headaches

Question 1

what is a headache?

Answer 1

a symptom

half to three quarters of adults age 18-65 in the world have had a headache in the past year

among those 30% or more have reported a migraine

Question 2

what are the general bases of generation of headaches?

Answer 2

some structural
some perhaps pharmacological (eg. GTN used to treat angina)
some psychological

Question 3

what are the main patterns of headache?

Answer 3

acute single headache

dull headache, increasing in severity

dull headache, unchanged over months

recurrent headaches

triggered headaches

Question 4

what are causes of an acute single headache?

Answer 4

much more serious than other headaches

febrile illness, sinusitis, first attack of migraine, following a head injury, subarachnoid haemorrhage, meningitis, tumour, drugs, toxins, stroke, thunderclap, low pressure

Question 5

what are causes of a dull headache that worsens in severity?

Answer 5

usually benign, but may be worrying

overuse of medication (eg. codeine), OCP, HRT, neck disease, temporal arteries, benign intercranial hypertension, cerebral tumour, cerebral venous sinus thrombosis

Question 6

what are causes of a dull headache, unchanging over months?

Answer 6

people complain most about these

chronic tension headache

depressive, atypical face pain

Question 7

what are causes of recurrent headaches?

Answer 7

lots of complaining about these

migraine, cluster headache, episodic tension headache, trigeminal or post herpetic neuralgia

Question 8

what are causes of triggered headaches?

Answer 8

coughing, straining, exertion, sex, food and drink

Question 9

what are headache red flags?

Answer 9

onset:
thunderclap, acute, subacute

meningism:
photophobia, phonophobia, stiff neck, vomiting

systemic symptoms:
fever, rash, weight loss

neurological symptoms or focal signs:
visual loss, confusion, seizures, hemiparesis, double vision, 3rd nerve palsy, horner syndrome, papilloedema

orthostatic:
better lying down

strictly unilateral

Question 10

what are focal signs of headaches that are red flags?

Answer 10

double vision

3rd nerve (occulomotor) palsy

horner syndrome

Question 11

what is 3rd nerve palsy?

Answer 11

palsy of the occulomotor nerve , it doesn’t work

symptoms:

one eye has a ptosis - levator palpabrae innervated by CN III

dilated pupil - as CNIII constricts pupil

eye points down and out - as lateral rectus and superior oblique are only extraoccular muscles not supplied by CNIII

Question 12

what is horner syndrome?

Answer 12

when sympathetic nerve supply to an eye is affected, doesnt work

sympathetic dilates the pupil and opens it

so in horners, one eye is smaller, constricted, looks pushed in (enopthalmos)

Question 13

what is the headache caused by a subarachnoid haemorrhage like?

Answer 13

sudden generalised headache “blow to the head”, thunderclap
often occipital

causes meningism - stiff neck and photophobia
blood irritates the meninges

most are caused by a ruptured aneurism, a few from arterovenous malformations and some are unexplained

Question 14

what are the risks and treatments of subarachnoid haemorrhages?

Answer 14

50% are fatal
high risk of further bleed

may be automatic vasospasm which may stop the leak

we give nimodipine and BP control

early neurological assessment. will confirm the bleed and assess the cause
CT brain, lumbar puncture (for RBC and Xanthochromia) (if cant tell if there is a bleed from CT), MRA and angiogram

Question 15

how are aneurisms treated?

Answer 15

used to be clipped or wrapped physically

now they are filled with platinum coils. doesnt require opening of the head. instead you use a catheter.
the platinum causes the aneurism to sclerose and seal

Question 16

what is an intracerebral bleed?

Answer 16

fatal haemorrhage due to coning

it increases ICP.
brain can tolerate a certain amount of bleeding into the brain due to compliance, but then it gets past this point and a small increase in volume highly increases the pressure

coning is when the brain creeps around the falx, or the tentorium, or the skull (worst coz this is the area that controls respiration)

Question 17

what is papilloedema?

Answer 17

optic disc swelling

due to raised ICP

visible when you look at the eye

Question 18

what are carotid and vertebral artery dissections?

Answer 18

the arteries leading up to the neck can split, blood collects in the split between layers, and causes turbulent flow

causes headache and neck pain

cause 20% of ischaemic strokes <45 yrs (young stroke)

mean age is 40, Carotid>vertebral

can be traumatic/spontaneous

diagnosed with MRI,MRA, doppler, angiography

Question 19

how are carotid and vertebral artery dissections treated?

Answer 19

aspirin or anticoagulation

as turbulent flow causes sticky blood prone to clotting

Question 20

what are symptoms of a vertebral vs carotid artery dissection?

Answer 20

vertebral - occipital and back of neck pain

carotid - phantom of the opera mask pain distribution

Question 21

what is chronic subdural haemorrhage?

Answer 21

SDH

due to a venous bleed. so slow.
causes blood to accumulate under the dura
can cause compression of the ventricles and the brain

common in old people who are on anticoagulants and fall

causes headache, unsteadiness and weakness on the (ipsilateral?) side

may be solved by just draining the blood

Question 22

what is temporal arteritis?

Answer 22

inflammation of the arteries in the temporal lobe

occurs in people over the age of 55.
three times more common in females

disruption of the internal elastic lamina is the main sign of vasculitis

Question 23

what are symptoms of temporal arteritis?

Answer 23

constant unilateral headache
scalp tenderness
jaw claudication

25% also get polymyalgia rheumatica - proximal muscle tenderness

involvement of the posterior ciliary arteries can cause blindness

Question 24

how is temporal arteritis diagnosed and treated?

Answer 24

may be seen on ultrasound. the arteries

biopsy shows inflammation and giant cells

elevates ESR and CRP (inflammatory markers)

treatment:
high dose steroids and aspirin

Question 25

what is cerebral venous thrombosis?

Answer 25

thrombosis in dural venous sinus or cerebral vein. blood cant leave the brain unusual high amount of headache due to raised ICP non territorial ischaemia "venous infarcts" haemorrhage may be caused by thrombophilia (sticky blood), pregnancy, dehydration, behcets

Question 26

what are causes of minigitis?

Answer 26

viral - Caxsackie, ECHO, mumps, EBV bacterial - menincococci, pneumococci, haemophilus, tubrculosis. (bacterial is more worrying) fungal - cryptococci granulomatous - sarcoid, lyme, brucella, syphilis carcinomatous

Question 27

what are the symptoms of meningitis?

Answer 27

very similar to that of a subarachnoid haemorrhage malaise, headache, fever, neck stiffness, photophobia, confusion, alteration to consciousness but the main one is fever they may look septic if they have been left untreated

Question 28

what is herpes simplex encephalitis?

Answer 28

infection that effects the brain tissue commonly effects the temporal lobe (meningitis affects the meninges, encephalitis affects the brain)

Question 29

how is meningitis treated and diagnosed?

Answer 29

treat first then think about diagnosis (because it kills fast) antibiotics diagnosis: blood and urine culture CT, MRI lumbar puncture (increased white cell count, decreased glucose, antigens, cytology, bacterial culture) CT, MRI must come before lumbar puncture. as meningitis causes cerebral oedema with effacement of ventricles and sulci and inflamed meninges. so LP will decompress this, and the brain might hurtle through the foramen magnum

Question 30

what are the symptoms of sinusitis?

Answer 30

causes a really bad headache but wont kill you malaise, headache, fever. blocked nasal passages, loss of vocal resonance, anosmia. nasal or postnasal catarrh. local pain and tenderness (sinuses, either side of nose, or above eyes) frontal pain starts 1-2 hours after waking up then clears up during the afternoon

Question 31

what is idiopathic intracranial hypertension?

Answer 31

people may think they have a brain tumour but they have this instead causes raised ICP aka pseudotumour cerebri often seen in overweight people and women may be caused by drugs: hormones, steroids, antibiotics, vitamin E

Question 32

what are symptoms of idiopathic intracranial hypertension?

Answer 32

headache, visual obscurations, diplopia, tinnitus, papilloedema +/- visual field loss

Question 33

how is idiopathic intracranial hypertension treated?

Answer 33

weight loss (maybe even bariatric surgery), diuretics, optic nerve sheath decompression, lumboperitoneal shunt, stenting of stenosed venous sinuses

Question 34

what is a low pressure headache?

Answer 34

headaches caused caused low ICP orthostatic headaches are a hallmark of these. (when they stand up) possible causes: CSF leak due to tear in dura. traumatic post lumbar puncture may be no apparent cause diagnosis: MRI with gadrolinium contrast. shows intense meningeal enhancement

Question 35

how are low pressure headaches treated?

Answer 35

rehydration, caffeine (seals the hole), blood patch (remove blood then inject it straight into the dura. it will find and seal the hole)

Question 36

what is chiari malformation?

Answer 36

normal brain, but it just sits very low down in the cranium cerebellar tonsils descend through the foramen magnum. they descend further when the patient coughs (as the pressure in the head goes up a bit). when this happens they tug on the meninges which causes a sudden, short lived horrible headache. treat the cold or the cough. or do an operation to remodel the base of the skull

Question 37

what is obstructive sleep apnoea (related to headache)?

Answer 37

cant breathe at night due to obstruction. may go with obesity. history of loud snoring and apnoeic spells causes hypoxia, CO2 retention, non refreshing sleep, depression, poor performance at work headaches - due to retained CO2. it is a potent vasodilator. vasodilates blood vessels in the brain. headache decreases over the course of the morning ass they breathe normally requires a sleep study. treatment: nocturnal NIV, surgery

Question 38

what is trigeminal neuralgia?

Answer 38

not necessarily a headache cause but causes really bad pain on the face. trigeminal: 3 branches electric shock like pain in the distribution of a sensory nerve often triggered by innocuous stimuli any division of the trigeminal can be effected cause: neurovascular conflict at the point of entry of the nerve into the pons can be a symptom of MS treatment: carbamazepine, lamotrigine, gabapentin, posterior fossa decompression

Question 39

what is atypical facial pain?

Answer 39

daily, constant, ill defined, poorly localised deep aching or burning. in facial or jaw bones, but may extend to neck ear or throat. not lancinating commonly occurs in middle aged women who are depressed or anxious doesn't conform to strict anatomical distribution of ay nerve no sensory loss unresponsive to conventional analgesics opiates and nerve blocs may be used also antidepressants

Question 40

what is post traumatic headache?

Answer 40

of people admitted with head injury, headaches are present in: 36% at discharge 24% at 6 months 16% at 1 year it correlates with a previous history of headache but unrelated to duration of post traumatic amnesia ``` it depends on the nature of the head injury: high in victims of car accidents low in perpetrators low in sports injuries (so psychological element) ``` ``` multiple mechanisms: neck injury scalp injury vasodilation? autonomic damage? depression - often delayed ```

Question 41

how is post traumatic headache treated?

Answer 41

``` give them an explanation stop them from abusing analgesics patience non steroidal anti inflammatories - ibuprofen, naproxen tricyclic antidepressants ```

Question 42

what is cervical spondylosis?

Answer 42

common cause of new headaches in old patients, due to arthritis ``` pain: bilateral normally occipital constant no nausea or vomiting worsened by moving the neck ``` management: rest, deep heat, massage anti inflammatory analgesics