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Rohan Mudkavi HeadacheCONTENTS 1. DIFFERENTIAL DIAGNOSIS 1. How to split the differential 2. Sinister causes 3. Non sinister causes 2. HISTORY 1. HPC 2. PMH 3. DH 4. FH 5. SH 3. QUIZ NUMBER 1 4. CONDITIONS CAUSING HEADACHE 1. Meningitis 2. Giant cell arteritis 3. Cluster headaches 5. QUIZ NUMBER 2CONTENTS 1. DIFFERENTIAL DIAGNOSIS 1. How to split the differential 2. Sinister causes 3. Non sinister causes 2. HISTORY 1. HPC 2. PMH 3. DH 4. FH 5. SH 3. QUIZ NUMBER 1 4. CONDITIONS CAUSING HEADACHE 1. Meningitis 2. Giant cell arteritis 3. Cluster headaches 5. QUIZ NUMBER 2How to split the differential Sinister headaches - can be life threatening/ have serious complications Non sinister headaches – may be severe but not physically dangerous Sinister causes Remember ‘VIVID’ for the sinister causes of a headache of a headache Vascular Infectious Vision-threatening ICP (raised) Dissection 1. SAH 1. Encephalitis 1. Pituitary apoplexy 1. Space occupying 1. Carotid 2. EDH/SDH 2. Meningitis 2. Giant cell arteritis lesion (tumour, artery 3. cerebellar infarct 3. Posterior reversible abscess) dissection 4. cerebral venous sinus encephalopathy syndrome 2. Cerebral oedema thrombosis 4. Cavernous sinus (hypoxia, trauma) thrombosis 3. Hydrocephalus 5. Acute-angle closure (comm. vs non- glaucoma comm) 4. Raised intracranial blood flow/ pressure Farne, H., Norris-Cervetto, E. and Warbrick-Smith, J. (2015). Oxford cases in medicine and surgery. Oxford ; New York: Oxford University Press. Non-sinister causes the non sinister causes of of a headache a headache 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) Farne, H., Norris-Cervetto, E. and Warbrick-Smith, J. (2015). Oxford cases in medicine and surgery. Oxford ; New York: Oxford University Press.CONTENTS 1. DIFFERENTIAL DIAGNOSIS 1. How to split the differential 2. Sinister causes 3. Non sinister causes 2. HISTORY 1. HPC 2. PMH 3. DH 4. FH 5. SH 3. QUIZ NUMBER 1 4. CONDITIONS CAUSING HEADACHE 1. Meningitis 2. Giant cell arteritis 3. Cluster headaches 5. QUIZ NUMBER 2HISTORY T AKING HISTORY OF PRESENTING COMPLAINT PAST MEDICAL HISTORY DRUG HISTORY FAMILY HISTORY SOCIAL HISTORY Farne, H., Norris-Cervetto, E. and Warbrick-Smith, J. (2015). Oxford cases in medicine and surgery. Oxford ; New York: Oxford University Press.HPC SOCRATES: Associated symptoms: 1. Weight loss, night sweats, loss of appetite 1. Site 2. Non blanching rash, neck stiffness 2. Onset 3. Jaw claudication, temporal tenderness 3. Character 4. Photophobia 4. Radiation 5. Changes in vision 5. Alleviating factors 6. Confusion/ decreased consciousness/ Focal 6. Timing neurological deficit/ seizures 7. Exacerbating factors 7. Nausea and vomiting 8. SeverityPMH 1. Pre-existing headache syndrome – that syndrome, MOH 2. Cardiovascular disease – vascular causes 3. Polymyalgia Rheumatica – GCA 4. Cancer – mets, SVC obstruction, pituitary apoplexy 5. Thrombophilia – thrombosis 6. Bleeding disorders – vascularDHX Drugs which cause Drugs causing MOH Drugs increasing the vasodilatation risk of bleeding • Nitrates ie GTN • Simple • Anticoagulants • CCBs analgesics • Theophylline • Triptans • Antihistamines • OpioidsFHX 1. Any conditions in PMH – (Headache syndrome, CV disease, cancer, PMR, thrombophilia, bleeding disorders)SHx 1. Lifestyle factors – Alcohol, smoking, diet, hydration, recreational drugs 2. Anybody else in the house has similar symptoms - CO poisoning 3. Any risk factors at work - ie exposure, other people with symptomsCONTENTS 1. DIFFERENTIAL DIAGNOSIS 1. How to split the differential 2. Sinister causes 3. Non sinister causes 2. HISTORY 1. HPC 2. PMH 3. DH 4. FH 5. SH 3. QUIZ NUMBER 1 4. CONDITIONS CAUSING HEADACHE 1. Meningitis 2. Giant cell arteritis 3. Cluster headaches 5. QUIZ NUMBER 21. Which of the following rules can be used to conceptualize the causesof raisedICP? 1. Kernohan’s phenomenon 2. Monro-Kellie doctrine 3. Courvoisier’s law 4. Evan’s index 5. Pemberton’s sign2. Which of the following is a cause of communicating hydrocephalus? 1. Tumour obstructing flow of CSF 2. Intraventricular haemorrhage obstructing flow 3. Choroid plexus papilloma 4. Cerebral aqueductal stenosis 5. Raised ICP3. Which of the following is not in the vision threatening causes of headache? 1. PRES 2. Pituitary apoplexy 3. Cavernous sinus thrombosis 4. Acute angle closure glaucoma 5. Paroxysmal hemicrania4. Which of the following is not a cause of MOH? 1. Triptans 2. B-blockers 3. Paracetamol 4. Ibuprofen 5. OpioidsCONTENTS 1. DIFFERENTIAL DIAGNOSIS 1. How to split the differential 2. Sinister causes 3. Non sinister causes 2. HISTORY 1. HPC 2. PMH 3. DH 4. FH 5. SH 3. QUIZ NUMBER 1 4. CONDITIONS CAUSING HEADACHE 1. Meningitis 2. Giant cell arteritis 3. Cluster headaches 5. QUIZ NUMBER 2MeningitisWhat is meningitis? Inflammation of the meninges surrounding the brainCAUSES 1. Lockwood, J. and Carr, D. (2014). Drug-induced aseptic meningitis secondary to trimethoprim/sulfamethoxazole: a headache to be aware of. PubMed, 16(5), pp.421–4 .Infectious causes - bacterial 1. 0-3 month olds – GBS, listeria monocytogenes, E.Coli 2. 3 months – 6 years – N.meningitidis, S.pneumoniae, H.influenzae 3. 6 years – 60 years – N.meningitidis, S.pneumoniae 4. >60 years - N.meningitidis, S.pneumoniae, listeria monocytogenes Rarer – mycobacterium tuberculosis, chlamidya pneumoniae, Pasteurella multocida https://microbeonline.com/neisseria-meningitidis-properties-pathogenesis-and-laboratory-diagnosis/?utm_content=cmp-true https://www.msdmanuals.com/professional/multimedia/image/gram-stain-streptococcus-pneumoniae-Infectious causes - others Viral Fungal Parasitic Amobeic 1. Non polio 1. Cryptococcus 1. A.cantonensis 1. Naegleria Fowleri enteroviruses 2. Candida 2. B.procyonis (coxsackie viruse, 3. Histoplasma 3. G.spinigerum echo virus) 4. Coccidioides 2. Paramyxoviridae – 5. Aspergillus measles, mumps 6. Blastomyces 3. Herpes viruses - HSV, VZV, CMVNon infectious causes Drugs Autoimmune Malignancy Other 1. NSAIDs 1. Systemic lupus 1. Lymphoma 1. Vaccinations 2. Antibiotics erythematosus 2. Leukaemia 3. Immunomodulato 2. Sarcoidosis 3. Metastatic cancer rs 3. Bechets 4. Immunoglobulins 1. 16(5), pp.421–4. Carr, D. (2014). Drug-induced aseptic meningitis secondary to trimethoprim/sulfamethoxazole: a headache to be aware of. PubMed,CAUSES 1. Lockwood, J. and Carr, D. (2014). Drug-induced aseptic meningitis secondary to trimethoprim/sulfamethoxazole: a headache to be aware of. PubMed, 16(5), pp.421–4 .Symptoms Symptoms in older children/ adults Symptoms in younger children/ neonates 1. Fever 1. Hypotonia 2. Neck stiffness 3. Altered mental status 2. Poor feeding 4. Headache 3. Lethargy 4. Hypothermia 5. Vomiting 6. Photophobia 5. Bulging fontanelle 7. Seizures 8. In meningococcal septicaemia, get non blanching rashDIAGNOSIS Examinations Lumbar puncture 1. Kernig’s sign 1. viral PCR, cell count, protein and, 2. Brudzinski’s sign glucose. 2. A blood glucose must be sent alongside this for comparison 3. and meningococcal septicaemiaed ICP Images - https://medizzy.com/feed/36288543 Bacterial TB Viral Fungal Appearance Cloudy Cloudy/ fibrin Clear/ cloudy Cloudy web Glucose Low (<1/2 Low (<1/2 60-80% plasma Low plasma) plasma) Protein High (over 1g/l) High (over 1g/l) Normal/ raised High Cell count 10-5000 30-300 15-1000 20-200 polymorphs / lymphocytes/ lymphocytes/ lymphocytes / mm 3 mm 3 mm 3 mm 3 passmedicine.com. (n.d.). Passmedicine. [online] Available at: https://passmedicine.com.Management (bacterial) Management in primary Management in secondary Management of care care contacts Stat dose of IM benzylpenicillin: 1. Antibiotics 1. 300 mg in under 1 year olds 1. IV Cefotaxime/ceftriaxone • Risk highest for those in 2. 600mg in 1-9 year olds 2. + amoxicillin for <3 months close contact for 7 days 3. 1200mg in 10+ year olds or >50 prior to symptoms 3. + vancomycin if resistance • Single dose of 2. IV Dexamethasone ciprofloxacillin given 3. Notify UK Health Security Agency ASAPCOMPLICA TIONS Hydrocephalus/ hearing loss ‘Remember HACTIVE for Abscess the complications of Cerebral palsy/ CN lesion meningitis’ Thrombosis Infarction Ventriculitis Extra-axial collection – empyema and hygroma Mohan, S., Rogan, E.A., Batty, R., Raghavan, A., Whitby, E.H., Hart, A.R. and Connolly, D.J.A. (2013). CT of the neonatal head. Clinical Radiology, [online] 68(11), pp.1155–1166CONTENTS 1. DIFFERENTIAL DIAGNOSIS 1. How to split the differential 2. Sinister causes 3. Non sinister causes 2. HISTORY 1. HPC 2. PMH 3. DH 4. FH 5. SH 3. QUIZ NUMBER 1 4. CONDITIONS CAUSING HEADACHE 1. Meningitis 2. Giant cell arteritis 3. Cluster headaches 5. QUIZ NUMBER 2Giant cell arteritisWhat is Giant cell arteritis? • Aka temporal arteritis • Systemic vasculitis • affecting medium/ large sized vesselsRISK FACTORS • Older age – above 50, peak age 70 • Caucasian • Female • Polymyalgia Rheumatica – around 50% of patients will have features of PMRSYMPTOMS Symptoms in the face and eyes Systemic symptoms 1. Headache (85%) 1. Symptoms of PMR (shoulder and pelvic girdle 2. Tender, palpable temporal artery pain and stiffness) 2. Weight loss, fatigue, low grade fever 3. Jaw claudication (65%) 4. Blurred/ double vision 5. Loss of visionDIAGNOSIS 1. Clinical presentation 2. Temporal artery biopsy – shows multinucleated giant cells 3. Raised ESR (>50mm/hour) 4. Fundoscopy – swollen pale disc and blurred margins 5. Duplex US – hypoechoic halo sign and stenosis of temporal arteryManagement Steroids Other management 1. 40-60mg of prednisolone daily if no jaw 1. Aspirin 75mg daily – reduces vision loss and claudication or vision loss strokes 2. claudication or vision losslone daily if jaw 2. and bone protection while on long term steroidsoCOMPLICA TIONS 1.Vision loss 2.StrokeCONTENTS 1. DIFFERENTIAL DIAGNOSIS 1. How to split the differential 2. Sinister causes 3. Non sinister causes 2. HISTORY 1. HPC 2. PMH 3. DH 4. FH 5. SH 3. QUIZ NUMBER 1 4. CONDITIONS CAUSING HEADACHE 1. Meningitis 2. Giant cell arteritis 3. Cluster headaches 5. QUIZ NUMBER 2What are cluster headaches? • Type of trigeminal autonomic cephalgia • Severe pain, one of the worst in the worldRISK FACTORS • Men (3:1 ratio) • Middle aged • Smoking • Alcohol, strong smells or exercise can triggerSYMPTOMS AND SIGNS Timing Features 1. Clusters typically last 4-12 weeks, with 1. 3 Ss - Severe, sharp and stabbing pain in year long breaks between clusters one eye 2. Headaches typically occurs 1-2 times a 2. 3 discharge - Nasal discharge, day Lacrimation (along with red eye), Facial sweating 3. Last 15 minutes – 3 hours 4. Typically occur at night 3. Horner’s-like syndrome – ptosis and miosisDIAGNOSIS 1. Clinical diagnosis – differentiate from other TACs 2. Imaging – MRI with gadolinium contrastCluster headaches Paroxysmal Hemicrania continua SUNCT/ SUNA hemicrania • 15mins-3 hours, • 2-45 mins • Continuous – • Both last • 1-2 a day, • 5+ a day persistent seconds • Stabbing, sharp, • Throbbing/ stabbing headaches that • Occur 1- 200 severe, • Females never go away times a day • Males • SUNCT – conjunctival injection and tearing • SUNA – other autonomic symptoms 1. Miller, S. and Matharu, M. (2014). Trigeminal Autonomic Cephalalgias: Beyond the Conventional Treatments. Current Pain and Headache Reports, 18(8). doi:https://doi.org/10.1007/s11916-014-0438-z.TREA TMENT Acute Prophylaxis 1. Subcutaneous or intranasal sumatriptan 1. Verapamil – first line 2. High flow 100% oxygen 2. Prednisolone 3. Lithium 4. Greater occipital nerve blockCOMPLICA TIONS • PsychologicalCONTENTS 1. DIFFERENTIAL DIAGNOSIS 1. How to split the differential 2. Sinister causes 3. Non sinister causes 2. HISTORY 1. HPC 2. PMH 3. DH 4. FH 5. SH 3. QUIZ NUMBER 1 4. CONDITIONS CAUSING HEADACHE 1. Meningitis 2. Giant cell arteritis 3. Cluster headaches 5. QUIZ NUMBER 21. Which of the following are the most common organisms causing bacterial meningitis in 0-3month olds? 1. Neisseria Meningitidis, Strep pneumoniae 2. Mycobacterium tuberculosis, Pasteurella multocida, chlamidya pneumoniae 3. GBS, E.Coli, Listeria 4. H.influenza, E.Coli, GAS 5. GBS, E.Coli, H.influenza2. Which of the following is true for LPresultsin meningitis? 1. An LP should be obtained urgently if meningococcal septicaemia is suspected 2. Bacterial infection causes high glucose 3. Viral infections never causes low glucose 4. TB infection causes raised lymphocytes 5. Fungal infection cause low protein counts6. What does Neisseria Meningitidis show on a gram stain? 1. Gram positive diplococci 2. Gram positive cocci in clusters 3. Gram negative diplococci 4. Gram positive bacilli 5. Gram negative bacilli3. Which of the following is the first line antibiotic treatment for bacterial meningitis in a 0-3month oldin secondary care? 1. IV cefotaxime + amoxicillin 2. IV ceftriaxone/ cefotaxime only 3. IV vancomycin 4. IV amoxicillin 5. Single dose of ciprofloxacillin4. Which of the following is not a risk factor for Giant Cell arteritis? 1. Caucasian 2. PMR 3. Older age 4. Female 5. Migraines5. What dose of methylprednisolone should be used in a patient with GCA withjawclaudicationandblurring of the vision? 1. 10-20mg per day 2. 40-60mg per day 3. 100-200mg per day 4. 500-1000mg per day 5. 1000-2000 mg per day7. Which of the following is not a type of trigeminal autonomiccephalgia? 1. Cluster headaches 2. Hemicrania continua 3. Paroxysmal hemicrania 4. Trigeminal neuralgia 5. SUNA/ SUNCT8. Which of the following is the first line for prophylaxis of cluster headaches? 1. Lithium 2. Verapamil 3. Prednisolone 4. Lamotrigine 5. Indomethacin @prescribing_the_essentials THANK YOU!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). Headache History Taking | Geeky Medics. [online] Available at: https://geekymedics.com/headache-history- taking/. 4. aware of. PubMed, 16(5), pp.421–4.Drug-induced aseptic meningitis secondary to trimethoprim/sulfamethoxazole: a headache to be 5. passmedicine.com. (n.d.). Passmedicine. [online] Available at: https://passmedicine.com. 6. Mohan, S., Rogan, E.A., Batty, R., Raghavan, A., Whitby, E.H., Hart, A.R. and Connolly, D.J.A. (2013). CT of the neonatal head. Clinical Radiology, [online] 68(11), pp.1155–1166. 7. Miller, S. and Matharu, M. (2014). Trigeminal Autonomic Cephalalgias: Beyond the Conventional Treatments. Current Pain and Headache Reports, 18(8). doi:https://doi.org/10.1007/s11916-014-0438-z.