Headache

Annotations:

• v common, usually benign

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

   Annotations:

   • migraines often co-exists w/other chornic probs treat person as whole -> aim = recover life
   1. recurrent severe headaches lasting hrs- few days (4-72 hours)
   2. common trigggers

      Annotations:

      • C-heese H-cHoc O-ral contracep C-affeine O L -alcohOL A-nxiety T-ravel E-xercise
      1. cheese, choc, alch, oral contracep
      2. 50% no trigger
   3. epidem
      1. first attack age >40 uncommon
      2. prevalence 8% F:M 2:1
      3. big cost £200million per year
   4. symptoms
      1. usually +: photophobial, N + V
      2. intense, throbbing, unilat, favor bedrest in quiet+ dark
      3. visual or other aura lasting 15-30min
      4. followed by 1h unilat, THROBBING headache
      5. or isolated aura w/no headache
      6. or episodic severe headaches without aura, often premenstrual usually unilat, with N+ V +/- photophobia/phonophobia
   5. signs
      1. none
      2. (so PERFECT FOR OSCE)
   6. assocs
      1. obesity
      2. patent foramen ovale
   7. tests
      1. NONE if typical hx
   8. prodrome (maybe hrs or days)
      1. yawning, food cravings or changes in sleep, appetite, mood
   9. aura
      1. precedes by mins + may persist during
      2. visual- chaotic cascading, distorting, 'melting' and jumbling of lines, sigzags, scotomata, hemianopia
      3. somatosensory- paresthesiae fingers -> face
      4. motor: dysarthria + ataxia (basilar migraine); opthalmoplegia or hemiparesis
      5. speech (8% of auras); dysphaia or paraphasia (eg phoneme substitution)
   10. Diag criteria if no aura
       1. 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)
   11. differential

       Annotations:

       • cluster tension cervical spondylosis increased BP intracranial pathology sinusitis/otitis media caries TIAs may mimic migraine aura. migraine rarely sign of other pathology
   12. extra notes for F

       Annotations:

       • -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
   13. treatment
       1. NSAIDs (less chance of med misuse headache)

          Annotations:

          • eg ketoprofen 100 mg dispersible aspirin 900mg/6h
       2. triptans

          Annotations:

          • 5HT IB/ID agonists- constrict cranial arts rizatriptan, sumatriptan NOT if IHD, coronary spasm, uncontrolled hypertension, recent lithium, SSRIs or ergot use
       3. ergotamine

          Annotations:

          • 1mg PO as headache starts, repeated at 1/2 hr
       4. prophylaxis if freq >2x/mo

          Annotations:

          • most achieve 50% decrease in attack frequency
          1. propranolol, topiramate, amitryptilline

             Annotations:

             • 2nd line: valproate, pizotifen, gabapentin, pregerbalin, or NSAIDS
       5. non pharm treat

          Annotations:

          • warm or cold packs to head rebreath into paper bag spinal manip, riboflavin, magnesium
3. Tension/Stress Headache
   1. usually bilat (often generalised or frontal)
   2. 'dull' 'tight' 'pressing', non pulsatile; +/- scalp musc tender
   3. N + V usually ABSENT
   4. pt can continue w/normal activities
   5. recurrent
   6. NO neuro signs
   7. treatment
      1. stress relief + massage

         Annotations:

         • may help more than neurology
      2. reassurance; avoid triggers
      3. antidepressants
      4. analgesia
4. sub-arachnoid hemorrhage

   Annotations:

   • spontaneous bleeding into subarach space -often catastrophic
   1. epidem
      1. typically 35-65
      2. annual incidence 9/100,000
      3. risk facotrs
         1. smoking, alcohol misuse, hypertension, bleeding disorders, FH, mycotic aneurysm (SBE), perhaps post-menopausal decrease estrogen? (F:M 3:2 once >45y)
   2. causes
      1. 80% rupture of saccular (berry) aneurysm

         Annotations:

         • 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
      2. arteriovenous malformations (15%)
   3. clin feats
      1. symps
         1. sudden onset (seconds), severe, occipital
            1. 'though i'd been kicked in head'
         2. vomiting, collapse, seizures + coma often follow
            1. coma/drowsiness may last for days
      2. signs
         1. distress and photophobia common, but nect stiff may take hrs to devel
         2. kernig's sign (takes 6h to devel)

            Annotations:

            • each hip flxed in turn, then try to straighten knee while hip flexed  in meningitis, this move gretly limited by spasm of hamstrings
         3. focal neurology at presentation may suggest site

            Annotations:

            • of aneurysm (eg pupil changes indicating a IIIrd nerve palsy w/a posterior communicating artery aneurysm or intracerebral hematoma later deficits suggest complics
         4. sentinel headache

            Annotations:

            • 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)
   4. differential

      Annotations:

      • in py care only 25% of thunderclap headache is SAH in50-65% no cause found remainder -> meningitis, migraine, intracerebral bleeds, cortical vein thrombosis
      1. benign thunderclap headache mimicks SAH but investig shows no evidence of intravasc disord
   5. investigs
      1. CT w/in 48hrs(>90% evident- if not do LP- for yellow sign)
      2. LP if CT -ve and no contraindic >12hr after headache onset
      3. CSF
         1. uniformly bloody early on
         2. becomes XANTHOCHROMIC (yellow) after several hrs to to Hb breakdown. confirms SAH b/c not just a blood tap
   6. management

      Annotations:

      • prognosis no signs- 0% neck stiff + CN palsy- 11% mort drowsy- 37% drowsy w/hemiplegia 71% prolonged coma- 100% in 1st mo
      1. all proven SAH -> refer to neurosurg immediately
      2. re-examine CNS often

         Annotations:

         • chart BP, pupils, GCS, repeat CT if deteriorating
      3. maintain cereb perfusion by keep well hydrated

         Annotations:

         • aim for SBP >160mmHg treat high BP only if very severe
      4. nimodipine

         Annotations:

         • for 3w Ca2+ antag that decreases vasospasm + consequent morbidity from cerebral ischemia
      5. endovascular coiling

         Annotations:

         • 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
   7. complics
      1. large bleed? may be complic by decreased GCH, seizure or focal neuro signs
      2. REBLEEDING

         Annotations:

         • often in 1st few days.  occurs in 20%. Is commonest Cause of Death
      3. CERBRAL ISCHEMIA due to vasospasm

         Annotations:

         • commonest cause of morbidity. may cause permanent CNS deficit
      4. hydrocephalus- requires drain
      5. hyponatremia

         Annotations:

         • common but should not be managed w/fluid restriction. seek expert help
5. giant cell arteritis

   Annotations:

   • aka temporal arteritis
   1. large vess vasculitis
   2. close assoc w/PMR (polymyalgia rheumatica)
   3. F>M, unusual if <50
      1. exclude in all >50yrs w/a headache that has lasted a few weeks
   4. clin feats
      1. localised temporal/occipital headache
      2. scalp tender
      3. jaw claudic
      4. sudden onset visual loss
         1. prompt daig + steroids avoid blindness
      5. thickened, tender, PULSELESS temporal arts
      6. ESR >40mm/h
      7. extracranial symps
         1. constitutional upset (malaise, night sweats, pyrexia, weight loss)
         2. dyspnea, morning stiff, unequal or weak pulses
   5. treat
      1. treat urgently with steroids

         Annotations:

         • because potential RAPID ONSET VISUAL LOSS
         1. (if suspect GCA, do ESR and give steroids (prenisolone) immediately
      2. temproal art biopsy (get w/in 3 days of starting steroids) may confirm, but don't delay treat

         Annotations:

         • skip lesions occur -so don't be put off by neg biopsy
   6. investigs
      1. ESR + CRP ++
      2. platelets +
      3. alk phos +
      4. Hb -
   7. prognosis

      Annotations:

      • 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
   1. dull throbbing headache, assoc w/facial pain over sinuses
   2. worse on bending forward
   3. ALWAYS NASAL SYMPS eg congest or discharge
   4. if ?8w req CT to confirm diag
8. other vasc cuases
   1. intracerebellar hemorrahge

      Annotations:

      • -abrupt onset headache -N and v -dizzy -ataxia +/- GCS
   2. Spontaneous intracerebral or intraventricular hemorrhage

      Annotations:

      • onset min -&gt; hrs. accompany by focal neuro deficit +/- GCS
   3. Cerebral venous thrombosis

      Annotations:

      • headache common but variable 'thunderclap' throbbing 'band-like' (may have assoc feats- eg N and V, seizures, CN palsies, hemiparesis, ataxia, decreased GCS)
   4. Vertebrobasilar dissection

      Annotations:

      • maybe acute occipital/post neck pain with brainstem signs/symps
9. other
   1. cluster
      1. severe, unilat
      2. retroorbital
      3. 5+ episodes
         1. agitation, restlessness, ipsilat lacrimation, conjunctival injection, rhinorrhea, facial sweating
         2. attacks short (15-90min) but frequent (1 per 2 days -> 8 per day)
         3. repeated, ( often same time each day), in clusters (days -> wks) separated by months w/o symps
      4. M: F 5: 1
   2. acute glaucoma
      1. because sudden increase ocular pressure
      2. typical pt
         1. long sighted, middle age/elderly
      3. present
         1. periorbital plain
         2. N + V
         3. blurred vision with halos aroudn lights + conjunctival injection
      4. urgent opthalmology referral mandatory
   3. raised ICP
      1. maybe primary (idiopathic)
         1. espec in overweight young females on oral contracep
      2. or secondary to Space Occupying Lesion
         1. clin signs
            1. focal neuro signs
            2. change in personality
            3. new-onset seizures
            4. headache, wosre in morning, lying flat, coughing or straining
            5. assoc? vomiting (often w/o nausea +/- papilloedema)
   4. other
10. TMJ syndromes
11. drugs
    1. analgesic headache
       1. assoc chronic analgesic use espec opioid eg codeine
       2. usualy bilat
       3. occur prior to next dose of analgesia
    2. vasodilats eg nitrates
    3. rec drugs eg solvents
12. RED FLAG FEATS
    1. new onset headache/change in headache (pt over 50)
    2. focal CNS signs, ataxia, or new cognitive or behavioural disturbance
    3. persistent visual disturb
    4. headache that changes w/posture or wakes pt up
    5. headache brough on by physical exertion
    6. papilledema
    7. new onset headache in pt w/known HIV or active malig