headaches for the amk
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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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