What are important red flag signs associated with headaches and what could they indicate?
Fever, photophobia + neck stiffness= meningitis
Sudden severe onset= haemorrhage/stroke
Dizziness= stroke
Visual disturbances= glaucoma
Sudden occipital headache= subarachnoid
Exacerbated by coughing, straining, standing, lying or bending over = RICP
Vomiting= carbon monoxide poisoning or RICP
History of trauma= intracranial haemorrhage
Pregnancy= pre-clampsia
What examination is important to carry out when raised ICP suspected?
Fundoscopy
-can identify papilloedema= optic disk swelling which occurs secondary to raised ICP
What are the main different types of headache?
Tension Secondary Sinusitis Analgesic Hormonal Association with trigeminal neuralgia
What are the key features of a tension headache?
What causes tension headaches?
How can they be treated?
- Ache in band-like pattern due to association with frontalis, temporalis and occipitalis muscles
- can be present all the time but doesn’t stop ADL
Causes: Stress Depression Alcohol Skipping meals Dehydration Medication overuse or withdrawl Cervicogenic i.e. cervical osteoporosis spondylsis Straining eyes i.e. especially if might need glasses but doesn’t currently use
TX:
- analgesia
- relaxation
- hot towels
- physio if cervical osteoporosis
- TCA= nortriptyline
- SSRI
How are secondary headaches different to tension headaches?
Associate with clear cause:
- infection
- obstructive sleep apnoea
- head injury
- carbon monoxide poisoning
Why are headaches associated with sinusitis? What feature can help to diagnose these form of headaches?
Inflammation in ethmoidal, maxillary, frontal and sphenoidal cause headache and facial pain
Type of headache indicated if there is tenderness over the affected sinuses
Why do hormonal headaches occur? When are they most likely to happen?
Low oestrogen produces generic, non-specific tension-like headache
Timing:
- 2 days before and 3 days of menstrual period
- menopause
- pregnancy= worst in first few weeks
What causes trigeminal neuralgia?
How might someone with trigeminal neuralgia present?
What is the recommended treatment?
Demyelination of one branch of trigeminal leads to upregulation of sodium channels meaning there is increased amount of Na+ crossing membrane meaning the Em is at point of depolarising all time
THEREFORE= increased sensitivity of the nerve
PX
- Severe stabbing facial pain which can present as headache
- triggered by something aggrevating trigeminal distribution i.e. cold wind, eating or touch
TX:
- carbamazepine
- oxycarbamazepine
- another AED
- MRI= might be presentation but there might be demyelination further up the pathway
What is a cluster headache? How might someone present?
Severe unilateral headache around the eye which comes in clusters of attacks for few days and then disappears for 1-2 years
Termed suicidal headache due to severity of the pain Unilateral presentation: -red, swollen, watering eye -pupil constriction (miosis ) -eyelid drooping (ptosis) -nasal discharge -face sweating
Why do cluster headaches occur and who is at risk of developing one?
Exact cause unknown but tend to occur in 30-50 yo males who smoke Triggers: -alcohol -strong smells -exercise
How are cluster headaches management acutely and how are recurrences minimised?
Acute:
- triptans
- high flow 100% oxygen for 15-20 mins
Prophylaxis:
- verapamil
- lithium
- prednisolone to break cycle between clusters
What are the different types of primary headaches rating from most severe pain to least?
Trigeminal neuralgia
Trigemial autonomic cephalalgias (TACs)
Migraine
Tension type headache
What are TACs?
What types of headaches fall under this category?
How can these types of headaches be treated?
Trigeminal autonomic cephalalgias
-unilateral (side-locked) headaches with pain in the trigeminal distribution
-associated with autonomic activation on same side as headache
I.e. rhinorritis/miosis/ptosis
-agititation
SUNCT
Paroxysmal hemicrania
Cluster headaches
Hemicrania continuas
TX:
- high flow O2
- fast acting triptan
- prednisolone
- indometacin
- MRI
- prophylaxis to prevent being on long term steroids
What is an important differential for TAC/trigmenial neuralgia? How would a patient present?
Acute closed-angle glaucoma
Px:
- intense eye pain
- N+V
- red eye
- headahce
- tenderness around the eye
- rings around lights
- blurred vision
What are secondary causes of headaches?
Raised intracranial pressure
Thunderclap headache
Vascular problems
Sinusitis
What are the possible causes of raised ICP?
Increased arterial blood pressure
- malignant hypertension
- pre-eclampsia
- hypercapnia i.e. OSA= C02 determines blood flow to brain
Increased CSF pressure
- obstruction to flow
- failure to reabsorb i.e. meningitis
- overproduction
Increased brain pressure
-SOL
Increased venous BP
-venous sinus thrombosis
Meningeal inflammation
What are the red flag signs indicative of raised ICP?
Papilloedema Seizures Focal neurological signs Visual disturbance Headache worse when lying down Pregnancy i.e. hypercoagulable state N+V Hx of vasculitis Diabetes i.e. at risk of skull base osteomyelitits Morning headache or causing to wake up from sleep i.e. indication that ICP is on edge of being raised
What are the causes of a thunderclap headache?
How would someone present?
What investigations need to be done?
Subarachnoid haemorrhage Meningitis Migraine= most common cause Central venous thrombosis Pituitary apoplexy Spontaneous intracranial hypotension Exertional headache Post-coital
Worst headache of life
Reaches maximum within 1-10 mins
Ix:
-CT head
If CT normal:
-lumbar puncture
What would you do it a CT head came back normal in suspected subarachnoid? What are you looking for?
Lumbar puncture
Xanthochromia:
- breakdown product of blood collects in CSF after bleeding into subarachnoid space
- takes 6-12 hrs to accumulate
Bacterial meningitis:
- increased protein
- neutrophilia
- decreased glucose
- cloudy appearance
Viral meninigitis
- not real increase in proteins
- lymphocytosis
- normal glucose
TB meningitis
- increased protein
- lymphocytosis
- decreased glucose
What vascualar problems can cause a headache?
How would patients present?
Carotid artery dissection
- neck/facial pain
- Horners syndrome
Vertebral artery dissection
- neck pain
- sudden onset vertigo/ataxia
Temporal arteritis
- vasculititis
- rare <60
- raised ESR/CRP
- jaw claudication
- general malaise
Why would carotid artery dissection present with Horners syndrome?
Due to sympathetic trunk running along side CA meaning that dissection causes compression of autonomic fibres
How might someone with a medication-overuse headache present?
How are these patients managed?
Headache present at least 15 days a month
Developed or worsened since taking analgesia
I.e. occurs with codeine-based analgesia, paracetamol, aspirin and ibuprofen
Management:
- withdrawal of medication for 3 months
- counselling that will likely get worse before better because need to reset pain threshold
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Stroke40
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UMN + LMN19
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Headaches22
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Migraines11
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Seizures + Epilepsy39
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Myasthenia Gravis0
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Meningitis13
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Subarachnoid Haemorrhage9
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Optic Neuropathy3
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CNIII Palsy5
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Bulbar Palsy1
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Syncope + Collapse11
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Localisation In Clinical Neurology30
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Weakness22
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Multiple Sclerosis16
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Tremors10
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Parkinson’s Disease12
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Encephalitis7
