CM II Neuro 8 - Headache

what is a tension headache?

recurrent HA 30 mins-7 days w/o N/V and with no neuro deficits, with at least 2 of these characteristics

• bilateral

• pressing/tightening (non-throbbing)

• mild/mod intensity

• not aggravated by routine physical activity (non-exertional!)

what pop is more common to get tension HA?

women, 2nd decade of life (teens)

prevalence DEC w/ inc age

what causes tension HA?

contraction of neck and scalp muscles caused by

1. stress, depression, anxiety

2. glare and eye strain

3. fatigue

4. hunger

5. noise

6. alc, smoking, caffeine use

7. sinus infection, nasal congestion, colds, flu

how do you treat tension HA?

acute general: non-narcotic analgesics

relaxation training, PT, tricyclic antidepressants orBB (for prophylaxis)

no narcotics!! limit NSAIDs. consider indomethacin

when does exertional HAs arise?

during or after physical exercise

what is primary exertional HA?

• usually benign and more common

• lasts minute-days

• unilateral or bilateral → throbbing in nature → mod to severe

• associated with nausea (NOT vomiting)

what is secondary exertional HA?

symptomatic of intracranial disease

• lasts 1-30 days

• bilateral → sudden/explosive in nature → severe

• N/V/diplopia

what is warranted in all cases of exertional HA?

neuroimaging studies to make sure there’s no intracranial lesion

what pop is most common in coital cephalgia?

male

what is coital cephalgia?

headache associated with sexual activity (HASA)

what is type 1 coital cephalgia?

bilateral (occipital)

pressure-like HA that gradually increases with mounting sexual excitement

what is type 2 coital cephalgia?

sudden, profound throbbing quality

appears just prior to or at moment or orgasm

similar in character to headache of subarachnoid hemorrhage

what is type 3 coital cephalgia?

holo-cephalic, positional and has features of low CSF pressure headache (feels better when you lay down, worse sitting up)

what is a cluster HA?

Severe or very severe unilateral orbital, supraorbital and/or temporal pain

• lasts 15-180 mins

• freq of every other day - 8/day during attack clusters

what are the s/sx of cluster HAs?

ipsilateral autonomic s/sx

1. conjunctival injection (redness)/lacrimation

2. nasal congestion/rhinorrhea

3. eyelid edema

4. forehead and facial sweating/swelling (opposite of horner syndrome!)

5. miosis/ptosis

6. restless/agitation

not attributable to another disorder

what is thought to be the cause of cluster HAs?

activation of posterior hypothalamic gray matter → trigeminal nerve parasympathetic activation → release of histamine/serotonin (which is what causes the s/sx)

what are triggers of cluster HAs?

1. smoking, alc, foods

2. glare

3. stress

what side to the HA will the symptoms of cluster HA be seen?

the same side (ipsilateral)

when you experience sudden pain, what happens to your eye?

it will dilate (fight or flight)

best tx for cluster HA?

• avoid triggers

• prophylactic: verapamil

• abortive: inhalation of 100% oxygen

what is chronic paroxysmal hemicrania?

“indomethacin-responsive headaches”

similar to cluster HA but less common and has a few difference in presentation

what is the presentation of chronic paroxysmal hemicrania?

1. occurs more often to cluster but shorter

2. women > m

3. good response to NSAIDs

4. provoked by neck movement

5. extraocular

6. conjunctival injection is less frequent

comparing cluster HA and paroxysmal hemicrania

ocular vs. extra-ocular

longer vs. shorter

less often freq vs. more often

poor vs. good response to NSAIDS

no to provoked by neck movement vs. yes

men vs. women

what is migraine HA prevalence?

• women 25-45

• familial predisposition

what is migraine HA?

vascular HA, caused by blood vessel abnormalities → open and constrict blood vessels

what is a prodrome definition?

affective/vegetative sx appears 24-48 hrs prior to onset of headache

what are migraine prodromes examples?

1. euphoria

2. depression

3. irritability

4. food cravings (vegetable)

5. yawning

if a patient yawns a lot, they’re not sleepy, maybe think they’re in?

opiate withdrawal

what is a migraine aura?

classic migraine

focal neuro sx preceding HA by no more than an hour

what might you see in migraine with aura?

1. 1 of following: fully reversible visual sx, fully reversible sensory sx, or fully reversible dysphasia (if not reversible → stroke)

2. 2 of following: unilateral/homonymous visual sx, 1 aura sx in 5 mins, different aura sx over 5+ mins, each symptom lasts 5 mins but not more than 60

examples of fully reversible visual sx in migraine w/ aura

+s: scotoma, flickering, spots, lines

OR

-: visual loss

examples of fully reversible sensory sx in migraine w/ aura

+: paraesthesia

and/or

-: numbness

what is the most common type of aura?

cintillating scotomata (visual)

can also be sensory/verbal/motor

what are signs of scintillating scotomata?

homonymous visual sx or unilateral sensory symptoms

develops over 5+ mins

sx last for 5-60 mins

what causes a scintillating scotomata?

regional reduction in blood flow (“spreading cortical depression”)

what is a migraine without an aura?

common migraine

bilateral, maybe pulsating, mod-severe pain, aggravated by physical activity (2/4 needed)

during HA at least 1 of the following**: N/V, photophobia (bothered by light, and phonophobia (sound)

NO motor weakness

what is an ocular migraine (retinal migraines)?

• pts get severe visual sx but NO HA

• unilateral

• 10-60 mins

what is amaurosis fujax?

temporary loss of vision

what are migraine triggers?

Emotional stress, OCP, hunger, weather, sleep disturbances, odors, neck pain, lights, alcohol, smoking, sleeping late, heat, tyramine-containing foods,  exercise, sexual activity

what drugs can you use to tx migraines acutely?

• simple analgesics (esp ketorolac (toradol))

• triptans or ditans

• dihydroergotamine or opioid

what are causes of secondary HA?

• head trauma (post-traumatic HA like concussion)

• vascular disorder (arteritis, subarachnoid hemorrhage, etc)

• cranial neuralgias or nerve dmg (trigeminal neuralgia or sphenopalatine ganglioneuralgia aka brain freeze)

• metabolic disorders (ie hypoxia or hypoglycemia)

• craniofacial pain

• substance use/withdrawal

• non-intracranial infection (UTI)

• nonvascular intracranial disorder (ie intracranial infection, low CSF pressure, pseudotumor cerebri)

what does temporal arteritis look like?

• tender or palpable temporal artery

• jaw claudication, low grade fever, fatigue, weight loss

• associated polymyalgia rheumatica

AKA giant cell arteritis

what labs would you see in temporal arteritis?

ESR > 50 mm/h, often > 100 mm/h (d/t increase of fibrinogen which makes RBCs sticky)

how do you make dx of temporal arteritis?

biopsy (multinucleated giant cells)

what is a risk you’ll have if you do not treat temporal arteritis?

blindness

what is the tx for temporal arteritis?

high dose steroids

what is granulomatous mean?

collection of macrophages

caseating means what?

there has been necrosis → liquify → “cheesy”

what is cavernous sinus thrombosis?

rare/life-threatening blood clot forms in cavernous sinuses

(can cause secondary HA)

what is cavernous sinus thrombosis sx?

• severe headache (periorbital + swelling)

• eye pain

• facial numbness

• fever

what are causes of cavernous sinus thrombosis?

• infection/trauma to face

• thrombophilia disorders

• erythrocytosis or thrombocytosis

• pimple popping

what does right CN VI palsy look like?

when the right eye cannot abduct (look to the right), BUT both eyes can move to the left because right CN VI is not needed

CN VI only is abducting, NOT adduct

what is chiari malformation?

aka arnold-chiari syndrome

• deficits in skull/spinal cord/cerebellum as a result of genes or lack of folate

• cerebellum is pushed down into and extends below the foramen magnum because the skull is smaller than normal

• → blocks CSF

what chiari I malformation?

most common

sx start adolescence or adulthood

cerebellar tonsils descended 5 mm into upper spinal canal (if <5 mm = cerebellar ectopia)

what is chiari II malformation?

cause problems in infancy/childhood

brainstem goes partially through foramen magnum

what is chiari II malformationa ssociated with?

associated with spina bifida/hydrocephalus

what does chiari III malformation occur w/?

occurs with cervical encephalocele

what is pseudotumor cerebri?

known as idiopathic or “benign” intracranial hypertension (IIH)

what would you see in labs for pseudotumor cerebri?

lumbar punction opening pressure is elevated (>25 cm H2O)

what are physical findings of pseudotumor cerebri?

• papilledema

• visual field loss

• 6th nerve palsy

what can cause 6th nerve palsy?

effect of elevated intracranial pressure on the 6th nerve (long course through the cranium before exiting the skull)

what does papilledema risk?

permanent vision loss

what are RF of pseudotumor cerebri?

• obese

• women

• childbearing age (same list of cholecystitis)

• certain meds (hypervitaminosis A/D, retinoids, hormonal contraceptives, growth hormone, tetracyclines)

what is the tx for pseudotumor cerebri?

• no evidence-based recs

• stop any offending meds

• weight loss

• acetazolamide to reduce CSF production ± furosemide

• palliative serial lumbar puncture

• if no symptoms → monitored w/o tx

what are headache red flags?

• after age 50 (mass lesion esp if papilledema) or temporal arteritis (esp jaw caudication)

• sudden onset/”worst headache ever”: Subarachnoid hemorrhage (SAH), AVM, bleed into mass lesion

• HA increasing in frequency and severity

• new onset HA in a pt with risk factors for HIV/cancer

• sx of systemic illness (fever, stiff neck, rash)

• papilledema

• focal neuro signs

• s/p (status post) head injury

if you have a pt with new onset HA in a pt with risk factors for HIV/cancer, what should yo urule out?

(r/o meningitis [chronic/carcinomatous], brain abscess [including toxoplasmosis], and brain metastasis)

if you have a HA in a pt with signs of systemic illness, what should you rule out?

• meningitis

• encephalitis

• lyme disease

• systemic infection

• collagen vascular (Rheumatologic) disease

if you have a pt with a HA + papillaedema, what should you suspect?

mass lesions, pseudotumor cerebri, meningitis → neuroimaging, LP

what do you do if your pt with a HA has focal neuro signs (other than aura)?

suspect mass lesion, CVA, AVM (arteriovenous malformation), collagen vascular disease → neuro imaging, collagen vascular (rheum) workup

if your pt with a HA has a s/p head injury, what should you rule out?

IC hemorrhage, subdural hematoma, epidural hematoma, post-traumatic HA → neuroimaging of brain, skull, and cervical spine