PD- neuro pathology - HEADACHES

differential diagnosis for headaches

• migraines

• sinusitis

• trigeminal neuralgia

• subarachnoid hemorrhage

• meningitis

• mass

• stress

• dehydration

what is a primary HA?

no underlying pathology

what is secondary HA?

arise from underlying structural, systemic, infectious causes, trauma

when to consider secondary HA causes?

• systemic symptoms (fever/chills)

• >50 y/o

• sudden onset

• change in HA pattern

• positional

• caused by valsava or exertion

• focal neurlogic deficits

• papilledema

what history considerations for HA?

• onset: sudden or graduation

• location

• duration (acute or chronic)

• alleviating/aggravating

• associated symptoms: vision changes, weakness, loss sensation

• different than previous HA?

• “worst HA of your life”

PE for headache complaints

• vitals: temp, HR, BP, evidence of infection/pain/sepsis

• HEENT: fundoscopic exam and additional considerations

• cardio: murmurs/rubs/gallops

• pulm: adventitious breath sounds

• neuro: depends on symptoms, general appearance, presence of red flags, mental status

fundoscopic examination

visualize the optic disc - you may see papilledema, swelling of optic disc/nerve, and is assoc. with inc intracranial pressure (the middle part is more swollen)

what are migraines?

• unilateral (can spread to bilateral)

• throbbing or pulsating

• rapid onset

• can last a few hours-day

• recurrent

• can be accompanied by photophobia, phonophobia

• may have an aura (without aura is most common, with is considered “classic migraine”)

• can have N/V

• aggravated by activity

who is at risk for migraines?

• present in adolescents or early adults

• women > men

• family history

• recurrent, may have specific triggers ie stress, lack of sleep, menstruation, missed meals, certain foods

what are s/sx of migraines?

• visual disturbances (scotomas, scintillating scotomas, photopsia)

• can have focal neuro disturbances that can cause aphasia, dysarthria, paresthesia, weakness

PE for migraines

• no neuro abnormalities

• pt may exhibit photophobia

• if focal neuro sx noted, may see on exam

migraine work-up

• clinical diagnosis

• imaging not needed unless unexplained abnormal findings

what is a tension HA?

• bilateral

• back or front of the head (hat band distribution)

• gradual onset

• episodic or chronic

• not aggravated by activity

• worsened with stress, fatigue

• no other symptoms associated with this, incl. N/V

RFs in tension HA?

• more common in adults

• mental stress

• poor posture

• eye strain

tension HA PE

• symptoms w/o accompanying features such as N/V, photophobia, phonophobia, throbbing, and aggravation of movement

• may be able to cause increased pain w/ palpation of the head, neck, or shoulders

tension HA work up

diagnosis of exclusion

• imaging is not helpful unless atypical/suspicious for secondary cause of HA

what is cluster HA?

• unilateral around eye or temple

• sudden onset

• lasts several hours

• typically associated with watery eye, running nose on same side as HA

• episodic and clustered (one attack every other day or multiple attacks per day)

cluster headache RF and notes

• middle aged men most common, men > women

• episodes happen at night and wake pts up from sleep

• may be triggered by stress, alcohol, various foods

cluster HA PE

• if eval done without current sx, exam is unremarkable

• history: short-lasting attack of head pain associated with lateralized cranial autonomic symptoms (ie lacrimation, conjunctival injection, aural fullness, or nasal congestion)

• if eval with current sx: can see unilateral tearing of eye, conjunctival erythema, and unilateral congestion

cluster HA work-up

• clinical diagnosis

• if first episode, may obtian MRI/CT brain to rule out a mass

pt w/ lateralized (this means unilateral) throbbing HA. the pt is complaining of N/V, and photophobia. what type of HA is most likely?

migraine HA

pt complains of regular HA, notes it starts mid-day and goes into evening. worse during the week, no vision changes, weakness, N/V, no aggravating factors. S1/S2 no murmurs, lungs are clear. no aphasia/cranial nerve abnormality. what is this?

tension HA

(supported by history and lack of findings)

what are rebound HA?

• occurs after withdrawal of medications (tylenol, NSAIDS, etc)

• daily headaches

• symptoms consistent with prior HA

• resembles chronic tension-type HA, bilateral/pressing feeling

rebound HA PE

• hx most telling with persistent use of meds

• no abnormalities are noted

what is sinusitis?

• located frontal/maxillary regions

• associated with cold symptoms (fever, nasal congestion, sore throat, ear pain)

• age is consideration (frontal sinuses do not develop until 9-10 y/o)

sinusitis PE

• erythema and hypertrophy of nasal turbinate

• tenderness to percussion/palpation of sinuses

• ± postnasal drip

• ± cervical lymphadenopathy

work up for sinusitis

• clinical diagnosis

• if recurrent symptoms or not improving with treatment, CT of maxillofacial is beneficial to see if structural abnormality

what is trigeminal neuralgia?

AKA “tic douloreux”

• brief episodes of unilateral, stabbing, shock-like facial pain caused by compression of trigeminal nerve

• women > men

• more common middle age or later

• pain can be exacerbated by chewing, light touch, movement

which location is most common for trigeminal neuralgia?

maxillary and mandibular → symptoms on cheek or jaw (forehead no common)

trigeminal neuralgia PE

• possible loss of sensation of face

• corneal reflex may be absent/diminished

• paralysis of muscles of mastication and deviation of jaw to weak side may occu4r

• may have heightened sensation with light touch to affected area (extra sensitive)

work up for trigeminal neuralgia

• clinical diagnosis with hx and physical exam supporting

• if bilateral symptoms (brain issues), MRI of brain w and w/o contrast to rule out MS/masses

• if unilateral, usually d/t peripheral nerve issues

what is pseudotumor cerebri?

idiopathic intracranial HTN w/ increased pressure noted during lumbar puncture (LP)

• no identifiable cause noted on imaging

• most common in women of childbearing age

pseudotumor cerebri findings

HA - lateralized, throbbing, worse with straining or position changes

• pain behind eye, worse with eye movement

• N/V common

• visual change

• on exam: papilledema usually bilaterally and symmetric = HALLMARK!!!

what is the hallmark of pseudotumor cerebri?

papilledema

work-up for pseudotumor cerebri

• first episode: CT of brain to rule out mass

• LP: shows increased CSF pressure (>250 mmH2O) with no other abnormal findings

what is meningitis?

• generalized HA

• rapid onset

• often has fever, chills

• stiff neck or nuchal rigidity

• N/V common

• back, abdominal, extremity pain

• confusion, delirium, seizures, coma if severe

meningitis PE

• nuchal and back rigidity (positive = inability to flex neck due to rigidity, negative = pain when flexion but ROM intact)

• with meningococcal meningitis: petechial rash appearing all over the body (incl. mucous membranes, LE, and at pressure points)

what are special tests for meningeal irritation?

• kernig’s sign: positive = pain in hamstrings upon extension of knee with hip at 90-degree flexion

• brudzinski’s sign: positive = flexion of the knee in response to flexion of neck

high sensitivity means what?

high negative predictive value (sensitivity helps RULE OUT diseases if negative0

what does high specificity mean?

positive predictive value, helps RULE IN disease if positive

kernig and brudzinski signs are what in terms of sensitive/specific?

highly sensitive AND specific

what if you have a pt that is neg for kernig and brudzinski?

you cannot rule out meningitis yet, so you have to do more work up

what is the meningitis work-up?

• LP (lumbar puncture): best initial test and provides definitive diagnosis

• CT of brain if mass is suspected (done if papilledema, seizures, focal neuro findings, or > 60)

what is subarachnoid hemorrhage?

• very severe

• generalized HA

• “thunderclap” headache

• worst headache of life

• 75% of nontraumatic subarachnoid hemorrhage are related to ruptured cerebral aneurysm

RFs for subarachnoid hemorrhage risk factors?

• HTN

• smoking

• excessive alc consumption

• polycystic kidney dz

• family history of subarachnoid hemorrhage

• coarctation of aorta

• marfan’s syndrome

• ehler’s danlos syndrome type IV

• a-antriypsin def

PE findings of subarachnoid hemorrhage?

• HA assoc. with consciousness, sz, diplopia, neuro signs, nuchal rigidity

• N/V, altered mental status, photophobia, or sx suggestive of ischemia stroke

• some develop sx while engaged in activities that cause inc BP, such as exercise, sex, defecation

• may have meningeal irritation with positive kernig or brudzinski test

what is subarachnoid hemorrhage work-up?

• CT of brain without contrast (to look for bleed or inc blood)

• if CT (with or w/o contrast) is negative (no hemorrhage) and no papilledema, do LP (looking for xanthchromia)

what is xanthrochromia?

change in color of CSF d/t RBC in the CSF

what is giant cell arteritis?

AKA temporal arteritis

• located over temporal artery

• throbbing, steady pain

• scalp pain

• jaw claudication (gets tired, lack of blood)

• visual symptoms (amaurosis fugax or diplopia)

what is amaurosis fugax?

curtain-like loss of vision

RF for giant cell arteritis

• age > 50 (mean is 79)

• women > men

• assoc. with polymyalgia rheumatica

what is your PE for giant cell arteritis?

• superficial artery may be tender/nodular/enlarged/pulseless

• possible blindness or asymmetric pulses

• murmurs or bruits

what is work-up for giant cell arteritis?

• ESR and CRP: elevated

• temporal artery biopsy (definitive diagnosis)

tx for giant cell arteritis

high dose steroids (prednisone), do before you do the biopsy/do it ASAP

sx for brain tumor?

• variable location

• worse on waking/makes them wake up (headaches, also if they cause them to wake up)

• very concerning if new/worsening headache in middle/later life

• progressive worsening

• sx like szs, vomiting, PAPILLEDEMA/intracranial pressure

red flags to consider for HA

SNOOP

• systemic symptoms, conditions, illness (does this person have underlying issues that make them more likely to have a life threatening issue?)

• neurologic s/sx (most HAs don’t have neuro s/sx unless serious)

• onset (sudden, trauma-related)

• older age of onset (age >= 50 y)

• pattern of change in previous HA condition

what is workup for mass in brian?

• CT or MRI of brain WITH contrast

• brain biopsy

39 y/o pt has intermittent severe HA on R side of head (unilateral), seconds to several mins (bursts), no vision changes. severe tenderness with palpation of right side of pt. hearing in intact, symmetric movement of face bilaterally. what do you think?

trigeminal neuralgia

intermittent shock-like pain should make you think TN

• Sudden, electric/shooting pain

• Lasts seconds to minutes

• Unilateral

• Can be triggered by touch, chewing, brushing

• Normal neuro exam between attack

25 y/o has sudden onset of severe hA, neck stiffness, fever, photophobia, intense, persistent, is not comfortable, N/V. what do you think?

maybe meningitis or subarachnoid hemorrhage (sudden onset + severe)

if this case had nuchal rigidity and pos brudzinski, it would not narrow down differential → imaging/labs

if they are normal or you have elevated WBC, maybe LP

72 y/o SUDDEN onset of severe HA, worsened in morning, intense and persistent. no fever/chills. thoughts?

• maybe subarachnoid hemorrhage, mass, giant cell arteritis

• if you find reproducible pain to left temple area → giant cell arteritis (temporal arteritis)

signs of a brain tumor

• Morning headaches → ↑ ICP worse when supine overnight

• Daily, progressive headaches

• Papilledema → objective sign of ↑ ICP

• Bilateral, pressing pain → common with ICP-related headache

• Temporary relief with analgesics doesn’t exclude tumor