm

Reversible cerebral vasospasm

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What are the 3 most common causes of SAH? List 5 rarer causes

Most common: ruptured cerebral aneurysm, undiscovered/unknown or ruptured AV malformation

Rarer: spinal AV malformation, arterial dissection, tumour, bleeding diathesis

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What should be done if a normal CT is produced in a case of suspected SAH? What are the expected findings?

Bloodstained CSF that does not clear on 3 consecutive collection tubes, and xanthochromia

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What is xanthochromia?

Yellow staining due to breakdown of Hb which occurs 6-8 hours post-SAH

How can the risk of rebleeding of cerebral aneurysms be reduced?

Dx and Mx of cause of SAH

Maintain normotension

Avoid pain, straining, coughing, vomiting, agitation

Surgical clipping of aneurysm neck or endovascular coiling

How common is re-bleeding of a cerebral aneurysm?

50% of patients within 6 weeks, 25% within 2 weeks

How is cerebral aneurysm diagnosed and treated?

Diagnosis: cerebral CT angiogram, formal catheter angiography, DSA

Treatment: surgical clipping of aneurysm neck, endovascular coiling

How does endovascular coiling work?

Platinum wires are placed in the aneurysm angiographically via a catheter to induce thrombosis

What is normal ICP?

10-15 mmHg

What is the Monro-Kellie doctrine?

ICP is directly related to the volume of the intracranial contents

What are the 2 main causes of raised ICP?

Space-occupying lesion

Increased volume of normal intracranial contents (brain, CSF, blood)

List 3 specific causes of raised ICP related to increased volume of normal intracranial contents

Brain: cerebral oedema

CSF: hydrocephalus

Blood: vasodilation due to hypercapnia from hypoventilation

List 6 symptoms of raised ICP

Headache N+V Drowsiness, eventual coma Papilloedema Cushing response Signs of transtentorial herniation

List 3 signs of transtentorial herniation and their underlying mechanism

Unilateral dilated pupil (3rd nerve palsy) Contralateral hemiparesis (midbrain compression) Respiratory failure (respiratory centre compression)

What are the 3 elements of the Cushing response?

Bradycardia HTN Disordered breathing

How is raised ICP treated? (6 important steps)

ELEVATE head to encourage venous return URINATE (diuresis) to reduce cerebral oedema/ECF HYPERVENTILATE/avoid hypoventilation (intubation may be necessary) SEDATE or paralyse EXCAVATE (remove) mass EVACUATE (drain) hydrocephalus (e.g. with external ventricular drain)

Mr Styles, 45 year old accountant, presents with a severe headache that came on suddenly while showering in the morning, associated with photophobia, nausea and 2 episodes of vomiting; describes it as "like being kicked in the back of the head" PHx: 25 pack year smoking, HTN, similar but much less severe headache 2 weeks prior (treated as "migraine") Rx: perindopril 5mg mane FHx: mother alive, father died age 52 "in his sleep" SHx: accountant, high stress job, 2 children aged 10 and 15, wife manages the home DDx?

Tension-type Migraine, cluster headache SAH Meningitis/encephalitis Subdural haematoma Intracerebral haematoma Space-occupying lesion GCA Glaucoma Other causes of sudden onset headache: headache with orgasm, reversible cerebral vasospasm

What demographic most commonly gets migraines?

More common in women Often have a FHx

What features on Hx might make you suspicious of a migraine (besides characteristics of the headache)?

Often FHx Often PHx

Mr Styles, 45 year old accountant, presents with a severe headache that came on suddenly while showering in the morning What further information will you seek from physical examination?

Vitals GCS Examine for associated features e.g. photophobia and neck stiffness Full neurological examination including cranial nerve examination

Mr Styles, 45 year old accountant, presents with a severe headache that came on suddenly while showering in the morning O/E: looks unwell, distressed, vomit bag on bed, BP 180/110, GCS 13 (eyes open to voice, got date wrong), photophobic, neck stiffness, L pupil \> R and poorly reactive to light, remainder of brief cranial nerve and peripheral examination normal What is the most likely Dx and why? Ix? Mx?

Hx and physical examination point to SAH, most likely from a ruptured cerebral aneurysm on the ICA/PCommA Ix: basic bloods (likely normal), CXR (expect normal), CT brain (hyperdense blood in the subarachnoid space, enlarged ventricles) Mx: monitor and treat symptoms and complications of SAH (pain, N+V, raised ICP, hydrocephalus), prevent rebleeding (Dx and Mx cause of SAH)

Mr Styles, 45 year old accountant, presents with a severe headache that came on suddenly while showering in the morning Dx: SAH What sort of analgesia is safe for Mr Styles? What might be the complications of analgesia? What observations/monitoring does Mr Styles need?

Complications: respiratory depression Obs: vitals with particular attention paid to BP

What BP parameters should be ordered in the case of SAH?

Mr Styles presents with SAH Mr Styles deteriorates immediately after his CT angiogram: his headache is worse, he comes increasingly drowsy and confused, his GCS drops to 8 (does not open his eyes, only verba response is grunts and moans, localises to pain) CT angiogram shows that the ventricles have enlarged due to worsening hydrocephalus Explain the mechanisms of raised ICP in Mr Styles and in general

Mechanism of raised ICP relates to the Monro-Kellie doctrine; ICP is directly related to the volume of the intracranial contents so anything that increases the volume (in this case blood and CSF) also increases the ICP