Headaches and facial pain

hrhodes's version from 2015-10-13 01:25

General Headaches

Question Answer
Red flag headache symptoms Sudden onset, First severe or worst ever, Onset during exertion, incl coughing, Focal neurology or papilloedema, Altered mental status, Toxic appearance, Meningism, Immunosuppression, New onset with age>50, morning headache
What is more common primary or secondary headache?Primary, even in over 50s. (Primary = tension, cluster, migraine)
List the worst type of secondary headaches? SAH, cerebral sinus thrombosis, CNS infection, temporal arteritis, malig HT, cerebral oedema, glaucoma, phaeochromocytoma, preeclampsia, hypoxia <1% have intracranial lesion
List some 'Not-immediately-life-threatening' headaches Substance, or its withdrawal e.g. CO, EtOH, nitrates, MAOI, medication overuse; Trauma or structure of head & neck e.g. sinusitis, TMJ, pseudotumor cerbri (BIH); Low pressure headache – secondary to LP, Psychiatric problems


Question Answer
What is a migraine?Brainstem serotonergic system dysfunction that leads to vascular and trigeminal effects.
What are the two different types of migraine and which society (that you would not want to be a member of) defines them?Common - no aura, Classic - aura. International headache society
Who gets migraines?F>M although reverse in kids. 80% have first one before age 30years. 70-80% FH
List criteria of common migraine5 episodes. last 4 – 72 hours. no other disease. 2 of Unilateral, throbbing, mod-severe, worse on movement; 1 of: photo/phonophobia, nausea, vomiting
List criteria of classic migraine3 episodes. no other disease. 3 of: one or more aura, onset >4mins, aura <60mins. headache within an hour
How can you remember the difference?aura more specific for migraine therefore need less episodes to diagnose. 3 epidoses, 3 of aura related things
How do you manage a patient with migraine?Reassure, dark room, quiet space, institute rx early. Simple: paracetamol, aspirin, codeine, NSAIDs; phenothiazines, tryptans, ergot alkaloids
How do you treat refractory migraine?Titrate propofol - 20mg every 5mins to 120mg
Which phenothiazines and what dose?Metoclopramide – 80% effective, risk of dystonia. Chlopromezine 12.5-25 mg. Side effects: Hypotension, drowsiness; Prochlopromazine: 2.5 mg Akathisia - main prop with both is drowsiness and LOS
What are tryptans?Highly selective 5HT1D,1B agonist. Potent intracranial vasoconstrictor. Injection, tablet, nasal
When are tryptans contraindicatedCAD
What are ergot alkaloids?also potent cerebral vasoconstrictors. Longer acting. Cheaper.
When are ergots contraindicated?CAD, pregnancy
What is an opthalmoplegic migraine?Migraine associated with extraoccular muscle palsy. i.e affects CN III, IV, VI. These people should have a focal neurological event excluded before the diagnosis of opthalmoplegic migraine is mad
Does migraine get better or worse in pregnancy?usually better, therefore if preg woman gets headache or abnormal symptoms/stroke-like think CVT or sinister pathology

Cluster headaches

Question Answer
Cluster headache prevalenceless common 0.4%
Cause?trigeminal nerve dysfunction
Symptoms of a cluster headache?Unilateral, severe, occur in clusters over 6-12 weeks. Ipsilateral autonomic symptoms: eye watering, conjunctival redness, rhinorrhoea, nasal blockage, miosis and ptosis
Who do cluster headaches affect?More common in: men, smokers, age>20y
Treatment and Advice?Stop smoking and not kill yourself. O2, sumatryptan, stop drinking

Temporal arteritis

Question Answer
How useful is location of headache in diagnosis?should be taken into consideration but PPV of location in diagnosis is low
What is temporal arteteritis?Granulomatous inflammation of the intima and media of large BVs. Marked thickening of artery causes ischaemia.
Who does temporal arteritis affect?Women, >50 years, associated with PMR
How does temporal arteritis present?URTI in 10%, Severe headache 65%, Fever>39 in 15%, Swelling tenderness and nodularity of temporal a. Large vessel bruits, Neuropathies 15%, PMR
How many patients who get diagnosed with TA also have PMR?40%!
What investigations do you order when suspecting temporal arteritis?CRP: more accurate than ESR, ESR: >50 often >100. ESR <50 has a NLR of 0.2 of being TA (having a positive biopsy). FBC-leukocytosis, LFT abnormal 30%. MOST IMPORTANTLY - BILATERAL TEMPORAL ARTERY BIOPSY
What is the sensitivity of unilateral TA biopsy?90%, bilateral is slightly higher
If affects other vessels how does it present?Optic - Blindness 20% usually irreversible. Facial - Masseter/temporalis/tongue claudication. Subclavian - Arm claudication. Thoracic aorta - Aneurysmal-rare
Treatment of PMR?1mg/kg prednisolone before results of biopsy are back or methylprednisolone 1g if recent blindness. aspirin may reduced thrombotic events

Cerebral Venous thrombosis

Question Answer
What is CVT?Presence of thrombosis (blood clot) in the dural venous sinuses
Risk factors for CVThyper coagulable states - pregnancy, puerperium, malignancy, OCP/hormonal therapy, recent surgery, head and neck infections. All pregnant women in ED should have CVT considered.
Symptoms of CVT severe headache, drowsy, venous findings: bilateral symptoms of stroke-like symptoms but in a non- arterial/vascular pattern, seizures
How is CVT diagnosed?Non con CT - Delta sign – blood clot in confluence of sinuses. CT head with contrast: Inverse Delta Sign- everything white except darker area in confluence of sinuses. Gold standard: MR Venography
How is CVT treated?neurosurgical consult, remove clot, dissolve with TPA, craniectomy

Cervical Artery dissection

Question Answer
What are the symptoms of cervical artery dissectionsevere, thunderclap headache (like SAH). If the dissection occurs in the carotid system: lancinating pain in the face, if in the vertebral system: nuchal lancinating pain
How does it occur?minor trauma like yoga/vigorous coughing/chiropractic manipulation
when doing tests what difference is there between it and SAH?CT head negative/LP negative. Need a angiogram, MR and doppler
What are bad sequelae? Clot from dissection can cause a stroke
how do you treat cervical artery dissection?Anticoagulation. (neurosurgical consult – angioplasty/stenting in very rare cases)