Headaches and Facial Pain
Traumatic Brain Injury
Injury that causes HA w/ temporary loss of Fxn A) Concussion: Slight or mild brain injury from bleeding and tearing of nerve fibers -Recovery likely with some memory loss B) Contusion: A more severe TBI w/ nervous tissue destruction that does not regenerate and has amnesia C) Cerebral edema: Swelling from inflammatory response to injury
A 34-year-old woman presents to the emergency department with constant and severe right-sided headaches. One day prior to presentation, she was in a minor motor vehicle accident where her head jerked forward. She has also noticed mild eye-lid drooping earlier in the day. She smokes approximately 2-3 cigarettes per day. On physical exam, she has right-sided ptosis and miosis without anhydrosis. A non-contrast CT scan and CT angiography is performed, which demonstrates a tapered stenosis of the internal carotid artery and an intimal flap. What is your Dx?
Internal Carotid Artery Dissection
How can you tell the difference from cluster headache and Internal Carotid Artery Dissection?
Internal Carotid Artery Dissection has NO ANHIDROSIS and neuro deficient may be present if clots are going into circulation causing a stroke or retinal ischemia
trigeminal autonomic cephalgias
A) Cluster HA: involves all 3 branches and causes *rhinorrhea* Frequency: 1-8/day (HA alternate days) Tx: O2 Prevention: Verapamil B) Hemicrania (paroxysmal-episodic or continua-chronic): Ophthalmic branch (V1) Frequency: 1-40/day Tx: indometacin C) short-lasting unilateral neuralgiform HA w/ conjunctival injection and tearing (SUNCT)- Ophthalmic branch (V1) Frequency: 3-200/day Tx: Lamotrigine, *gabapentin*
Dizziness, dysarthria, ophthalmoplegia are characteristics of which migraine?
Basilar Migraine (migraine w/ brainstem aura) Dizziness- CN VII dysarthria- bulbar Dysfxn ophthalmoplegia (eye weakness)- CN III, IV, or VI
Which CN are compromised w/ Cavernous Sinus Thrombosis?
CN: III, IV, V (V1 & V2), and VI (MC) Remember 3-6 ER! Admit pt. Tx: IV ABx, Heparin, surgical consultation (for drainage)
Hemiplegic migraine (migranious stroke)
serious type of migraine. Symptoms mimic those common to stroke like muscle weakness can be so extreme that it causes a temporary paralysis on one side of your body. Caused by severe vasocontriction followed by vasodilation. If severe enough can lead to stroke
Subdural hematoma
Subdural hematoma results from a traumatic rupture of the bridging veins that connect the cerebrum to the venous sinuses within the dura. This venous hemorrhage will result in a gradual increase of the hematoma, with a progressive clinical picture over days or weeks. The CT scan will show a concave crescent-shaped hyper-density compared to the convex lens-shaped hyper-density in epidural hematoma.
Internal Carotid Artery Dissection
Sx: Orbital pain, horner's syndrome (but NO ANHIDROSIS), Ipsilateral neuro deficits and retinal ischemia Pt will have risk factors
What is the difference b/t TACs and trigeminal neuralgia?
TAC is activation of ANS fibers and trigeminal neuralgia is activation of the sensory fibers
A 65-year-old woman presents to the emergency department due to a severe headache and visual impairment in the right eye. Her symptoms are associated with pain with chewing and proximal muscle morning stiffness. On physical exam, she has decreased visual acuity of the right eye, scalp tenderness on the right, and an absent pulse in the right temporal area. Laboratory testing is significant for an elevated erythrocyte sedimentation rate. What is you Dx?
Temporal arteritis
A 28-year-old male lawyer presents with headache. He describes the headache as of tightening quality on both sides of his forehead. It is non-throbbing, but feels like a "tight cap." He denies phonophobia or photophobia. On physical exam, there is pericranial muscle tenderness. What is your Dx
Tension HA
Differences in HA
The typical presentation of migraine is moderate to severe pain that is often unilateral and throbbing. Pain is often accompanied by nausea, vomiting, photophobia, and phonophobia. A visual, auditory, sensory, or motor aura may occur with migraine but does not need to be present for diagnosis. Migraine headaches typically last 4-72 hours. Cluster headaches typically present with severe unilateral pain lasting anywhere from 15 minutes to 3 hours. The "clusters" may occur multiple times daily and usually occur daily for weeks to months. Associated symptoms include nasal congestion, lacrimation, rhinorrhea, conjunctival erythema, miosis, ptosis, or anhidrosis on the affected side. Following a series of attacks, patients typically have remission of several weeks or even months. Tension headaches are usually bilateral and described more as a tightness sensation than throbbing. Tension headaches usually last only 30 minutes. Symptoms of brain tumor vary by location, but the headache tends to be worst in the morning, gradually increasing in severity and frequency over time. Symptoms include vision changes, nausea, vomiting, sensory changes, confusion, and seizures. Pseudotumor cerebri is a condition in which the intracranial pressure increases. The associated headache is typically located behind the eyes and worsens with eye movement. Other symptoms include tinnitus, nausea, vomiting, dizziness, and changes in vision.
Trigeminal Autonomic Cephalgias (TACs)
-Activation of ANS fibers of CN V -Scalp tenderness for paroxysmal hemicrania
Further Evaluation of Headaches
-CBC: infection -ESR: Temporal arteritis -CMP: Metabolic HAs -Non-contrast CT: Intracranial hemorrhage -Contrast CT -MRI w and w/out contrast -Lumbar puncture
Intracerebral Hemorrhage
-HA with neurological deficit and subsequent LOC. They will be paralyzed in someway from the bleeding inside the brain. Can happen from risk factors like HTN causing an aneurysm or arteriovenous malformation Key look for a pt who has neuro deficits, HA, and N/V
Migraine
-Lateralized, pulsatile/throbbing HA associated w/NS, V and photophobia -Common migraine w/out aura MC (80%) -Classic migraine w/aura less common (20%) -Rx: -Prevention for > 4 attacks per month and those lasting > 12 hrs: Beta blockers, antidepressants -Mild-moderate: Combination analgesics (Excedrin migraine) -Moderate-severe: Triptan (5HT-1 agonist) -> vasoconstrictor (will help since migraines are thought to be caused by vasodilation of blood vessels)
Temporal arteritis AKA Horton's Disease
-MC females -Unilateral temporal HA -Jaw claudication -Polymalgia rheumatica -Visual defects -Sudden, painless, monocular vision loss -ESR elevated -Rx: 60 mg Prednisone Bx bilateral temporal arteries to confirm Dx
Cluster headache
-One sided facial pain that is repeated and excruciating pain -*Typically lasting 15-180 mins* -Unilateral periorbital ache associated w/ at least 1 of the following on same side of HA: -Partial ptosis -Pupillary constriction -Conjuctival redness -Tearing -Rhinorrhea -Facial swelling -Facial sweating *Rx: High flow O2 1st line! (10 L/min for 20 mins), Verapamil for prevention*
Idiopathic Intracranial HTN ("Pseudomotor Cerebri")
-Primarily in young, obese women of childbearing age -Predisposing factors: *OCPs*, anabolic steroids, tetracycline, Vitamin A -Enlarged blind spots, HA -Increased CSF pressure, otherwise nml -CT scan to rule out CNS mass -Rx: Lumbar puncture w/ or w/out blood patch, Acetazolamide-based diuretic, Diamox
What are the 4 phases of a classic migraine?
-Prodrome (2 hrs- 2 days) -Aura( < 60 mins) -Pain -Postdrome
Rx of Primary HAs
1. Migraine: A) Mild-Moderate: Combination analgesics e.g. Excedrin + NSAIDs B) Moderate-Severe: Triptan (must r/o CVD, CAD, PVD, and migraine w/ neuro deficits) Prevention: Topirmate, Metoprolol or propranolol 2. Cluster HAs: A) High flow O2 (10 L/min for 20 mins) + Triptan Prevention: Verapamil 3. Tension HA: A) Acute: NSAIDs B) Chronic: Amitriptyline, biofeedback therapy Prevention: Amitriptyline 4. Hypnic HA: A) bedtime lithium
What is first line Rx for trigeminal neuralgia?
Carbamezapine (Tegretol)
A 24-year-old female presents with worsening headache, fever, and double vision. Her headache is located in the periorbital region. Medical history is significant for a left-sided mid-facial furuncle which she attempted to squeeze over one week prior. On physical exam, there is bilateral supraorbital edema, lateral gaze palsy, ptosis, mydriasis, and chemosis. What is your Dx?
Cavernous Sinus Thrombosis Key Signs: recent facial infection, Fever, periorbital edema, chemosis (conjunctival edema), lateral gaze palsy or other CN palsies
A 31-year-old female presents with a headache that is throbbing and affecting the right-side of her head. She also reports nausea and had one episode of vomiting. Her symptoms began approximately 8 hours ago, where she began to see a bright light that progressively expanded, making it difficult for her to see. Sitting in a quiet dark room improves her symptoms. Medical history is insignificant. She denies alcohol, smoking, or illicit drug use. What is your Dx?
Classic Migraine
A 36-year-old male presents with recurrent bouts of left-sided severe lancinating periorbital pain. His symptoms began 20 minutes prior, and appears to occur daily for the past several weeks. He describes his headache as the "worst headache". During his headache episodes, he constantly tears, and has a "runny nose." Miosis, ptosis, and conjunctival injection is appreciated on exam. What is your Dx?
Cluster HA
A 51-year-old man presents to the emergency department due to headache, nausea, vomiting, and pupillary abnormalities after a physical altercation. The patient was in his usual state of health until there was a fight that resulted in head trauma. Medical history is significant for hypertension and chronic alcohol abuse disorder of over 15 years, which is treated with hydrochlorothiazide and disulfiram. His blood alcohol level is 0.32%. On physical examination, the patient appears confused and has a dilated pupil that is unresponsive to light. What is your Dx?
Intracerebral Hemorrhage
Intracerebral parenchymal hemorrhage
Intracerebral parenchymal hemorrhage is most likely caused by hypertension complicated with Charcot-Bouchard aneurysms. The blood accumulates into the brain substance and most commonly involves the basal ganglia.
How to you tell apart a Hemiplegic migraine from a TIA
In TIA, they don't get a HA and plus pt wont have risk factors for stroke
A 19-year-old man presents to the emergency department with a headache. His headache was initially mild but then subsequently worsened over the course 2 days. His headaches are associated with fevers, chills, photophobia, and neck stiffness. His temperature is 101°F (38.3°C), blood pressure is 124/95 mmHg, pulse is 118/min, and respirations are 22/min. Physical examination is notable for nuchal rigidity and petechieal hemorrhages in the skin. He has a + Kernig's Test and Brudzinski's Test. What is your Dx?
Meningitis
A 42-year-old male presentswith confusion, headache, and fever. The patient is unable to answer questions. A head CT is negative for a space-occupying lesion or hemorrhage. The MRI shows focal abnormalities secondary to edema. A lumbar puncture is performed, with cerebral spinal fluid (CSF) analysis showing a lymphocytic pleocytosis and normal glucose. PCR of the CSF is positive for HSV-1. What is your Dx?
Encephalitis
Encephalitis vs Encephalopathy
Encephalitis (fever and delirium caused by inflammation of the cerebrum from infection): -Fever common -HA common -Focal neurological signs common -Leukocytosis common -*Pleocytosis (Increased WBC in CSF)* -Focal abnormalities on MRI secondary to edema Encephalopathy (delirium d/o metabolic state of brain eg. liver failure causes hepatic encephalopathy): -Fever uncommon -HA uncommon -Focal neurological signs uncommon -*Leukocytosis uncommon (not an infection)* -MRI often normal
A 28-year-old man presents to the emergency department after a motor vehicle accident. The patient has a Glasgow score of 10. After airway, breathing, and circulation is secured, he undergoes a head CT without contrast, which demonstrates a lens-shaped hyperdensity that does not cross the suture line. There is a mild midline shift demonstrated on head imaging. What is your Dx
Epidural Hematoma
Epidural Hematoma vs Subdural Hematoma
Epidural Hematoma: Between skull and dura caused by Fx of the skull -Rapid high pressure *arterial bleed* -Loss of consciousness followed by a lucid interval and a more profound loss of consciousness -Imaging shows *biconvex bleed that does not cross the suture line* Subdural Hematoma: Between dura and arachnoid -Slow low pressure *venous bleed* -HA -Progressive delirium -LOC (not likely to be conscious until the hematoma is evacuated) -imaging shows *cresent-shaped bleed crosses suture line*
A lucid interval happens when they quickly regain consciousness after a short period of loss of consciousness, but the lucid period happens because after leaving the hospital then they will return with worsening conditions from the continuous bleed and increased ICP. What type of hematoma is this likely to be?
Epidural hematoma
Epidural hematoma
Epidural hematoma most often results from a traumatic tear of the middle meningeal artery. Although a lucid interval ranging from minutes to hours followed by altered mental status and focal deficits is typical for epidural hematoma, this clinical picture is only encountered in up to 1/3 of patients. The collection of blood between the skull and dura mater causes an evident mass effect with ophthalmic nerve palsy and the contralateral hemiparesis. Surgical evacuation of the clot via burr holes is the treatment of choice.
Traumatic Brain Injury Levels of Severity
Grade I: Confusion lasting less than 15 mins Grade II: Confusion and amnesia lasting more than 15 mins Grade III: Brief unconsciousness, more serious amnesia Guidelines for athletes Grade I: May return to sport after 15 minutes if symptoms are gone Grade 2: May return to sport after one symptoms-free week Grade 3: May return to sport after two symptom-free weeks
A football player suffered a head injury and he was unconscious for 15 minutes. The coach asks you whether he can put him back on the field because they need a strong defense to win? What is your response?
He may return to football after one week of no symptoms
A 56-year-old man with a history of alcoholism and liver cirrohsis presents with new onset confusion and irritatibility. He was recently admitted for sepsis caused by pneumonia. On physical exam he has a flapping tremor, ascites, jaundice and is not oriented to time or place. What is your Dx?
Hepatic Encephalopathy
First line Tx in cluster HA
High flow O2 (10 L/min for 20 mins)
What is 1st line Rx for a cluster HA?
High flow O2 (10 L/min) for 20 mins -Prevention: Verapamil
Tension headache
Non-pulsing "bandlike" pressure on both sides of head "my head feels tight"
Subarachnoid Hemorrhage
Life-threatening type of stroke caused by bleeding into the space surrounding the brain. SAH can be caused by a ruptured aneurysm, AVM, or head injury. Positive Kernig's Test and Brudzinski's Test Signs: -Thunderclap HA, sudden "worse HA of my life" -Neck stiffness, vomiting, photophobia, delirium and LOC -Presents similar to meningitis Rx: Ca channel blockers
Risk Stratification of Headaches
Low Risk Factors: -Age < 30 Y/O -Hx of similar HAs **No further investigation High Risk Factors: -Age > 50 Y/O -Fever/Wt loss -New severe onset HA -Hx of anticoagulation -seizure/paralysis **Get imaging
What is a MULTIFOCAL CONSTRICTION OF INTRACRANIAL BLOOD VESSELS THAT NORMALIZE WITHIN 3 MONTHS ON REPEAT MRA OR CTA?
Reversible cerebral vasoconstriction syndrome
A 14-year-old boy presents with recurrent nasal congestion and left suborbital pain of 2 weeks duration. 1 week prior to the onset of these symptoms, he described having a "cold." On physical exam, there is pain over the left maxillary sinus. What is your Dx?
Sinusitis Look for: Paranasal headache w/ rhinorrhea, nasal congestion, posterior nasal drip & tender on palpation
When should you suspect a brain tumor in a PT with a HA?
Sleep-Interrupting HA preceded by vomiting and followed by sz and neurologic deficits. *CT scan!
A 77-year-old man with a history of hypertension and a 46 pack-year smoking history presents to the emergency department from an extended care facility with acute onset of headache, nausea, vomiting, and neck stiffness and pain which started 6 hours ago and has persisted since. He is alert, but his baseline level of consciousness is slightly diminished per the nursing home staff. His temperature is 99.0°F (37.2°C), blood pressure is 164/94 mmHg, pulse is 90/min, respirations are 16/min, and oxygen saturation is 98% on room air. The patient's neurological exam is unremarkable with cranial nerves II-XII grossly intact and with stable gait with a walker. Kernig's Test and Brudzinski's Test are both positive. What is your Dx?
Subarachnoid Hemorrhage
Intracranial bleed hidden in the arachnoid space is associated w/ meningeal irritation and presents like meningitis EXCEPT no fever. What type of hemorrhage is this?
Subarachnoid Hemorrhage *(thunderclap HA and meningeal irritation)*
Subarachnoid hemorrhage
Subarachnoid hemorrhage is the result of an aneurysm rupture; the most common is the congenital berry aneurysm. The clinical picture is of a sudden severe headache with meningeal irritation. A CT scan will show blood in the subarachnoid space, and a lumbar puncture will reveal xanthochromia CSF.
Thunderclap headache, "the worst HA ever" w/ rapid onset and persistent
Subarachnoid hemorrhage or reversible cerebral vasoconstriction
A 76-year-old man presents to the emergency department with increasing somnolence and lethargy. His symptoms developed on the day of admission. His symptoms are associated with a headache with mild nausea but no vomiting. He tripped over a carpet and hit his head on the floor. A head CT without contrast demonstrates a crescent-shaped hyperdensity that crosses the suture lines. What is your Dx?
Subdural Hematoma
Vertebral Artery Dissection
This is associated with coughing, sneezing, diving, MVA, and neck manipulation. It causes a stroke presentation, headache, and unilateral Horner's syndrome (w/out anhidrosis), but a major key is *Dysarthria, Dysphagia, and Dysynergia (uncoordinated movements)*
Reversible cerebral vasoconstriction syndrome
Thunderclap Headache, recurs up to 3 months then when you repeat the MRA/CTA it disappears. Patho: blood rushes to the brain d/t HTN BUT also there is endothelial dysfunction. The endothelial dysfunction causes a HA from the severe vasoconstriction. Now the vasoconstriction causes an area of ischemia which leads to Posterior reversible encephalopathy syndrome (PRES)
A 54-year-old female presents with severe, stabbing pain on her left mandible. The pain lasts a few seconds and is triggered by brushing her teeth or chewing food. The pain episodes lasts a few seconds and occur 20 times per day. She denies any recent trauma or dental procedures. Over the counter simple analgesics do not improve the pain. On physical exam, touching the mandibular region reproduces the pain. Neurological exam is otherwise normal. What is your Dx?
Trigeminal Neuralgia
Rx of Secondary HAs
Trigeminal Neuralgia: Carbamazepine (1st line), Gabapentin if Tegretol not effective Temporal Arteritis: Prednisone 1 mg/Kg/d for 2-4 wks Vascular dissection: ASA for stroke prevention Reversible vasoconstriction syndrome: Verapamil and nimodipine (CCB) Intracranial HypoTN: blood patch Nummular HA: Gapapentin Cough HA: Indomethacin for acute Rx, lumbar puncture for long term control Sexual HA: No specific HA, prophylactic NSAIDs, BBs, CBBs Intracranial hemorrhage: ET intubation for hyperventilation and Dilantin to prevent sz TBI: APAP or amantadine Brain tumor: Dexamethasone (decrease intracranial pressure) Pseudotumor Cerebri: Lumbar puncture w or w/out blood patch, Acetazolamide-based diuretic
Cluster headache is a variant of a more complex disorder such as trigeminal autonomic cephalgia. T or F?
True
In a person with a cough HA or a HA precipitated by valsalva maneuver, must rule out brain tumor. T or F?
True
Meningitis is typically preceded by septicemia. T or F?
True
T/F Nummular headache is a localized HA to a small round area of the scalp. It is a form of trigeminal neuralgia causes pain to be localized as a patch distribution
True
T/F a pt with deafness, trigeminal neuralgia, and a facial palsy is a CPA tumor
True
Common migraines are more common than classic migraines. T or F?
True, (80%)
How can you tell the difference from Vertebral Artery Dissection and Internal Carotid Artery Dissection?
Vertebral Artery Dissection: Posterior circulation affects the brainstem causing *Dysarthria, Dysphagia, Dysynergia* Internal Carotid Artery Dissection: anterior circulation but *NO Dysarthria, Dysphagia, Dysynergia*
A 53-year-old man is brought to the emergency department by his friend after losing consciousness for more than 15 minutes following a bike accident in which he was not wearing a helmet. After falling, the patient hit his head and was difficult to arouse. In the emergency department, the patient appears agitated and had an episode of emesis. He had a short period of amnesia but he is starting to recall what happened. A noncontrast CT scan of the head is negative. What is your Dx?
contusion
signs of hemotympanum, battle's sign, raccoon eyes indicate a
basilar skull Fx Must do CT!
What should you consider when a pt c/o a cough HA (cough, sneezing, and straining)?
brain tumor, or Intracranial HYPOtension, or Chiari Malformation (bony abnormality at the base of the skull)
Intracranial hypotension
caused by CSF leakage causes orthostatic HA. This HA is aggravated by valsalva maneuver and onset of HA after getting up from bed w/in 15 min and relieved w/in 30 min of lying back down Predisposition: CT Dz (Marfan's Syndrome and Ehlers-Danlos Syndrome) Precipitation: bone spurs, back injury, LP, spine surgery Dx: low opening pressure on LP and MRI w/ subdural fluid collection, pachymeningeal enhancement, sagging of the brain, venous engorgement Rx: seal the leak w/ a blood patch
Primary headaches
migraine, tension, cluster, trigeminal autonomic cephalgia, and hypnic HA (in elderly associated with REM sleep)
Trigeminal Neuralgia
sensory fibers activated on trigeminal N. that cause eye pain, nose pain, mouth pain, *but NO REDNESS*. They won't sx associated to ANS like tearing, conjunctival redness, ptosis, runny nose A) Typical: Intermittent sudden severe shooting pain on one side of the face B) Atypical: Constant shooting pain -Caused by compression of trigeminal nerve root (by superior cerebellar artery or vein (90%) Eg: aneurysm and AVM, CPA tumor, postherpetic neuralgia, MS (<50 y/o) Rx: Carbamezapine (Tegretol) 1st line!
stabbing pain, sharp, shooting, sudden onset, think of
trigeminal neuralgia, nummular headaches, or TACs
Indications for Head CT in Traumatic Brain Injury
• Age >60 years • Seizure • Vomiting • Headache • Coagulopathy (eg. Apixaban) • CSF Rhinorrhea • Neurological Deficit • Glassgow Coma Scale Score <15 • MOI: fall > 3 ft, pedestrian vs auto • signs of hemotympanum, battle's sign, raccoon eyes
