Headache and Brain Tumors Flashcards
(28 cards)
1
Q
What percent of HAs are due to significant underlying pathology?
A
~1%
2
Q
Where HA’s can originate
A
- Extracranially
- skin, muscle, blood vessels, periosteum
- Intracranially
- venous sinuses/arteries
- Dura
- Falx cerebri
- Brain parenchyma itself incapable of producing pain
3
Q
Migraine Headache Epidemiology
A
- 70% have family history
- usually begins in adolescence or young adulthood
- may begin in childhood
4
Q
Common Migraine
Characteristics, Duration
A
AKA Migraine without aura
- MC kind
- Duration: 4-72hrs
Symptoms
- Unilateral
- Pulsating or Bounding
- Intensity: moderate to severe
- Aggravated by physical activity
- N/V
- Photophobia/phonophobia
Should have at least 5 attacks before dx
5
Q
Classic Migraine
A
- SImilar characteristics to common migraine but has aura that comes on gradually, lasting <60min
Types of aura
- visual most common (scotoma - blind spots; flashing lights also common)
- sensory (unliteral paresthesias, numbness)
- motor aura (unilateral weakness, speech difficulty)
6
Q
Migraine Precipitants
A
- Menstruation
- too much/little sleep
- fasting
- physical activity
- stress
- tyramine containing foods (red wines, hard cheeses, herring)
- chocolate (phenylethlamine)
- nitrites (processed meats)
- caffeine withdrawal or excess
- medications (OCPs, anti HTN)
7
Q
Classes of Drugs to Tx Migraines
ppx and abortive
A
PPX
- beta-blockers
- CCB
- SSRI
- TCA
- AED
Abortive
- OTC Analgesics
- Ergots (vasoconstrictors)
- Anti-emetics
- Serotonin agonists
- Narcotics
- Steroids
8
Q
Cluster Headaches
A
- A cluster or series of HA’s over a period of 2-3 months, usually occuring every 1-2 years
- Much less common than migraines, affecting more males (late 20’s)
- May be triggered by **alcohol, nitroglycerin, histamine **
- Path: dilation of retroorbital blood vessels and inflammation of trigeminal nerve branches
Symptoms
- ALWAYS unilateral
- excrutiating
- penetrating or stabbing pain
- pain in trigeminal nerve distribution, usually behind eye
- often with autonomic features - lacrimation, conjunctival injection, nasal congestion/rhinorrhea, ptosis/miosis
**Treatment: **
- Oxygen - very effective!
- pharm similar to migraines ( - BB)
9
Q
Tension Headaches
A
- Most common type of HA
- Duration: 30min - 7days
Symptoms
- pressing/tightness/band-like (non-pulsating)
- mild-moderate intensity
- unaffected by physical activity
- +/- photo/phonophobia
- no N/V
Treatment
- mild analgesics
- stress reduction
- relaxation techniques
10
Q
Extracranial Sources of HA
A
- Sinusitis
- Acute glaucoma
- Temporal arteritis
- TMJ
- Trigeminal neuralgia
11
Q
Sinusitis
A
- stabbing or aching that is worse with bending forward, coughing
- better when supine
- percussion over sinuses produces pain
- often associated with nasal congestion, rhinorrhea, URI sxs
12
Q
Acute Glaucoma
A
- Orbital pain often associated with N/V
- cornea is edematous, injected conjunctiva
- decreased vision
- measure intra-ocular pressure via tonometry device
13
Q
Temporal arteritis
A
- vasculitis of the temporal artery affected pts >50, more common in females
- Presentation
- jabbing, excrutiating pain over temple
- usually unilateral, but can be bilateral
- visual loss may be present
- may have symptomatic sx (fevers, malaise)
- temporal artery tender to palpation
- Lab: elevated ESR; bx
- prompt tx with steroids to decrease chance of vision loss
14
Q
TMJ Syndrome
A
- usually due to spasms around TMJ
- causes: overbite previous dental work, grinding teeth
- unilateral or bilateral TMJ pain, tender to palpation
- may feel clicking in joint
- tx - NSAIDs + dental referral
15
Q
Trigeminal Neuralgia
A
- AKA tic doloureux
- brief, severe attacks in trigeminal nerve (or branch of) distribution
- due to partial demyelinization of trigeminal nerve, possibly due to compression
- pain is lancinating, electric shock pain
- may be triggered by eating, talking, or washing face (pt will be hesitant to do these actions)
- Rx: narcotic analgesics, carbamezapine, phenytoin
- surgery by ENT if doesn’t respond to medical treatment
16
Q
Life Threatening Headaches
A
- subarachnoid hemorrhage
- meningitis
- brain tumors
- subdural/epidural hematoma
- hypertensive HA
17
Q
Subarachnoid Hemorrhage
A
- bleed from ruptured aneurysm, or less commonly AVM
- aneurysm MC’ly comes off of the Circle of Willis
- sudden onset of severe HA - “worst HA of my life,” thunderclap HA
- may have a sentinal HA where aneurysm begins to bleed, but then clots off; will rupture later
- often brought on when ICP increases - valsalva (BM, heavy lifting, sex)
- LOC, focal neuro signs, sz possible
- +/- nuchal rigidity
- CT scan ~90% sensitive. If negative do LP
Treatment:
- CCB –> decrease secondary vasospasm
- phenytoin –> sz ppx b/c ICP rising
- urgent neurosurgical consultation - clipping or interventional radiology coiling
18
Q
Meningitis
A
- symptoms
- HA
- fever
- toxicity
- nuchal rigidity
- diagnosis
- LP
- treatment
- bacterial: IV antibodies, possibly steroids
- viral: supportive
19
Q
Subdural Hematoma
A
- HA, often with confusion, obtundation
- often seen in elderly after previously forgotten minor head injury
- dx: CT
20
Q
Epidural Hematoma
A
- hx. of trauma
- brief LOC, then awake with HA, then deteriorating mental status
- may rapidly progress by herniation
- dx by CT
- urgent neurosurg consult to drill burr holes
21
Q
Hypertensive HA
A
- DBP >130
- lower BP with antiHTN to relieve HA
- may be overdiagnosed - have to question if high BP caused HA or HA caused high BP
22
Q
Symptoms of Brain Tumors
A
- Headache that is progressively worsening over days to weeks, often worse in the morning with vomiting
- weakness, paralysis, sensory deficits, cranial nerve palsies
- visual disturbance
- ataxia
- altered mental status
- seizures (new onset)
- dx: MRI is best, can also use CT with contrast
23
Q
Types of Brain Tumors
A
Astrocytoma (gliomas)
Meningioma
Acoustic neuroma
Metastases - secondary brain tumors
24
Q
Astrocytoma
A
- MC primary brain tumor
- arise from astrocytes (type of glial cell)
- MC site - cerebral hemispheres
- Grading (from least to most malignant)
- low grade astrocytoma
- anaplastic astrocytoma
- glioblastoma multiforme
- Risk factors: radiation, genetics, +/- cell phones
- Treatment: surgery, radiation (gamma knife), chemo; steroids if cerebral edema present, anticonvulsants for szs
25
Meningioma
* Second most common type of brain tumor
* arise from meninges--\> on the surface of the brain (out the outside)
* may be single or multiple
* usually **benign, slow growing** --\> good survival rates
* risk factors: radiation, genetics, +/- cell phones
* treatment: **observation** with regular f/u imaging if small and asymptomatic; otherwise **surgery** is generally very successful b/c tumor is **superficial and easily accessible **
26
Acoustic Neuroma
* benign, slow-growing tumor
* arises from Schwann cell sheath around vestibulocochlear nerve
* occupies cerebello-pontine angle
* risk factors: radiation, neurofibromatosis type 2
* symptoms:
* **unilateral hearing loss** (sudden, persistent, or fluctuating)
* tinnitus
* vertigo
* disequilibrium
* **HA**
* facial numbness or weakness (b/c of proximity to facial nerve)
* tx: surgical excision
27
Cerebral Metastases
* **more common than primary brain tumors** - \>20% of all cancer patients
* MC sources: lung and breast
* general presents with multiple lesions
* want to do a systemic work up to find primary source - CT of chest, abdomen, pelvis +/- CXR
* brain bx if etiology is uncertain and no hx of CA
* management: mainly palliative, can consider whole brain radiation therapy (WBRT) and surgery (if solitary lesion \>3cm in noneloquent part of brain; limited systemic disease)
28
Summary - RED FLAGA in HA Eval
* first severe HA or worst HA of pt's life especially with acute onset
* HA that gets progressively worse over days to weeks
* severe HA with fever
* nuchal rigidity - subarachnoid hemorrhage or meningitis
* decreased LOC or focal neuro signs
