Session 6:Assorted Headaches

Vignette

• 28 yo computer programmer with worsening headaches. She had rare severe headaches as teenager. Present h/as are 1/month, retro-orbital or right temporal with nausea, photo- and sono-phobia. At times she has to leave work. Over the counter analgesics are not beneficial. Headaches are worse on the weekend and wonders if she needs a brain CT scan. Her neurological examination is normal.

Questions

• Headache timing and triggers

• Exacerbating and/or relieving factors

• Accompanying symptoms

• Family history

• Other features on examination

• Type of headache

Headache type temporal profile pain location Neuro exam gen exam

Migraine bitemporal Normal Normal

Tension Posterior Normal Normal

Analgesic Normal Norlml

Sinusitis Sinuses Normal Snus tenderness

Trigeminal neuralgia Trig nerve Exam triggrs sx normal

Temporal arteritis temporal arteries Nl? Temporal artery tenderness

TMJ TMG normal TMJ

Brain tumor ? Normal

Tension Headache

Sinus Headache

pain and tenderness behind the forehead, cheeks and around the eyes pain in the back of the neck or upper teeth pain ranging from mild to severe pain that is more intense first thing in the morning pain that may worsen when you bend over headache occurring with other symptoms of sinusitis, including:

nasal stuffiness and congestion, thick nasal drainage, post-nasal drip, fever, fatigue, stuffy ears, sore throat, cough, and puffiness around the eyes

Sudden lancinating, severe, brief pain

Repetitious, but with significant pain-free intervals

Can be triggered by a nonpainful stimulus

Ordinarily prevented or reduced by carbamazepine

Almost exclusively a disorder of adults

Involves the right side of the face more often than the left (about a 3:2 ratio)

Affects women more than men (about a 2:1 to 4:3 ratio)

Has various causes

Giant Cell (Temporal) Arteritis

Management of Giant Cell (Temporal) Arteritis

Figure 3-14.—Ligaments of a temporal mandibular joint.

Figure 3-13.—Temporal mandibular joint.

Pain or tenderness in the face, jaw joint area, neck and shoulders, and in or around the ear when you chew, speak or open your mouth wide Limited ability to open the mouth very wide Jaws that get "stuck" or "lock" in the open- or closed-mouth position Clicking, popping, or grating sounds in the jaw joint when opening or closing the mouth (which may or may not be accompanied by pain) A tired feeling in the face Difficulty chewing or a sudden uncomfortable bite – as if the upper and lower teeth are not fitting together properly Swelling on the side of the face

The symptoms of a cluster headache include stabbing severe pain behind or above one eye or in the temple. Tearing of the eye, congestion in the associated nostril, and pupil changes and eyelid drooping may also occur.

Questions

• What are the alarming features from a headache history

• On exam?• Tests: LP, CT scan, etc.• Abortive treatment options• Preventive treatment options

• See link

Questions

• What structures in and around the cranium are pain sensitive?

• What is the sensory innervation of the face, head and neck?

• What kind of nerves transmitt pain?

• What are the neurotransmitters involved?

Migraine Pathophysiology - trigeminovascular

Vignette

• 40 yo rh woman who developed a severe sudden onset, whole head pain while playing tennis. It peaked quickly and began abruptly and she stopped playing sat down became nauseated and vomited twice.

• History of milder headaches in the past• Exam: pale, diaphoretic, nauseated, 140/75 BP;

HR 80; supple neck; tightness in cervical and upper chest. Photophobia noted.

• Subarachnoid hemorrhage

Questions

• Differential diagnosis

• Workup

• Management

ANEURYSMS PRESENTATIONOften asymptomaticFocal neurological deficits depending on location; for example, if the aneurysm compresses the area of brain controlling the left leg, then left leg weakness will occur.Mild headachesNauseaNeck stiffnessSevere "thunderclap" headaches if the aneurysm ruptures (Subarachnoid Hemorrhage)

Genetic predisposition in persons with Polycystic Kidney Disease or coarctation of the aorta

Look for on examination: Nuchal (Neck) rigiditySigns of meningeal irritationFocal cranial nerve signs (e.g., 3rd nerve) or limb weakness, etc.

Testing for a SAH/aneurysm

CAT scan to check for the Subarachnoid Hemorrhage.

If the CAT scan is normal, but Subarachnoid Hemorrhage is suspected, then a lumbar puncture (spinal tap) is performed and examined for blood or xanthochromia.

Cerebral Angiogram, where a dye is injected and X-Rays of the blood vessels in the brain are taken, may be necessary to find the site of bleeding (e.g., a ruptured aneurysm).

MR Angiogram may be considered, but it is not as accurate as a Cerebral Angiogram

Symptoms, Signs and Studies for the Following:

• Chronic subdural hematoma

• Subarachnoid hemorrhage

• Temporal arteritis

Hit on the head with a hammer.

There is extradural hemorrhage present in the right parietal region. The bleed is lens shaped and causes mass effect upon the adjacent brain parenchyma

Findings: There is a moderately sized hyperdense crescentic extraaxial fluid collection overlying the right frontal lobe. Associated midline shift to the left and mass effect on the frontal horn of the right lateral ventricle and cortical sulci of the right frontal lobe is seen.  Most (85%) subdural hematomas are unilateral, commonly occurring in the frontoparietal convexities, and the middle cranial fossa. Acute subdural hematomas are usually diffusely hyperdense. However, they can have a mixed attenuation of hyperdense and hypodense areas, which represents unclotted blood in the hematoma.

Acute Epidural Hematoma Acute Subdural Hematoma

There are bilateral crescent shaped extraaxial fluid collections, compatible with subdural hematomas. Each collection has a fluid-fluid level. The high attenuation dependent portion represents acute blood from repeated hemorrhage superimposed on chronic hemorrhage (low attenuation). The larger left subdural hematoma has mass effect with effacement of the left lateral ventricle.

A subdural hematoma is caused be stretching and tearing of the bridging cortical veins which cross the subdural space to drain into the adjacent dural sinus. Ten to thirty percent have repeat hemorrhage, secondary to rupture of stretched cortical veins as they cross the enlarged fluid filled subdural space or from the vascularized neomembrane.

Acute on Chronic Subdural Hematoma

Questions

• Risk factors for chronic subdural hematoma

• Clinical presentation of a chronic SDH:

• Diagnosis of SDH

• Overall mortality of recognized SAH

• Complications of SAH and time course

• Management of temporal arteritis

• Risks of missing diagnosis

Giant Cell (Temporal) Arteritis

Management of Giant Cell (Temporal) Arteritis

Vignette

• 18 yo college freshman with headache, fatigue, sore throat and muscle pain. Subsequently develops shaking chill, nausea, light-headedness and increasing headache. Becomes increasingly ill over 30-45 minutes with temp 102.6 F and develops reddish-purplish spots.

The bacteria leak poisons which damage the walls of the blood vessels, so the blood leaks into the skin – causing the rash.

The glass test, or pressure test – a septicaemic rash usually does not fade under pressure. (Not 100% reliable.

Suspect meningococcal meningitis if a patient presents with a bad cold progressing to: Fever over 38.3C AND sudden severe Headache along with any of: Neck/back stiffness, mental changes (agitation/confusion/coma), petechial rash (late sign)

Questions

• Differential diagnosis

• Workup and treatment

• How quickly

Condition Onset Course Sys MenPyo men

Viral men

Viral encep

Brain abs

CJD

Condition OP app glc pro cell diff gm st Pyo men

Viral men

Viral encep

Brain abs

CJD

Questions

• Pyo men:

• Viral encep

Questions

• Pyogenic meningitis

• Viral meningitis

• Viral encephalitis

• Brain abscess

Plain Head CT

Head CT with Contrast

Brain MRI withGado

Herpes Simplex Virus (HSV) encephalitis has its own neuroanatomy. It tends to attack a part of the brain known as the "limbic system", a set of interconnected brain structures responsible for the integration of emotion, memory, and complex behavior. This disease is important to recognize because there is an effective drug treatment, acyclovir. We will see the limbic system on this tour, as shown by the lesions of a typical case of HSV encephalitis. HSV is ubiquitous, but fortunately, only 1 or 2 cases per million infected individuals develop the encephalitis of HSV each year in the US. It is the most frequently fatal of all encephalitides.

In this set of images, there is a region of very bright signal on MR in the medial temporal lobe at left (patient's right). This corresponds to an area of active viral leptomeningeal and brain tissue infection. Hemorrhage can occur acutely, but is not seen in this case. You can see obliteration of the temporal horn of the lateral ventricle because of swelling of the hippocampus. The remainder of the brain is relatively hypoperfused and structurally normal. The MR images were obtained 5 days after onset of symptoms.

Encephalitis refers to viral infection of the brain. Herpes simplex is the most important virus causing encephalitis. It leads to hemorrhagic necrosis of the temporal lobes.

Questions

• Typical infections– Asplenia

– Cellular immunodeficiency