Headaches for the AMKBy Sanaa Butt

Aims

• Define headaches / their classifications

• Review different types and their management

• Review MCQ’s and approach how to answer them

• Throw in some AMK gold!

Why?

Headaches are COMMON!

Almost everyone has suffered from a tension headache at some point!

The key is in the history….

Definition

‘pain in the head which can arise from many disorders or may be a disorder in and of itself’

Classifications

• Tension• Migraine• Cluster

Primary Secondary• Subarachnoid

haemorrhage • Temporal

Arteritis (Giant Cell Arteritis)

• Meningitis

Tips on the AMK approach

1.FIRST READ THE QUESTION!!!2. Cover up the answers.3. Read the vignette if need be. See if you know the answer.4. Uncover the options.

If you can eliminate 2 answers try and guess.Work through all the answers you know and return to the tricky questions. (applies to 2nd years)Follow your gut instincts!

Case 1A 38 year old male attends the A&E complaining of an episode of right sided peri-orbital pain earlier that evening. He described it as 10/10 on the pain scale and ‘boring’ in nature. He mentioned it was weepy and the pain did not relent for 50 minutes. He described a similar episode occurring 6 weeks ago.On examination his eye is red and the pupil is constricted. What is the most likely diagnosis?

A. Tension headacheB. ConjunctivitisC. MigraineD. Cluster headacheE. Subarachnoid HaemorrhageF. Don’t know

Case 1A 38 year old male attends the A&E complaining of an episode of right sided peri-orbital pain earlier that evening. He described it as 10/10 on the pain scale and ‘boring’ in nature. He mentioned it was weepy and the pain did not relent for 50 minutes. He described a similar episode occurring 6 weeks ago.On examination his eye is red and the pupil is constricted.

What is the most likely diagnosis?

A. Tension headacheB. ConjunctivitisC. MigraineD. Cluster headacheE. Subarachnoid HaemorrhageF. Don’t know

Case 1A 38 year old male attends the A&E complaining of an episode of right sided peri-orbital pain earlier that evening. He described it as 10/10 on the pain scale and ‘boring’ in nature. He mentioned it was weepy and the pain did not relent for 50 minutes. He described a similar episode occurring 6 weeks ago.On examination his eye is red and the pupil is constricted.

What is the most likely diagnosis?

A. Tension headacheB. ConjunctivitisC. MigraineD. Cluster headacheE. Subarachnoid HaemorrhageF. Don’t know

Primary Headaches: Character

Tension Migraine Cluster

Bilateral

Tight/ band likeNon tender

Pain +

Unilateral or Bilateral

Pulsating & throbbing

Pain ++

Unilateral

Periorbital‘like an ice-pick in my eye’. So painful sufferers may bang their head against the wall/with an object

Pain +++

Primary Headaches: Associated Features

Tension Migraine Cluster

Non tender forehead Photo/phono-phobiaAura - Classical migraine approx 20% casesVisual: Scintillating scotomafortification spectraTactile: NumbnessSpeech: Speech disturbance

Weepy/Red eyeRhinorrhoeaConstricted pupil Unilateral sweatingPtosis

AURA

Primary Headaches: Extras

Tension Migraine Cluster

StressAnxietyFatiguePoor posture

Women>Men 2:1Neuro/Vasodilation theory

Precipitants:Pneumonic CHOCOLATECHeese/CHocolateOCPCaffeineOL (alcohOL)AnxietyTravelExercise

Men >Women 5:1

Nocturnal

Often regular cycle:up to 160 mins1-2/day4-12 week cycles before remission

Primary Headaches: Management

Tension Migraine Cluster

Conservative:Control sleep, exercise & diet.

Medical:ParacetamolNSAIDs

S.E. Paracetamol/NSAID chronic use may induce headaches!!

AcuteNSAIDsTriptans – sumitriptan/rizatriptan

Prophylactic:B-blockersAmitriptyline

AcuteO2 15 mins Triptans

Prophylactic:MedicalVerapamil

Surgical:Occipital nerve block

Case 2A 45 year old female is brought in to the A&E by paramedics after collapsing in a supermarket. A primary survey is carried out ABC are clear however her GCS is noted to be 8/15 and she has marked neck stiffness. She vomited twice since her arrival.You look at her past notes and see she has a known history of Polycystic Kidney Disease and is on ACEi's for her high blood pressure. What is the most likely cause of her collapse?A. Temporal ArteritisB. Vasovagal syncopeC. Subarachnoid HaemorrhageD. MigraineE. MeningitisF. Don’t know

Case 2A 45 year old female is brought in to the A&E by paramedics after collapsing in a supermarket. A primary survey is carried out ABC are clear however her GCS is noted to be 8/15 and she has marked neck stiffness. She vomited twice since her arrival.You look at her past notes and see she has a known history of Polycystic Kidney Disease and is on ACEi's for her high blood pressure. What is the most likely cause of her collapse?A. Temporal ArteritisB. Vasovagal syncopeC. Subarachnoid HaemorrhageD. MigraineE. MeningitisF. Don’t know

Case 2A 45 year old female is brought in to the A&E by paramedics after collapsing in a supermarket. A primary survey is carried out ABC are clear however her GCS is noted to be 8/15 and she has marked neck stiffness. She vomited twice since her arrival.You look at her past notes and see she has a known history of Polycystic Kidney Disease and is on ACEi's for her high blood pressure. What is the most likely cause of her collapse?A. Temporal ArteritisB. Vasovagal syncopeC. Subarachnoid HaemorrhageD. MigraineE. MeningitisF. Don’t know

Brief Anatomy

Brief Anatomy

Brief Anatomy

Brief Anatomy

Brief Anatomy

Brief Anatomy

Subarachnoid Haemorrhage

Aetiology:Berry aneurysmAV malformation

Subarachnoid Haemorrhage: Associations

Subarachnoid Haemorrhage

THUNDERCLAP HEADACHE Collapse

VomitingNeck stiffnessPhotophobia

‘Worst headache of my life’

‘Hit round the head with a baseball bat’

Sentinel headache – prior leak

Subarachnoid Haemorrhage: Management

ABC

CTLumbar Puncture > 12 hrXanthocromia - billirubin

REFER TO NEURO

CT cerebral angiogram

Subarachnoid Haemorrhage: Management

Medical: Oral hydration/ IV if unconscious

Nimodipine – reduce vasospasm

Systolic >160mmHg

Surgical: Endovascular coiling/Surgic

al clips/Stenting

Why do people die?

1. Re-bleeding2. Cerebral Ischemia3. Hydrocephalus4. Hyponatremia

MeningitisInflammation of the meninges • Headache!!

• Neck stiffness

• Malaise

• Nausea & Vomiting

• Joint pain

• Altered consciousnessCold hands and feet

• NON BLANCHING PETICHIAL RASH

Meningitis: Children

http://www.kidsgrowth.com/images/fp_images/meningitis_symptoms_baby.jpg

Meningitis: AetiologyBacterial Babies Group B Strep, E coli, Listeria monocytogenes

Kids Neisseria Meningitides(meningiococcus), Streptococcus pneumonia(streptococcus), Haemophillus influenza B

AdultsMeningiococcus, Streptococcus, Listeria monocytogenes. TB.

Viral – Enterovirus, Herpes SV2, Varicella zoster CMVFungal – Cryptococcal meningitis in immunosuppressed/HIV/ elderly pts.Parasitic - SchistomaNon infectious - Ca

Meningitis: Management

ABC

O2 + IV fluids

High Suspicion: 2 GRAMS IV cefotaxime

Meningitis: Management

FBC, U&E

Blood cultures, swab throat &

rectum

Lumbar puncture

Meningitis: LP resultsBacterial TB Viral

Appearance(clear)

Turbid Fibrin webs Clear

Bacteria(none)

Present in smear/culture

Often not found on smear

-

Glucose(80% blood)

<1/2 plasma <1/2 plasma >1/2 plasma

Protein(0.2-0.4)

>1.5 1-5 <1

WCC/mm3(<5)

>1000 Neutrophil predominant

10-1000lymphocyte predominant.

50-1000Lymphocytepredominant.

Meningitis: LP resultsBacterial TB Viral

Appearance(clear)

Turbid Fibrin webs Clear

Bacteria(none)

Present in smear/culture

Often not found on smear

-

Glucose(80% blood)

<1/2 plasma <1/2 plasma >1/2 plasma

Protein(0.2-0.4)

>1.5 1-5 <1

WCC/mm3(<5)

>1000 Neutrophil predominant

10-1000lymphocyte predominant.

50-1000Lymphocytepredominant.

Case 3A 66 year old enters your practice complaining of grumbling aches and pains in her shoulders and hips for the past 6 weeks. You look at her bloods from last week and see a CRP of 84 (normal = <10) and ESR 117 (normal approx 38). A diagnosis of Polymyalgia Rheumatica is made. Before she leaves you examine her temples and feel for any tenderness and ask if she has noticed any change in vision. What are you concerned about?A. Hemiplegic MigrainesB. Giant Cell ArteritisC. Multiple SclerosisD. Skull fractureE. ShinglesF. Don’t know

Case 3A 66 year old enters your practice complaining of grumbling aches and pains in her shoulders and hips for the past 6 weeks. You look at her bloods from last week and see a CRP of 84 (normal = <10) and ESR 117 (normal approx 38). A diagnosis of Polymyalgia Rheumatica is made. Before she leaves you examine her temples and feel for any tenderness and ask if she has noticed any change in vision. What are you concerned about?A. Hemiplegic MigrainesB. Giant Cell ArteritisC. Multiple SclerosisD. Skull fractureE. ShinglesF. Don’t know

Case 3A 66 year old enters your practice complaining of grumbling aches and pains in her shoulders and hips for the past 6 weeks. You look at her bloods from last week and see a CRP of 84 (normal = <10) and ESR 117 (normal approx 38). A diagnosis of Polymyalgia Rheumatica is made. Before she leaves you examine her temples and feel for any tenderness and ask if she has noticed any change in vision. What are you concerned about?A. Hemiplegic MigrainesB. Giant Cell ArteritisC. Multiple SclerosisD. Skull fractureE. ShinglesF. Don’t know

Temporal ArteritisAKA Giant Cell Arteritis50% association with PMR

RED FLAGS:Abnormal superficial temporal artery:– tender, thickened or beaded –reduced or absent pulsation.

Scalp tenderness

Transient or permanent visual loss

Jaw Claudication

Temporal Arteritis

ABC

Temporal A. BiopsyBloods – CRP, ESR, Plasma viscosity

High Suspicion: Start high dose steroids

Duplex ultrasonogrophy

Brief AnatomyCN (I) OlfactoryCN(II) OpticCN (III) OcculomotorCN (IV) TrochlearCN (V) TrigeminalCN (VI) AbducensCN (VII) FacialCN (VIII) VestibulocochlearCN (IX) GlossopharyngealCN (X) VagusCN (XI) Accessory CN (XII) Hypoglossal

Brief AnatomyTrigeminal

Brief AnatomyFacial Nerve

Chorda tympani – branches off earlier

1. Special Sensory - TasteAnt 2/3 of tongue

2. General sensory of ear canal

Trigeminal Neuralgia

Trigeminal Neuralgia

• Paroxysmal stabbing pain• Lasts seconds / minutes• Unilateral• Triggers:

washing the area/Shaving/Eating/ talking

MRI: Be concerned about secondary causes like tumours, aneurysms or MS!

ManagementMedical:Carbamezapine

Surgical:

Rhizotomy

Shingles

Reactivated herpes zoster (chicken pox)Immunosuppressed/old

Dormant: Dorsal Root Ganglia

General: malaise/pyrexia/feverSpecific: Burning painItch (pruritus)Vesicular rash --> Blister

Shingles : Ramzay Hunt Syndrome Type 2

Reactivation of Herpes zoster of the facial nerve

Facial nerve paralysisBlisters on anterior 2/3 of the tongue Loss of tasteOtalgia

NB: PT45Coital cephalagia AKA primary sexual headacheAKA benign exertional headache

Diagnosis by exclusion

BEWARE: Similar precipitant/presentation as a subarachnoid.

MUST RULE OUT SUBARACHNOID FIRST!!

ReferencesNICE. Headaches. Diagnosis and management of headaches in young people and adults. www.guidance.nice.org.uk/cg150 Sept 2012Date accessed 14/11/2013.

Murray Longmore, Ian Wilkinson, Edward Davidson, Alexander Foulkes, and Ahmad Mafi. Oxford Handbook of Clinical Medicine (8 ed.) Oxford University Press. Feb 2010.

Dr Hayley Willacy. Headache. http://www.patient.co.uk/doctor/headache-pro Date accessed 15/11/2013.

The Free Dictionary. Headache. http://medical-dictionary.thefreedictionary.com/headache Date accessed 16/11/2013.

Theresa Pitassi. Neuro (Except Seizures) http://www.studyblue.com/notes/note/n/neuro-except-seizures-/deck/4427166 Accessed 17/11/2013

Inflammation of Ear Canal. Medicine Decoded. http://lh3.ggpht.com/_zMAsR4nBNbU/SG2cke8cdEI/AAAAAAAAAvc/RN64CkRVMO0/ramsay%20hunt1.jpg?imgmax=800 Accessed on 17/11/2013

Ramzay Hunt Syndrome. All About Rehab: Pain & Others http://rehabmed.wordpress.com/category/ramsay-hunt-syndrme/ Accessed on 17/11/2013

DR P. MARAZZI. Ramsay Hunt syndrome. Science Photo. http://www.sciencephoto.com/media/262351/view Acessed on 17/11/2013

Netter. Dermatomes. http://medimages.hostzi.com/album2/Mappe%20e%20dermatomeri/slides/dermatomes-netter2.html Accessed 17/11/2013

Peripheral Nervous System: Spinal Nerves and Plexuses. http://antranik.org/peripheral-nervous-system-spinal-nerves-and-plexuses/ 17/11/2013

Dr Richard Draper. Shingles. http://www.patient.co.uk/doctor/shingles Accessed 17/11/2013

ThE LonelY TravelleR. Trigeminal Nerve. Human Anatomy. http://msk-anatomy.blogspot.co.uk/2013/02/trigeminal-nerve.html 17/11/2013

Beao, Dwstultz. Brain human normal inferior view. http://en.wikipedia.org/wiki/File:Brain_human_normal_inferior_view_with_labels_en-2.svg Accessed 17/11/2013

Polymyalgia Rhumatica. http://www.primehealthchannel.com/polymyalgia-rheumatica-symptoms-causes-diet-and-treatment.html 17/11/2013Polymyalgia Rhumatica. http://www.primehealthchannel.com/polymyalgia-rheumatica-symptoms-causes-diet-and-treatment.html 17/11/2013

Dasgupta B. Diagnosis and management of giant cell arteritis. Royal College of Physicians. http://www.rcplondon.ac.uk/sites/default/files/giant-cell-arteritis-concise-guideline.pdf

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