headaches -neurology in clinical medicine, Summaries of Clinical Medicine

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HEADACHE SC2 Common Medical Presentations 2021 - 2022 RCSI LEARNING OUTCOMES At the end of this session, students should be able to: • Define headache • Formulate a differential diagnosis for the aetiology of headache • Perform a focussed history to elicit the most important characteristics of a patient presenting with headache • Perform a focussed clinical exam to determine the underlying aetiology of a headache • Compare and contrast the differing clinical features present in the most significant causes of headache • Identify high risk features of headache that may indicate a clinically significant underlying aetiology • Construct an investigative plan for a patient presenting with headache PRIMARY HEADACHES • Majority of headaches fall into this category (90%) • “benign” • Can be debilitating in terms of symptoms • Most common examples: – Migraine – Tension headache – Cluster headache SECONDARY HEADACHES • Headache arising secondary to another medical condition in the head, neck or elsewhere • Includes many serious and potentially life- threatening causes of headache SECONDARY HEADACHES- EXAMPLES • Meningitis/encephalitis • Intracranial haemorrhage • Subarachnoid haemorrhage • Brain tumour • Giant cell arteritis/vasculitis • Acute angle closure glaucoma • Ischaemic stroke • Intracranial hypertension • Cerebral venous thrombosis • Cranial neuralgias • Post-traumatic • Substance abuse/withdrawal • Psychiatric etc. HIGH RISK HISTORICAL FEATURES – “RED FLAGS” • Onset • Concomitant infection • Age > 50 • No similar headaches in the past • Altered mental status • Exertional symptoms • Seizure • History of trauma • Location of pain • Immunosuppression • Family history • Medications • Visual disturbances • Toxic exposure • Comorbidities • Pregnancy HIGH RISK EXAMINATION FEATURES – “RED FLAGS” • Neurological abnormalities • Meningism • Abnormal vital signs • Altered/decreased level of consciousness • Ophthalmologic findings – Exophthalmos – Abnormal pupil dilation – Papilloedema • Signs of trauma LOW RISK PATIENTS • Patients presenting with a pre-existing headache history usually due to failure of standard treatment • No change to headache pattern • No new concerning symptoms • No focal neurologic symptoms/signs • No high risk comorbidities • These patients do not require routine neuroimaging TENSION HEADACHE • Usually bilateral • Mild to moderate intensity • Non-throbbing headache • Usually no other associated features CLUSTER HEADACHE • Severe headache • Unilateral • Orbital, supraorbital, or temporal pain • Accompanied by autonomic phenomena – Ipsilateral to the pain – ptosis, miosis, lacrimation, conjunctival injection, rhinorrhea, and nasal congestion. • Occurs in “attacks” – usually lasting 15 to 180 minutes • Can be confused with a life-threatening headache, 1. SUBARACHNOID HAEMORRHAGE (SAH) • Causes – Cerebral aneurysm rupture – Trauma – Arteriovenous malformations – Non-aneurysmal perimesencephalic haemorrhage – Disorders of the blood vessels in the spinal cord – Bleeding into various tumours – Cocaine abuse and – Sickle cell anaemia (usually in children) and – Rarely anticoagulant therapy, problems with blood clotting and pituitary apoplexy can also result in SAH – Dissection of the vertebral artery, usually caused by trauma, can lead to subarachnoid haemorrhage if the dissection involves the part of the vessel inside the skull 4. SAH - GRADING Hunt and Hess Grading: Grade Signs and symptoms Survival 1 Asymptomatic or minimal headache and slight neck stiffness 70% 2 Moderate to severe headache: neck stiffness; no neurologic deficit except cranial nerve palsy 60% 3 Drowsy; minimal neurologic deficit 50% 4 /Stuporous; moderate to severe hemiparesis; possibly early decerebrate rigiity and vegetative disturbances 2% 5 |Deep coma; decerebrate rigidity; moribund 10% The World Federation of Neurosurgeons (WFNS) classification uses Glasgow coma score (GCS) and focal neurological deficit to gauge severity of symptoms." Grade Gcs Focal neurological deficit 1 of Absent 2 14 Absent 3 14 Present 4 7-12 Present or absent 5 J Present or absent 1. MENINGITIS • Inflammation of the meninges: • Various aetiologies – Non-infectious/Inflammatory – Infectious • Viral • Fungal • Parasitic • Bacterial 2. MENINGITIS – RISK FACTORS • < 5 years, > 60years • Immunosuppression • Non-immunised • Crowding • Exposure to pathogens • Asplenia • Sickle cell disease • Cranial defects/VP-shunt 2. GCA – CLASSIFICATION CRITERIA • ACR classification criteria - effective in distinguishing GCA from other forms of vasculitis (i.e. not diagnostic criteria): 1. Age greater than or equal to 50 years at time of disease onset 2. Localized headache of new onset 3. Tenderness or decreased pulse of the temporal artery 4. Erythrocyte sedimentation rate (ESR) greater than 50 mm/hour 5. Biopsy revealing a necrotizing arteritis with a predominance of mononuclear cells or a granulomatous process with multinucleated giant cells • Given that a patient has a diagnosis of some form of vasculitis, the presence of 3/5 criteria is associated with 94% sensitivity and 91% specificity for the diagnosis of GCA. 3. GCA – SYMPTOMS • Common symptoms – Constitutional symptoms – Headache – Jaw Claudication – Visual disturbance • Less common symptoms – Musculoskeletal – Large vessel involvement – Central nervous system involvement – Upper respiratory tract symptoms – Other head and neck involvement 4. GCA – PHYSICAL EXAM • Pulses • Temporal artery abnormalities • Bruits • Cardiac auscultation • Eye Examination • Musculoskeletal findings CSF EVALUATION • Many physicians reluctant to perform LP without prior CT – Potential risk of herniation in context of raised intracranial pressure (ICP) – LP alone safe in most of these patients, however in practice CT will usually be performed – Can assess for potential raised ICP clinically to risk stratify although not fully reliable (e.g. papilloedema, absence of venous pulsations on fundoscopy, altered neurological status, focal neurologic deficits) • Do not delay treatment of suspected CNS infection regardless of decision to image or not LAB TESTS • Specific tests can be helpful in evaluating possible causes of headache • Generally indicated by the patient's history and examination. • Many tests are supportive rather than diagnostic • Examples: – FBC – Blood cultures – Antigens – Urea and electrolytes – Glucose – Erythrocyte sedimentation rate (ESR) – C reactive protein (CRP) – Coagulation profile – Arterial blood gas – Carboxyhemoglobin – Temporal artery Biopsy MANAGEMENT • Specific management will vary depending on diagnosis • Relief of symptoms is important – analgesia and adjuvant therapy • Refer to Handbook of Clinical Medicine for Management CASE 3 A 52 year old man with a history of migraine presents to the emergency department complaining of headaches. He has a history of migraine and normally suffers with 3-4 attacks per year, often triggered by stress. These usually presents with visual aura and typically right sided headache, with photophobia but no other associated symptoms. He now complains of headaches which are present on waking each morning, and reports several episodes of vomiting in the last week. Examination reveals papilloedema. • Are there “red flag” symptoms/signs in this case? • What differentials should be considered? SUMMARY • Headache is an extremely common acute presentation • Multiple differentials • Important to differentiate between less serious primary causes and potentially more serious secondary causes of headache • History and examination are key to evaluation • Neuroimaging and CSF are mainstay of investigation • Management will be guided by specific condition