Flashcards in Symposium 2: Headache Deck (23):
What proportion of headaches seen in primary care are sinister?
What are the key questions that need to be addressed during the consultation.
- Can I classify the headache?
- Do I need to investigate?
- How do I explain the diagnosis?
- What are the patients expectations?
- Is treatment appropriate?
What are the important considerations regarding the pattern of pain?
Acute (seconds to minutes)
- SAH/Intra-cerebral haemorrhage/coital/thunderclap
Evolving (hours to days)
Chronic (weeks to months)
- Chronic daily headache/ ↑ICP
What associated features need to be considered?
- Diurnal variation/postural element
- Nausea and vomiting (meningeal irritation)
- Photophobia/ phonophobia (meningeal irritation)
- Autonomic features (lacrimation/Horners/red eye)
What features of periodicity need to be considered?
Episodic (at least a few days free between attacks)
- Migraine /Cluster headache
Chronic (headache most days)
- Medication overuse/chronic migraine/hemicrania continua
What red flag must you be aware of?
- Cognitive effects
- Visual disturbance
- Weight loss
What are the other important questions to ask?
- Lies down in dark room (Migraine)
- Agitation/pacing (Cluster)
- Migraine is often familial
Medication/ self medication
- Analgesia (what? And how often?)
What is the patient concerned about?
What should you look for on examination?
- Fever/rash/neck stiffness/↑BP/organomegaly
- Fundal changes (papilloedema)
- Cranial nerve signs/Horners Syndrome
- Focal abnormalities
- Long tract signs
What are the primary headache syndromes?
- Tension headache
- Cluster headache
- Paroxysmal hemicrania
- Exertional headache
- Ice-pick headache
- Coital headache
- Hypnic headache
What are the secondary headache syndromes?
- Intra-cerebral haemorrhage/Stroke
- Intracranial venous thrombosis
- Giant cell arteritis
- Tumour with raised ICP
- Cervicogenic headache
- Benign intracranial hypertension
If a CT scan is normal in a patient presenting with the symptoms of a SAH what further steps need to be taken?
Perform a 24hr LP and look for xanthochromia (bilirubin released from lysing red cells). If negative then SAH can be ruled out.
- 54 year old female
- 72 hours evolving generalised headache and nausea
- Left ear pain for 3 days prior to start of headache
- Received antibiotic ear drops from GP
- Obtunded, pyrexial, hyperreflexia in right arm and leg with right extensor plantar.
- Intubated and taken to ITU
What is the possible diagnosis?
Raised ICP and SOL on LHS (causing RHS hyperreflexia) - possible abscess secondary to ear infection.
What is the difference between a prodrome and an occipital seizure?
Occipital seizure - couloured dots/lines
Prodrome - black and white, straight lines
What are the possible causes of raised ICP?
- Mass Effect (brain tumour, abscess)
- Brain swelling (Hypertensive encephalopathy)
- Increased venous pressure
- CSF outflow obstruction (hydrocephalus)
- Increased CSF production (meningitis/SAH)
What are the symptoms of raised ICP?
- Headache (worse on lying or awakening)
What are the signs of raised ICP?
- lateralising signs
What is the most common first presenting sign of a tumour? (90%)
- 70 year old female
- General malaise and left temporal headache for 2 weeks
- Radiates into jaw and worse when eating
- Tender temporal area and scalp feels sensitive
- Can’t sleep on left side
- This morning visual disturbance
- Top half of visual completely obscured for several minutes then seemed to resolve
- Feels nauseated
Giant cell arteritis (temporal arteritis)
What are the features of temporal arteritis?
- Think in patient >60 years old (F>M)
- Association with PMR
- Weight loss
- Transient loss of vision
- Jaw claudication
- Tender non-pulsatile temporal artery
- Do ESR which is often elevated but not always
How would you manage temporal arteritis?
- Commence immediate high dose steroids
- Prednisolone 60mg od for 1st week
- Slow taper over 6 weeks to 15-20mg od
- Response is excellent within 48 hours
- Arrange temporal artery biopsy
What are the characteristics of the trigeminal autonomic cephalagias?
- short-lasting headaches
- variable autonomic features
What are the types of trigeminal autonomic cephalagias?
- Cluster headache (attacks last 30-180 minutes; 1 per 24hrs)
- Paroxysmal hemicrania (2-30 minutes; >5 per 24hrs)
- SUNCT (v. rare; seconds; up to 200 attacks per 24hrs)