Headache

Headache

1. Meningitis

   • viral- usually self limiting, headache main feat
   • bact- life threat: decreased GCS, shock signs, purpuric rash (non blanch), focal neuro signs
   • beware atyp presentation: immunosuppressed, preg, alcoholic patients
   • organisms
     • meningococcus or pneumococcus
     • less: H influenze; Listeria monocytogenes. If HIV +ve: CMV, cryuptococcus or TB if HIV +ve
   • differential diag
     • malaria
     • encephalitis
     • septicemia
     • subarachnoid
     • dengue
     • tetanus
   • features
     • classic triad: headache, fever, meningism (stiff neck, photophobia + headache)
     • onset: hours
     • early: headache, leg pains, cold hands and feeet, flu-ey abnormal skin color
     • later: meningism: neck stiff + photophobia, Kernig's sign (pain and resistance on passive knee extension w/hip fully flexed)
     • decreased conscious lvl, coma; seizures (20%) +/- focal CNS signs (20%) +/- opisthotonus; petechial rash (non-blanching - may only be 1 or 2 spots)
     • signs of galloping sepsis: slow cap refil; DIC; BP down, Temp and pulse up or normal
   • treatment
     • when to act now: if any 2 coexist, give BENZYLPENICILLIN 1.2 IM/IV before admitting if pt not yet in hosp
       • headache
       • raised temp
       • neck stiffness
       • altered mental state
     • if raised ICP, summon help and inform neurosurg
     • prophylaxis: household contacts in droplet range or those who have kissed pts mouth (rifampicin, ciprofloxin)
     • antiobiotics stat (see trust guidelines eg cefotaxime or aciclovir if viral)
   • investig
     • LP- helpful, but don't delay IV antibiotics
       • usually done after CT but safe w/o (if no mass or raised CIP suspected- look for papillodema, focal signs, decreased cons)
       • for mets, gram stain, protein, glucose, virology/PCR, and lactate
     • U + E, FBC (WBC decreased- immunocomp) LFT, glucose, coag screen
     • blood cult, throat swab, rectal swab for viruses. Serology eg EBV, HIV
     • if aseptic meningitis (usually self limiting) do CSF PCR
     • CXR (signs of TB? -> TB meningitis)

2. Migraine

   • migraines often co-exists w/other chornic probs treat person as whole -> aim = recover life
   • recurrent severe headaches lasting hrs- few days (4-72 hours)
   • common trigggers
     • C-heese H-cHoc O-ral contracep C-affeine O L -alcohOL A-nxiety T-ravel E-xercise
     • cheese, choc, alch, oral contracep
     • 50% no trigger
   • epidem
     • first attack age >40 uncommon
     • prevalence 8% F:M 2:1
     • big cost £200million per year
   • symptoms
     • usually +: photophobial, N + V
     • intense, throbbing, unilat, favor bedrest in quiet+ dark
     • visual or other aura lasting 15-30min
     • followed by 1h unilat, THROBBING headache
     • or isolated aura w/no headache
     • or episodic severe headaches without aura, often premenstrual usually unilat, with N+ V +/- photophobia/phonophobia
   • signs
     • none
     • (so PERFECT FOR OSCE)
   • assocs
     • obesity
     • patent foramen ovale
   • tests
     • NONE if typical hx
   • prodrome (maybe hrs or days)
     • yawning, food cravings or changes in sleep, appetite, mood
   • aura
     • precedes by mins + may persist during
     • visual- chaotic cascading, distorting, 'melting' and jumbling of lines, sigzags, scotomata, hemianopia
     • somatosensory- paresthesiae fingers -> face
     • motor: dysarthria + ataxia (basilar migraine); opthalmoplegia or hemiparesis
     • speech (8% of auras); dysphaia or paraphasia (eg phoneme substitution)
   • Diag criteria if no aura
     • 5+ lasting 4-72 hrs w/1 of : N+ V or phto/phonophobia and 2+ of: unilat, pulsating, interferes w/normal life, worsened by routine activity (eg stairs)
   • differential
     • cluster tension cervical spondylosis increased BP intracranial pathology sinusitis/otitis media caries TIAs may mimic migraine aura. migraine rarely sign of other pathology
   • extra notes for F
     • -perimenstural migraine: do NSAID at onset of menses to last day of bleeding +/- transdermal estradiol for 7 days starting 3d before menses -preg :migraine often better. if not, may have increased risk of pre-eclampsia and CVS complics -DON'T GIVE COCONTRACEP if migraines, partic if aura b/c increased risk of stroke
   • treatment
     • NSAIDs (less chance of med misuse headache)
       • eg ketoprofen 100 mg dispersible aspirin 900mg/6h
     • triptans
       • 5HT IB/ID agonists- constrict cranial arts rizatriptan, sumatriptan NOT if IHD, coronary spasm, uncontrolled hypertension, recent lithium, SSRIs or ergot use
     • ergotamine
       • 1mg PO as headache starts, repeated at 1/2 hr
     • prophylaxis if freq >2x/mo
       • most achieve 50% decrease in attack frequency
       • propranolol, topiramate, amitryptilline
         • 2nd line: valproate, pizotifen, gabapentin, pregerbalin, or NSAIDS
     • non pharm treat
       • warm or cold packs to head rebreath into paper bag spinal manip, riboflavin, magnesium

3. Tension/Stress Headache

   • usually bilat (often generalised or frontal)
   • 'dull' 'tight' 'pressing', non pulsatile; +/- scalp musc tender
   • N + V usually ABSENT
   • pt can continue w/normal activities
   • recurrent
   • NO neuro signs
   • treatment
     • stress relief + massage
       • may help more than neurology
     • reassurance; avoid triggers
     • antidepressants
     • analgesia

4. sub-arachnoid hemorrhage

   • spontaneous bleeding into subarach space -often catastrophic
   • epidem
     • typically 35-65
     • annual incidence 9/100,000
     • risk facotrs
       • smoking, alcohol misuse, hypertension, bleeding disorders, FH, mycotic aneurysm (SBE), perhaps post-menopausal decrease estrogen? (F:M 3:2 once >45y)
   • causes
     • 80% rupture of saccular (berry) aneurysm
       • common sites for berry aneurysm: junction of post communic w/internal carotid OR junct of ant communic w/ant cerebral artery or bifurc of middle cerebral art 15% are multiple assocs: polycystic kidnesy, coarct of aorta, Ehlers Danlos synd
     • arteriovenous malformations (15%)
   • clin feats
     • symps
       • sudden onset (seconds), severe, occipital
         • 'though i'd been kicked in head'
       • vomiting, collapse, seizures + coma often follow
         • coma/drowsiness may last for days
     • signs
       • distress and photophobia common, but nect stiff may take hrs to devel
       • kernig's sign (takes 6h to devel)
         • each hip flxed in turn, then try to straighten knee while hip flexed  in meningitis, this move gretly limited by spasm of hamstrings
       • focal neurology at presentation may suggest site
         • of aneurysm (eg pupil changes indicating a IIIrd nerve palsy w/a posterior communicating artery aneurysm or intracerebral hematoma later deficits suggest complics
       • sentinel headache
         • may have had small warning leak from aneurysm (6%) be suspiciuos of ANY sudden headache w/neck or back pain (surg is more successful in the least symptomatic)
   • differential
     • in py care only 25% of thunderclap headache is SAH in50-65% no cause found remainder -> meningitis, migraine, intracerebral bleeds, cortical vein thrombosis
     • benign thunderclap headache mimicks SAH but investig shows no evidence of intravasc disord
   • investigs
     • CT w/in 48hrs(>90% evident- if not do LP- for yellow sign)
     • LP if CT -ve and no contraindic >12hr after headache onset
     • CSF
       • uniformly bloody early on
       • becomes XANTHOCHROMIC (yellow) after several hrs to to Hb breakdown. confirms SAH b/c not just a blood tap
   • management
     • prognosis no signs- 0% neck stiff + CN palsy- 11% mort drowsy- 37% drowsy w/hemiplegia 71% prolonged coma- 100% in 1st mo
     • all proven SAH -> refer to neurosurg immediately
     • re-examine CNS often
       • chart BP, pupils, GCS, repeat CT if deteriorating
     • maintain cereb perfusion by keep well hydrated
       • aim for SBP >160mmHg treat high BP only if very severe
     • nimodipine
       • for 3w Ca2+ antag that decreases vasospasm + consequent morbidity from cerebral ischemia
     • endovascular coiling
       • preferable to surgical clipping do CT angiography or catheter to ID single vs multiple aneurysms prior to intervention intracranial stents and balloon remodelling for wide necked aneruysms
   • complics
     • large bleed? may be complic by decreased GCH, seizure or focal neuro signs
     • REBLEEDING
       • often in 1st few days.  occurs in 20%. Is commonest Cause of Death
     • CERBRAL ISCHEMIA due to vasospasm
       • commonest cause of morbidity. may cause permanent CNS deficit
     • hydrocephalus- requires drain
     • hyponatremia
       • common but should not be managed w/fluid restriction. seek expert help

5. giant cell arteritis

   • aka temporal arteritis
   • large vess vasculitis
   • close assoc w/PMR (polymyalgia rheumatica)
   • F>M, unusual if <50
     • exclude in all >50yrs w/a headache that has lasted a few weeks
   • clin feats
     • localised temporal/occipital headache
     • scalp tender
     • jaw claudic
     • sudden onset visual loss
       • prompt daig + steroids avoid blindness
     • thickened, tender, PULSELESS temporal arts
     • ESR >40mm/h
     • extracranial symps
       • constitutional upset (malaise, night sweats, pyrexia, weight loss)
       • dyspnea, morning stiff, unequal or weak pulses
   • treat
     • treat urgently with steroids
       • because potential RAPID ONSET VISUAL LOSS
       • (if suspect GCA, do ESR and give steroids (prenisolone) immediately
     • temproal art biopsy (get w/in 3 days of starting steroids) may confirm, but don't delay treat
       • skip lesions occur -so don't be put off by neg biopsy
   • investigs
     • ESR + CRP ++
     • platelets +
     • alk phos +
     • Hb -
   • prognosis
     • typically 2 year course, then complete remission reduce prednisolone after 5-7d guided by symps + ESR increase dose if symps recur main COD + morbidity is long term steroid treat give gastric + bone protect (PPI and alendronic acid)

6. stroke

7. sinusitis

   • dull throbbing headache, assoc w/facial pain over sinuses
   • worse on bending forward
   • ALWAYS NASAL SYMPS eg congest or discharge
   • if ?8w req CT to confirm diag

8. other vasc cuases

   • intracerebellar hemorrahge
     • -abrupt onset headache -N and v -dizzy -ataxia +/- GCS
   • Spontaneous intracerebral or intraventricular hemorrhage
     • onset min -&gt; hrs. accompany by focal neuro deficit +/- GCS
   • Cerebral venous thrombosis
     • headache common but variable 'thunderclap' throbbing 'band-like' (may have assoc feats- eg N and V, seizures, CN palsies, hemiparesis, ataxia, decreased GCS)
   • Vertebrobasilar dissection
     • maybe acute occipital/post neck pain with brainstem signs/symps

9. other

   • cluster
     • severe, unilat
     • retroorbital
     • 5+ episodes
       • agitation, restlessness, ipsilat lacrimation, conjunctival injection, rhinorrhea, facial sweating
       • attacks short (15-90min) but frequent (1 per 2 days -> 8 per day)
       • repeated, ( often same time each day), in clusters (days -> wks) separated by months w/o symps
     • M: F 5: 1
   • acute glaucoma
     • because sudden increase ocular pressure
     • typical pt
       • long sighted, middle age/elderly
     • present
       • periorbital plain
       • N + V
       • blurred vision with halos aroudn lights + conjunctival injection
     • urgent opthalmology referral mandatory
   • raised ICP
     • maybe primary (idiopathic)
       • espec in overweight young females on oral contracep
     • or secondary to Space Occupying Lesion
       • clin signs
         • focal neuro signs
         • change in personality
         • new-onset seizures
         • headache, wosre in morning, lying flat, coughing or straining
         • assoc? vomiting (often w/o nausea +/- papilloedema)
   • other

10. TMJ syndromes

11. drugs

    • analgesic headache
      • assoc chronic analgesic use espec opioid eg codeine
      • usualy bilat
      • occur prior to next dose of analgesia
    • vasodilats eg nitrates
    • rec drugs eg solvents

12. RED FLAG FEATS

    • new onset headache/change in headache (pt over 50)
    • focal CNS signs, ataxia, or new cognitive or behavioural disturbance
    • persistent visual disturb
    • headache that changes w/posture or wakes pt up
    • headache brough on by physical exertion
    • papilledema
    • new onset headache in pt w/known HIV or active malig

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