Chapter 18 - Headaches

Questions

Define the following terms:

subarachnoid hemorrhage, migraine, photophobia, phonophobia, tension-type headache, cluster headache, temporal arteritis, paresthesia, aura.
Subarachnoid hemorrhage is bleeding into the cerebrospinal fluid, usually due to leakage of an aneurysm or vascular malformation.
Migraine is a syndrome characterized by intermittent pounding or throbbing headache, potentially preceded by an aura. It has frequent association with nausea, photophobia, phonophobia and exertional worsening.
Photophobia is light sensitivity.
Phonophobia is sound sensitivity.
Tension-type headache is a recurrent headache with a bilateral, squeezing and pressing sensation that usually does not prevent normal activity and does not significantly worsen with exertion.
Cluster headache is a recurrent, severe headache, which is unilateral and periorbital and often associated with autonomic symptoms of tearing and nasal congestion.
Temporal arteritis is a condition of inflammation of major cranial blood vessels. It can result in blindness or stroke depending on the vessels involved.
Paresthesia is an abnormal sensation that is not due to an external stimulus.
Aura is a warning, prior to the onset of a symptom (this may occur in migraine or seizures.

18-1. What are bad signs/symptoms in the headache patient (and what might it signify)?

Answer 18-1. There are several worrisome signs and symptoms of headache: Sudden onset worst headache of life - subarachnoid hemorrhage; Sudden onset headache with focal neurologic deficit - intracerebral hemorrhge; New or different headache in older patient - giant cell (temporal) arteritis; Headache that awakens from sound sleep - increased intracranial pressure; Escalating headache that is always in the same location - focal lesion such as tumor, abscess or hemorrhage; Headache associated with a focal neurological deficit - focal lesion; Headache with recent head trauma, systemic disease, fever, malignant hpertension; Positional or exertional headache - obstruction of CSF flow

18-2. What does subarachnoid hemorrhage indicate and how can you rule it out?

Answer 18-2. It is usually due to aneurysm or arteriovenous malformation. LP may be the only way to rule this out and angiogram is the definitive test for identification of the specific cause.

18-3. How can you rule out intracerebral hemorrhage?

Answer 18-3. Imaging (particularly CT scan) can identify.

18-4. How can you test for giant cell (temporal) arteritis?

Answer 18-4. Sedimentation rate is almost always high. Biopsy is the only way to diagnose it definitively. It is critical to make the diagnosis because this is treatable with steroids.

18-5. How can you examine for intracranial pressure?

Answer 18-5. Looking for venous pulsations or papilledema in the eye grounds. Otherwise, the only way to determine pressure is by lumbar puncture (which is hazardous unless imaging has showed no intracranial masses).

18-6. What are possible causes of increased intracranial pressure?

Answer 18-6. Mass lesions (tumor, abscess), disruptions of resorption of CSF (meningitis, subarachnoid hemorrhage), sagittal sinus thrombosis or pseudotumor cerebri can all cause increased intracranial pressure.

18-7. What are the symptoms of common migraine?

Answer 18-7. It has no warning. Migraine headache is usually moderate to severe intensity, usually pounding, often unilateral and usually accompanied by nausea, vomiting, light and sound sensitivity. It is worse with exertion, and usually lasts several hours up to a couple of days. The headache may be provoked by food, drink, stress, erratic schedules, lights/glare, smells, part of menstrual cycle, etc.

18-8. How do you recognize classic migraine?

Answer 18-8. Classic migraine has warning before headache begins (aura). This aura is usually visual or paresthesia, although it may result in actual loss of function on some occasions (numbness, weakness, aphasia, etc). The aura often includes positive phenomena (lights, bright spots, lines, tingling/prickling) rather than simple loss of function.

18-9. How do you recognize tension-type headache?

Answer 18-9. These headaches are usually pressing or squeezing pain of mild to moderate intensity, with few associated symptoms and no warning. The headaches are not worsened by exertion.

18-10. How do you recognize cluster headache?

Answer 18-10. Cluster headaches are severe, unilateral pain starting in the orbit area, often occurring on a regular and predictable schedule that may awaken the patient from sound sleep. Usually the eye is red and teary, and nose is congested on that side. Horner's syndrome may be present on that side. Patients are agitated and are often awakened from a sound sleep. Headaches are short, usually lasting less than 90 minutes but they may occur in clusters lasting weeks to months and then go away.

18-11. What is analgesic rebound headache?

Answer 18-11. Regular intake of certain analgesics can increase frequency and decrease responsiveness of headaches.

18-12.What medical conditions can produce headaches?

Answer 18-12. Many medical conditions can produce headache, consider the possibility of problems with the temporomandibular joint, sinusitis or occipital neuralgia (greater occipital nerve). Systemic illness (such as the flu) can produce headache as can diseases such as: malignant hypertension, various infections in and around the brain, meningeal inflammation (infectious and non-infectous), inflammatory vasculitis, arterial dissection, thyroid and parathyroid disease, cardiac disease, pulmonary disease, renal disorders, sleep disorders. Also many medicines can trigger headaches.