EMQ revision - Headache

• 56 year old, Female, Unilateral stabbing pain on the surface of her scalp and around her eye, Pain is precipitated by washing or touching the specific area
• Trigeminal neuralgia
• Ophthalmic division of the trigeminal nerve
• Usually affects the Maxillary and Mandibular divisions
• 28 year old, Female, Headache and double vision which is worse when lying down, Examination reveals papilloedema but no feocal signs, There are no abnormal findings on CT
• Benign intracranial hypertension
• Usually affects obese women
• Steroids and tetracyclines are recognised precipitants
• Raised CSF pressure made in LP
• Symptoms often resolve after LP
• Chronic treatment includes the use of repeated LPs and diuretics
• 30 year old, Male, Dull headache worse when lying down or when coughing, Recently suffered a seizure
• Space-occupying lesion
• Raised intracranial pressure
• Development of seizures is sinister finding and urgent imaging is warranted
• 65 year old, Female, Complains of constant aching pain around the right eye radiating to the forehead, Reduced vision in the eye, Red and congested with a dilated pupil
• Acute glaucoma
• Long-sighted elderly population affected more
• Blockage of drainage of aqueous humour from the anterior chamber via canal of Schlemm
• Stimuli that cause pupillary dilatation (e.g. sitting in the dark) increases the tightness of contact between the iris and the lens and can precipitate an attack
• 70 year old, Female, Headache, Drowsiness, Unsteadiness over last couple of days, Examination reveals papilloedema, Falling 3 weeks ago
• Subdural haematoma
• Not always prior history of head injury
• Alcohol abuse is a risk factor for chronic subdural haemorrhage
• Neurosurgical opinion should be sought early, althugh many subdural haemorrhages can be handled conservatively because the bleeds clot spontaneously
• The presence of papilloedema indicates that the subdural bleed is increasing the intracranial pressure
• Initially the intracranial compliance is high and so the increase in volume caused by the developing bleed causes only small increases in intracranial pressure
• However, this compliance decreases (compensatory mechanisms to cope with increases in pressure are limiting)
• And small increases in volume are associated with large increases in intracranial pressure
• This is clinically important because patients may deteriorate very rapidly and therefore should be regularly monitored
• 40 year old, Male, Severe headache of sudden onset 4h ago, As if kicked in the back of the head, Vomited twice and is now feeling stiff in the neck
• Subarachnoid haemorrhage
• Rupture of berry aneurysms found on the circle of Willis
• Disease states associated with high blood pressure (e.g. coarctation of the aorta, polycystic kidney disease or defective collagen synthesis, e.g. Ehlers-Danlos syndrome, predispose to berry aneurysm formation)
• Typical symptoms are of a severe occipital headache that is sometimes likened to being 'kicked in the back of the head'
• Initial investigation of choice is a CT brain scan
• However, findings can be negative in 10-15 percent of subarachnoid haemorrhage
• In patients in whom clinical suspicion is high and CT scan is negative, lumbar puncture (LP) should be performed
• Subarachnoid haemorrhage is confirmed by presence of xanthochromia resulting from denatured red blood cells within the cerebrospinal fluid (CSF)
• This can take up to 12h to form and therefore, LP should be delayed for at least 12h after onset of headache. Discolouration of the CSF should be uniform, unlike a bloody tap where more red blood cells are present in the initial samples
• Some patients may present with a small sentinel bleed with minimal symptoms
• It is important to make this diagnosis because timely intervention may prevent a more catastrophic later event
• 40 year old, Businesswoman, Headache that feels like a tight band around her head
• Tension headache
• Diagnosis requires absence of symptoms and signs of other types of headache
• Treatment is rarely effective and avoidance of precipitants, e.g. stress, is the best remedy
• Chronic use of analgesics can lead to 'rebound headache' on withdrawal
• Antidepressants are prescribed with uncertain benefit
• 55 year old, Woman, Headache that had lasted a few weeks, Pain in her jaw during meals and scalp is tender to palpation
• Giant cell arteritis
• Medium-sized vessel vasculitis
• Classifically it affects the temporal vessels giving symptoms of headache, scalp tenderness and jaw claudication
• There is a risk of blindness if the disease is left untreated and treatment should be commenced empirically on oral corticosteroids
• Diagnosis can be confirmed with a temporal artery biopsy and the condition is usually associated with a high erythrocyte sedimentation rate (ESR)/C-reactive protein (CRP)
• CRP is always elevated, although ESR is occasionally normal
• As disease may not affect the part of the artery that has been biopsied, treatment should be continued even though the biopsy is negative if the clinical suspicion is high. Giant cell arteritis is recognised to overlap with polymyalgia rheumatica
• 30 year old, Man, Rapid-onset pain around his left eye every night for the last 2 weeks, Associated with lid swelling, Watery eye and flushing. Suffers from these bouts every 3 months
• Cluter headache
• Recurrent brief attacks of headache around the eye
• The hallmark of cluster headache is the association with autonomic symptoms and signs, e.g. nasal stuffiness, conjunctival hyperaemia, Horner's syndrome
• The clusters usually last between a few weeks and a few months
• 24 year old, Woman, Unilateral throbbing headache lasting 6 hours associated with vomiting and photophobia, Several episodes in the past
• Migraine
• The classic description of migraine includes a preceding aura before the onset of the headache, but this feature does not occur in most patients