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Headaches at a Glance - Usman Ahmed

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Headaches at a Glance - Usman Ahmed

  1. 1. P a g e | 1 Introduction Have you ever felt that studying about headaches has actually ended up giving you a headache? Well luckily you’re not alone. Trying to remember the different headaches, how they present and how they are treated is particularly difficult. This guide intends to help you briefly understand the common cause of headaches. Headaches are a commonly assessed area on the Applied Medical Knowledge (AMK) exam and over the past few years, usually one or two questions are related to headaches in each exam. The guide has been prepared especially as a revision tool for Peninsula Medical School Students who sit the dreaded AMK exam. In order to successfully tackle the questions in the AMK, students should have a good all round knowledge about the patient’s presenting symptoms. Therefore this guide helps you to produce a differential diagnosis from the patient’s presenting complaint. As this is a brief guide it is highly encouraged that you read about these topics in greater depth, to allow a greater understanding and use this as a quick reference. Along with the AMKs this booklet may be used for preparing for placements, especially at the GP or neurology wards
  2. 2. P a g e | 2 Gross Anatomy Figure 1 - Meninges of the CNS Epidural Space – Useful in anaesthetics, also epidural haematoma may develop. Dura Matter – Outermost of the 3 layers of the Meninges, subdural haematoma occurs when bridging veins damaged! Subdural Space – artificial space between the Dura and Arachnoid mater Arachnoid Matter – Second Meninge covering the spinal cord Pia Matter – Delicate innermost of the FRONTAL LOBE – The front of each cerebral hemisphere, contains most of the dopamine-sensitive neurons. Think of personality change, e.g. Frontal lobe dementia! PARIETAL LOBE – Integrates sensory information from different modalities. Determines spatial sense and navigation. Includes somatosensory cortex. TEMPORAL LOBE – This is involved in auditory perception, home to primary auditory cortex. Includes Wernickes and
  3. 3. P a g e | 3 Figure 2 - Brain Lobes History QUESTIONS TO ASK You should ask specifically about the symptoms of the headache - • Is it Acute/Chronic? • What was the speed of onset? • SOCRATES o S - SITE o O - ONSET o C - CHARACTER o R - RADIATION o A - ASSOCIATIONS o T - TIME COURSE o E - EXACERBATING/RELIEVING FACTORS o S - SEVERITY (SCALE 1-10) NOTES
  4. 4. P a g e | 4 Subarachnoid Haemorrhage WHAT IS THIS? This is a spontaneous bleed into the subarachnoid space and is catastrophic Incidence – 8/100,000 CLINICAL FEATURES ‘First and Worst’ Headache Occipital Headache Vomiting, seizures and coma. RISK FACTORS Ruptured saccular aneurysm (>80%) Atriovenous malformation (15%) No cause found (<15%) RFs - Smoking, alcohol misuse, increased BP, bleeding disorder, INVESTIGATIONS CT Scanners detect >90% of bleeds within first 48 hours If CT-ve do a lumbar puncture. CSF would be uniformly bloody and then xanthochromic after a MANAGEMENT Neurosurgical Help required, if confirmed patients require a craniotomy, followed by clipping or coiling of the aneurysm Also continue observations on patients – BP, pupils, coma level
  5. 5. P a g e | 5 Meningitis EXTRA NOTES WHAT IS THIS? Inflammation of the pia and arachnoid membranes, caused by bacteria, viruses, fungi or other organisms 90% of all cases of meningitis occur within the first five CLINICAL FEATURES Headache, leg pains, cold hands and feet initially Later – meningism (neck stiffness and photophobia) Kernigns sign, conscious level decreases CAUSES Meningococcus, Pneumococcus, Haemophilus Influezae, Listeria Monocytogenes INVESTIGATIONS Bloods – FBC UnEs, Blood cultures Lumbar puncture Pyogenic CSF – Turbid CSF, with a low glucose and high protein
  6. 6. P a g e | 6 Migraine MANAGEMENT Empirical Treatment – Cefotaxime (<55yrs) Cefotaxime and Ampicillin (>55yrs) Viral Encephalitis - Aciclovir EXTRA NOTES WHAT IS THIS? A debilitating condition characterised by moderate to severe headaches and CLINICAL FEATURES Visual or other aura, lasting approx 15-30 minutes Aura – visual – chaotic, cascading, distorting, melting and jumbling of lines, dots or zigzags or scotoma. Followed by usually 1hour of unilateral/throbbing headache Nausea and vomiting. Other stimuli RISK FACTORS CH- cheese O – oral contraceptives C - caffeine OL - alcohol A - anxiety DIAGNOSTIC CRITERIA >5 headaches lasting 4-72 hours with either nausea or vomiting, with photo/phonophobia, with either: unilateral or pulsating headache, which interferes
  7. 7. P a g e | 7 Cluster Headaches MANAGEMENT 1 st Line – NSAIDs (aspirin, ketoprofen) 2 nd Line – Triptans – e.g. Sumatriptan (Useful in first 8 hours) EXTRA NOTES WHAT IS THIS? A type of headache which may be caused by superficial temporal artery, with smooth muscle hyperactivity to 5HT CLINICAL FEATURES Rapid onset of severe pain around one eye, may become watery and bloodshot, with lid selling, lacrimation, facial flushing, rhinorrhoea, miosis and ptosis. Pain is strictly unilateral and always affects the same side Lasts 15-160 mins, occurs once or twice a day, often nocturnal DIAGNOSTIC CRITERIA The diagnosis is made from the history. The International Headache Society (IHS) guidelines suggest the following diagnostic criteria: At least 5 attacks fulfilling the following: Severe, or very severe, unilateral orbital, supraorbital and/or temporal pain lasting 15 to 180 minutes if untreated Headache accompanied by at least one of: ipsilateral conjunctival injection and/or INVESTIGATIONS History and neurological examination only are required to make the diagnosis usually. As with any primary headache, some patients may need imaging, and the red flags of headache indicating the need to search for a secondary cause are: Change in pattern of headache New headache at age over 50 Onset of seizures Headache with systemic illness
  8. 8. P a g e | 8 Trigeminal Neuralgia MANAGEMENT Acute Attack - 100% oxygen for 15 minutes, Followed by sumatriptan Preventatives – 1 st Line is Verapamil (Calcium channel blocker) or Topiramate (anti-convulsant) EXTRA NOTES WHAT IS THIS? Trigeminal neuralgia can be described as a chronic, debilitating condition resulting in intense and extreme episodes of pain in the face. The episodes are sporadic and sudden and CAUSES Compression: blood vessels may press on the trigeminal nerve as it leaves the brain stem at its cerebellopontine nerve root. Degeneration: some have postulated it to be part of the ageing process as with increasing age the brain atrophies leading to redundant arterial loops which can cause compression. DIAGNOSTIC CRITERIA • Paroxysmal attacks of pain lasting a second to two minutes and affecting one or more divisions of trigeminal nerve (typically maxillary or mandibular branches) • Pain has at least one of the following characteristics: intense, sharp, superficial, stabbing, precipitated by trigger areas/factors • Attacks are similar in individual patients INVESTIGATIONS The diagnosis is clinical and it can be difficult to make. No investigations are required initially unless there is uncertainty regarding the diagnosis. Patients who are referred on for specialist review will usually have a brain MRI - this is to document the presence
  9. 9. P a g e | 9 Giant Cell Arteritis MANAGEMENT Carbmazepine – 100mg/12hr, Lamotrigine, Phenytoin OR Gabapentin EXTRA NOTES WHAT IS THIS? An inflammatory disease of blood vessels, a form of vasculitis. The giant cell is the cell involved in the pathogenesis The aetiology is unknown, but the pathogenesis involves a chronic inflammatory process, CLINICAL FEATURES Headache – temporal area of forehead Temporal artery and scalp tenderness (e.g. combing hair) Jaw claudication RISK FACTORS Increased prevalence of PMR and GCA exists in individuals with a European background, and a decreased incidence and prevalence is noted in African Americans. Most patients with PMR or GCA present after their sixth decade, and peak incidence occurs in patients aged 60-80 INVESTIGATIONS ESR Elevated Normocytic, normochromic anaemia and thrombocytopenia are common Temporal artery biopsy – Gold
  10. 10. P a g e | 10 Increased Intracranial Pressure MANAGEMENT For people with visual symptoms, give oral prednisolone 60 mg and arrange an urgent (same-day) assessment by an ophthalmologist Start aspirin 75 mg daily unless there are contra-indications, e.g. active peptic ulceration EXTRA NOTES WHAT IS THIS? Raised intracranial pressure (ICP) can arise as a consequence of intracranial mass lesions, disorders of CSF circulation and more diffuse intracranial pathological processes. Its development may be acute or chronic. The combination CLINICAL FEATURES Headache - worse on coughing or moving head and associated with altered mental state. Early changes in mental state include lethargy, irritability, slow decision making and abnormal social behaviour. Untreated, can deteriorate to stupor, coma and death. Vomiting (in early stages without nausea), which can progress to projectile with rising ICP. Pupil changes including irregularity or dilatation in one eye.
  11. 11. P a g e | 11 Encephalitis CAUSES Localised mass lesions: Neoplasms, Abscess Focal oedema secondary to trauma, infarction, tumour Obstructive hydrocephalus, Diffuse brain oedema or swelling: INVESTIGATIONS CT/MRI to determine underlying lesion. Check and monitor blood glucose, renal function, electrolytes and osmolality. MANAGEMENT – Depends on cause, anticonvulsants to control ICP, CSF drainage if required, elevate head of bed, analgesia and sedation. Mannitol (intravascular osmotic agent) EXTRA NOTES WHAT IS THIS? Encephalitis is inflammation of the brain parenchyma, often caused by viral infections but also by other pathogenic organisms and occasionally by other conditions, e.g. toxins, CLINICAL FEATURES Most patients with viral encephalitis present with the symptoms of meningitis (fever, headache, neck stiffness, vomiting) followed by altered consciousness, convulsions, and sometimes focal neurological signs, signs of raised intracranial pressure, or psychiatric RISK FACTORS HIV Infection, Viral (herpes simplex, EBV, mumps, measles and enteroviruses) Bacterial – TB, mycoplasma, listeria, lyme INVESTIGATIONS CSF FBC and Blood Film CT, MRI Scan
  12. 12. P a g e | 12 Other Headaches to Consider MANAGEMENT Urgent hospital admission, prompt treatment with IV acyclovir IV fluids EXTRA NOTES ACUTE GLAUCOMA - An opthamology condition, usually acute closed angle glaucoma. Symptoms with this include – red eye, sees haloes, fixed and dilated pupil! Decreased acuity. Diagnosis is made on history and examination. Refer immediately – Intravenous Acetazolamide. Other topical agents given e.g. ACUTE SINUSITIS – This is an inflammation of membranous lining of one or more of the sinuses. This is defined as a bacterial or viral infection of the sinuses lasting fewer than four weeks and resolving completely. It is most commonly caused by Streptococcus pneumonia, Haemophilus Influenzae and Moraxella Catarrhalis. Acute sinusitis is diagnosed if there is facial discomfort, nasal obstruction and decreased or absent sense of smell. Management –
  13. 13. P a g e | 13 Test Yourself TENSION HEADACHE - Typically described as pressure or tightness, like a vice or tight band around the head. There is often a relationship to the neck, with pain into or from the neck. These headaches can be disabling for a few hours but lacks the specific features and associated symptoms of migraine. Management – Ibuprofen, Diclofenac, Naproxen, Paracetamol (if intolerant to MEDICATION OVERUSE HEADACHE - Medication-overuse headache is caused by taking painkillers or triptan drugs too often for tension-type headaches or migraine attacks. It is a common cause of headaches that occur daily, or on most days. Diagnosed by taking and accurate history. Treated by withdrawing the NOTES QUESTION 1) A 50 year old woman attends the AnE department complaining of an acute headache, she describes this as her first and worst headache. She has also been vomiting for the past couple of hours. CT Scan reveals a fresh bleed in the anterior circulation. What is the most likely diagnosis?  A – Migraine  B – Extradural Haemorrhage  C – Meningioma  D – Subarachnoid Haemorrhage
  14. 14. P a g e | 14 Test Yourself QUESTION 2) You review a 64 year old lady at a GP practice. She complains of pain over her right forehead, which is worse when she combs her hair. She also has some pain on chewing. What would be your initial management?  A – Advise some simple analgesia  B – Arrange an urgent CT scan of the brain  C – Commence high dose prednisolone (steroids)  D – Perform a lumbar puncture QUESTION 3) A 46 year old male bank manager comes to you complaining of a right sided throbbing headache, with photophobia. He has had these symptoms at least once a week for the past month. What is the most likely diagnosis?  A – Analgesic overuse headache  B – Meningitis  C – Migraine  D – Increased intracranial pressure headache QUESTION 4) A 2 year old boy attends the ED with his mother, who says her son has been irritable all morning, crying and developed a rash all over. You examine the child who is very irritable and has a temperature. You notice the rash is non-blanching and he does not like you assessing his neck. What is the most likely diagnosis?  A –Cluster headache  B – Subdural Haemorrhage  C – A fall resulting in an extradural haemorrhage  D – Measles
  15. 15. P a g e | 15 Extra Resources The following sources may be used to gather more information on the content discussed within this booklet. 1 – Patient.co.uk – (The section on headaches.) http://www.patient.co.uk 2 – GP Notebook.com – (Look up each condition separately.) http://www.gpnotebook.com QUESTION 5) A 57 year old lady with a longstanding history of epilepsy has been brought in by her daughter, she is suffering with fluctuation in her conscious level and seems to have some weakness in the right hand side of her body. This has come on suddenly over the past few hours. What is the most likely diagnosis?  A – Extradural Haemorrhage  B – Subdural Haemorrhage  C – Cluster headache  D – Medication overuse headache ANSWERS – 1-D 2-C 3-C 4-E 5-B
  16. 16. P a g e | 16 3 – Tortora GJ, Derrickson BH. Principles of Anatomy and Physiology. 11 th ed. John Wiley and Sons; 2005 4 – Longmore M, Wilkinson I, Turmezei T, Kay Cheung C. Oxford Handbook of Clinical Medicine. 7 th ed. Oxford: Oxford University Press; 2007 5 – International Headache Society - http://www.ihs-headache.org/ Please Note: Images are sourced from Wikipedia.com which allows permission specifically granted for this learning resource. Special Thanks to – All of the participants including medical students, Neurology Consultants and the SSU providers for their input and support in producing this booklet.

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