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Headache By MedRx Headache is a common medical presentation with a widerangeofcausesofdifferentdegreesofseverity. In this handout, we will go through the differential diagnosis of headache and the important aspects of a history. We will then cover three important conditions which cause headache: Meningitis, giant cell arteritis and cluster headaches. Contents Using this handout 1. Diffa. Sinister causes of headache b. Non sinister causes 2. How to take a headache history The content in this handout is quite a. HPC are the differential diagnosis (section 1), b. PMH the ‘essential advice’ and any writing in c. DH bold - prioritize these first! At the same d. FH time, the content is not exhaustive and e. SH should not be seen as covering every 3. Heada. Meningitisns detail but instead the most important b. Giant cell arteritis ones. This handout is for purely c. Cluster headaches used when treating patients.uld not be The essential differential diagnosis of headache The differential diagnosis of dysphagia can be split into Sinister and Non sinister causes. Sinister causes of a headache The sinister causes of a headache can be remembered with the mnemonic VIVID . This stands for vascular, infectious, vision-threatening, ICP and dissection. Category Differentials Vascular 1. SAH 2. EDH/SDH 3. cerebellar infarct 4. cerebral venous sinus thrombosis Infectious 1. encephalitis 2. meningitis Vision-threatening 1. Giant cell arteritis 2. posterior reversible encephalopathy syndrome 3. pituitary apoplexy 4. acute angle closure glaucoma 5. cavernous sinus thrombosis Intracranial pressure 1. Space occupying lesion a. Tumour b. Abscess 2. Cerebral oedema a. Hypoxia b. Trauma 3. Hydrocephalus a. Communicating (ie SAH, choroid plexus papilloma) b. Non-communicating (ie tumour) 4. Increased intracranial blood flow/pressure: a. Vasodilation – (hypoglycemic, hypoxic, hypercapnic, CO poisoning) b. Malignant hypertension c. SVC obstruction d. Idiopathic intracranial hypertension e. Hyperglycaemic headache Dissection 1. Carotid artery dissection Non-sinister causes of a headache The non-sinister causes of a headache can be remembered with the mnemonic 2 Ps, 2 Cs, 2 Ts, 2 Ms, 2 Ss 1. 2 Ps – pressure (spontaneous intracranial hypotension, post LP), paroxysmal hemicrania and other TACS 2. 2 Cs – cervicogenic headaches, cluster headaches 3. 2 Ts - Tension headache, trigeminal neuralgia 4. 2 Ms – migraine, medication overuse headache 5. 2 Ss - sinus headaches, sexual intercourse (post-coital) Taking a headache history HPC PMH A headache HPC can be split into the SOCRATES mnemonic and Pre-existing associated symptoms headache syndrome Could be 1. SOCRATES recurrence/ treatment could Site – unilateral (migraine), around eye (cluster, acute angle closure cause MOH. glaucoma), band-like distribution (tension), temples (GCA) Onset – sudden onset thunderclap (SAH), Polymyalgia Character – throbbing (migraine), pressure (tension), stabbing (cluster) Rheumatica Radiation – neck (cervicogenic, tension, meningitis), face (trigeminal Strong correlation neuralgia) with giant cell Alleviating factors – lying in dark room (migraine, meningitis), lying arteritis down (low pressure), vomiting (migraine), simple pain meds (tension) Cardiovascular Timing – at night in clusters (cluster), 4-72 hours (migraine), continuous disease and worst first thing in morning (raised ICP) Hypertension Exacerbating/ triggering factors - chocolate/caffeine/cheese makes vascular (migraine), dehydration or stress causes more likely (tension), smoking or strong smells (cluster), Thrombophilia coughing/bending over (raised Increased risk of ICP), light (meningitis), trauma venous sinus (EDH/SDH), sex (post-coital) thrombosis Severity – worst pain ever experienced (cluster), mild and can still cope with everyday activities (tension), Bleeding 2. Associated symptoms disorders Increased risk of 1. Weight loss, night sweats, loss of appetite - cancer bleeding 2. Non-blanching rash, neck stiffness – meningitis 3. Jaw claudication, temporal tenderness – GCA Cancer 4. Photophobia – AACG, meningitis, SAH, migraine Makes metastases/ SVC 5. Reduced visual acuity – GCA, AACG, carotid dissection obstruction/ 6. Confusion/ decreased consciousness/ focal neurological deficits/ pituitary apoplexy seizures – sinister causes more likely 7. Nausea and vomiting – could be any, but give anti-emetics FH DH 1. FH of any of the above conditions There are three important categories of drugs which one needs to ask about in a headache history: SH 1. Vasodilators – nitrates (ie GTN), theophylline, antihistamines, CCBs 2. Medication overuse headache – simple analgesics, tripans, opioids 1. Lifestyle factors – smoking, 3. Anticoagulants – make risk of bleeding higher alcohol, diet, hydration, recreational drugs 2. Anybody else in the house with headache 3. Work – does it impact work and any exposure at work Meningitis – what causes it? Fungal What is it? 1. Cryptococcus Meningitis is inflammation of the 2. Candida meninges of the brain, usually due to 3. Histoplasma 4. Coccidioides infection. 5. Aspergillus 6. Blastomyces What are the causes Parasitic The causes of meningitis can broadly be split into infectious and non-infectious. 1. A.cantonensis These can then be further split as shown 2. B.procyonis below. Keep in mind that this list is 3. G.spinigerum extensive and by far the most common causes of meningitis are viral and Amoeba bacterial. 1. Naegleria Fowleri Infectious Bacterial 2. Non-infectious 1. 0-3 month olds – GBS, listeria monocytogenes, E.Coli Drug induced 2. 3 months – 6 years – N.meningitidis, S.pneumoniae, H.influenzae 1. NSAIDs 3. 6 years – 60 years – N.meningitidis, 2. Antibiotics S.pneumoniae 3. Immunomodulators 4. >60 years - N.meningitidis, 4. Immunoglobulins S.pneumoniae, listeria monocytogenes 5. Rarer – mycobacterium tuberculosis, Malignancy chlamidya pneumoniae, Pasteurella multocida 1. Lymphoma Viral 2. Leukaemia 3. metastatic cancer 1. Non polio enteroviruses (coxsackie Autoimmune viruse, echo virus) 2. Paramyxoviridae – measles, mumps 1. Systemic lupus erythematosus 3. Herpes viruses - HSV, VZV, CMV 2. Sarcoidosis 3. Bechets Essential advice: Remember that, in most ages, Other the two most common causes of bacterial 1. Vaccinations 4 meningitis are Neisseria Meningitidis and Streptococcus pneumonia. The former is a gram negative diplococcus and the latter is gram positive diplococcus. Meningitis – symptoms and diagnosis What are the What is the diagnostic symptoms? technique? The symptoms of meningitis can be In addition to a standard work-up of bedside split into ‘symptoms in older children tests, bloods and imaging, there are a few and adults’ and ‘symptoms in neonates specific diagnostic tools for meningitis: and young children’. Specific examinations – Kernig’s and Symptoms in older children and Brudzinski’s adults 1. Kernig’s test – flex hip and knee to 90 1. Fever degrees, then slowly extend knee. Positive test is pain/ limited extension. 2. Neck stiffness 3. Altered mental status 2. Brudzinski’s test – flexing patient’s neck causes flexion of hips and knees 4. Headache Lumbar puncture 5. Vomiting Lumbar puncture is the main diagnostic 6. Photophobia investigation for meningitis – samples are sent for bacterial culture, viral PCR, cell 7. Seizures count, protein and glucose. A blood glucose must be sent alongside this for comparison. 8. In meningococcal septicaemia, get These factors can be used to not only non blanching rash diagnose meningitis but also differentiate 5 different causes. Symptoms in neonates and young children Bacterial TB Viral fungal 1. Hypotonia eppearanc Cloudy Fibrin web cloudy Cloudy 2. Poor feeding Glucose Low (<1/2 Low (<1/2 60-80% Low plasma) plasma) plasma 3. Lethargy glucose 4. Hypothermia Protein High (over High (over Normal/ High 1g/l) 1g/l) raised 5. Bulging fontanelle Cell count 10-5,000 30-300 15-1000 20-200 polymorphs lymphocyte lymphocyt lymphocytes/ / mm3 s/ mm es/ mm3 mm 3 Meningitis – management and complications What is the Note the management above is for bacterial meningitis. Management for other types of management? meningitis would be different, with viral meningitis being managed with acyclovir if 1. Management in primary care HSV/VZV is suspected, and noninfectious meningitis being managed by treating the If a child is seen in primary care with signs of meningitis and a non-blanching underlying condition. rash they should be given a single stat What are the dose of benzylpenicillin. This should be: complications? • 300 mg in under 1 year olds • 600mg in 1-9 year olds The complications of meningitis can be • 1200mg in 10+ year olds remembered with the mnemonic HACTIVE : 6 Importantly, this should not delay transfer to hospital – this is the priority. Hydrocephalus/ hearing loss Abscess 2. Management in secondary care Cerebral palsy/ CN lesion a. Antibiotics i. Under 3 months – IV Thrombosis cefotaxime + amoxicillin (covers listeria) Infarction ii. 3 months-50 years – IV cefotaxime/ ceftriaxone Ventriculitis iii. Over 50 – IV cefotaxime/ ceftriaxone + amoxicillin Extra-axial collection – empyema and iv. Add vancomycin if risk of penicillin rssitant hygroma pneumococcal infection b. IV Dexamethasone i. especially if pneumococcal disease suspected c. Notify UK Health Security Agency i. Bacterial meningitis is a notifiable disease 3. Management of contacts a. Risk highest for those in close contact in 7 days prior to symptoms b. Post-exposure prophylaxis - usual choice is single dose of ciprofloxacillin given ASAP 2,5 Giant cell Arteritis Giant cell arteritis, also known as temporal arteritis, is a systemic What is the diagnostic vasculitis affectin2,5he medium and large sized vessels. technique? What are the risk There are 5 main important elements to GCA diagnosis: factors? 1. Clinical presentation • Older age – above 50, peak age 2. Temporal artery biopsy – shows 70 multinucleated giant cells 3. Raised ESR (>50mm/hour) • Caucasian 4. Fundoscopy – swollen pale disc • Female and blurred margins • Polymyalgia Rheumatica – 5. Duplex US – hypoechoic halo sign around 50% of patients will and stenosis of temporal artery have features of PMR What is the What are the symptoms? management? Steroids The symptoms of GCA can be split into symptoms in the head and eyes and 1. 40-60mg of prednisolone daily if systemic symptoms. no jaw claudication or vision loss 2. 500mg-1000mg Symptoms in the face and eyes: methylprednisolone daily if jaw claudication or vision loss a. Headache (85%) b. Tender, palpable temporal artery Other medications c. Jaw claudication (65%) d. Blurred/ double vision 1. Aspirin 75mg daily – reduces vision e. Loss of vision loss and strokes 2. PPIs, bisphosphonates, Ca and vit Systemic symptoms D – for gastro and bone protection a. Symptoms of PMR (shoulder and while on long term steroids pelvic girdle pain and stiffness) b. Weight loss, fatigue, low grade What are the fever complications? Essential advice: Remember the link 1. Vision loss between Giant cell arteritis and 2. Stroke 2,5 polymyalgia rheumatica – this is important both in clinical practice and in exams! Cluster headaches Cluster headaches are a type of trigeminal autonomic cephalgia. They What is the diagnostic are known to be one of the most severe technique? pains in the world and are hence important to understand. 2,5 1. Clinical diagnosis – differentiate from other trigeminal autonomic cephalgias 7 Cluster Paroxysmal Hemicrania SUNCT/SUNA What are the risk headaches hemicrania continua 15mins-3 2-45 mins, Continuous – Both last factors? hours, 1-2 5+ a day, persistent seconds, occur 1- day, Throbbing/ headaches 200 times a day. • Men (3:1 ratio) Stabbing, stabbing, that never SUNCT – only severe, Females awayly go tearing. SUNA – • Middle aged Males other autonomic symptoms (forehead • Smoking sweating etc) • Alcohol, strong smells or exercise can trigger 2. Imaging a. MRI with gadolinium contrast b. Rule out structural pathology What are the symptoms? What is the Timing management? 1. Symptoms come in clusters which Acute typically last 4-12 weeks, with year long breaks between clusters 1. Subcutaneous or intranasal sumatriptan 2. During cluster headaches typically 2. High flow 100% oxygen occurs 1-2 times a day 3. Last 15 minutes – 3 hours Prophylaxis 4. Typically occur at night 1. First line – verapamil Features 2. Prednisolone 3. Lithium 1. 3 Ss - Severe, sharp and stabbing 4. Occipital nerve block pain in one eye 2. 3 discharge - Nasal discharge, Lacrimation (along with red eye), What are the Facial sweating 3. Horner’s-like syndrome – ptosis complications? and miosis 2,5 1. Psychological – pain is severe and can have profound psychological impact References 1. Farne, H., Norris-Cervetto, E. and Warbrick-Smith, J. (2015). Oxford cases in medicine and surgery. Oxford ; New York: Oxford University Press. 2. Anon, (n.d.). Zero To Finals – Tools for Medical School. [online] Available at: https://zerotofinals.com. 3. Geeky Medics. (2016). 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