Neurosurgery

• Headache


  In 99.9% of people with headache there is no sign of tissue damage, injuring the brain itself does not cause pain – it causes altered brain function, however the membrane and blood vessels of the brain are very pain sensitive
• Causes of headache


  • Primary (99%+)
  • Tension-type (69%)
  • Migraine (16%)
  • Stabbing (2%)
  • Exertional (1%)
  • Cluster (0.1%)
  • Due to something else (<1%)
  • Systemic infection (63%)
  • Head injury (4%)
  • Vascular / bleeding (1%)
  • Brain tumour (0.1%)

  
• Headache diagnosis is almost entirely on the patients story, tests, scans etc rarely helpful

  
• Headache history questions


  • How old were you when the headaches started?
  • How often do they come?
  • Do they come in relationship to anything else?
  • At what time do they come on?
  • How do they start?
  • Where is the pain?
  • How long does it last?
  • How bad is it?
  • Are there other symptoms?
  • Does anything bring it on?
  • What helps?
• Tension-type headache


  • Frequency: chronic, often daily
  • Pain: mild-moderate, pressure, tightness
  • Duration: 30 mins - 7 days
  • Location: both sides, whole head and neck
  • Symptoms: no light / sound sensitivity, no aura

  
• Tension-type headache


  Now thought to be due to increased brain sensitivity to normal sensory inputs, few effective treatments, we are trialling a non-drug treatment

  
• Migraine ("half-head")


  • Frequency: 1-2/year- 2-3/week
  • Pain: moderate - severe, pulsating, throbbing
  • Duration: 4 hrs - 3 days
  • Location: usually one sided (but side can swap between attacks)
  • Symptoms: aura, nausea, vomiting, sensitive to light, sound, smells

  
• Typical migraine patient


  Onset often as child / teenager / young adult, but can start at any age, 2-3 x more common in women than men, typical patient: young woman (15% of all young women)

  
• Migraine cause is unknown but strongly inherited, a lower threshold to spontaneously produce symptoms as if the head and brain had been injured, many effective treatments

  
• Migraine triggers


  • Foods: spices, wine, chocolate, citrus
  • Food additives: monosodium glutamate
  • Sleep: both too much and too little
  • Stress: mainly offset
  • Female hormones: fluctuating or falling oestrogen

  
• Migrainous aura is a visual disturbance that can occur before a migraine

  
• Medication overuse headache


  Headache made WORSE by pain killers, only occurs in people who already had headache, mainly due to codeine-containing medicines or stronger morphine-like drugs, need to stop responsible medicines: easier said than done, we are trialling a new treatment for this
• Cluster headache


  • Frequency: clusters – every time each year or season; then free
  • Pain: excruciating, penetrating, boring, continuous, non-throbbing
  • Duration: 15mins-3 hrs; same clock time each day (2am); several episodes / day
  • Location: ALWAYS the same side
  • Symptoms: watering eyes, nasal stuffiness, runny nose, red eye, swollen eyelids, sweating

  
• Typical cluster headache patient

  Middle aged male smoker
• Trigeminal neuralgia


  • VERY short (<1 sec) severe pain, Knife-like, Local triggering: eating etc
• Typical trigeminal neuralgia patient


  Middle aged / elderly woman
• Other headaches


  • Paroxysmal hemicrania
  • "SUNCT" - short lasting neuralgiform;conjunctival injection, tearing
  • Stabbing headaches
  • After head injury / head surgery
  • Sexual headaches
  • Altitude sickness

  
• Headache treatment


  • Explanation, set realistic objectives
  • Lifestyle change
  • Treatment of the attack
  • Treatment to reduce attack frequency

  
• Treatment of the attack


  • General pain relievers
  • Migraine-specific treatments - triptans and ergots
  • Cluster specific treatment - oxygen, triptans

  
• General pain relievers: migraine, tension


  • Aspirin
  • Paracetamol
  • Ibuprofen
  • Codeine
  • Tramadol

  
• Triptans


  • FOR: can be very effective: migraine, cluster (NOT tension), tablets, wafers, nasal spray, injection

  AGAINST: feel strange, chest pain, expensive, small supply, overuse makes headaches more frequent, constrict blood vessels

  
• Ergots


  • FOR: can be very effective when others fail, nasal spray, suppository injection

  AGAINST: hard to get, overuse causes poor circulation and more headache, not for tension
• Preventative drugs


  • "mixed bag" of drugs used for other conditions found to be effective in headache usually by chance, usually for high blood pressure, depression, epilepsy, all work in somebody; none works in everybody, generally reduce frequency but do not change attacks, key to success: trial and error: persist, need to start at low dose and increase until effective or not tolerated, about 50 % of patients will get 50% or more reduction in attacks
• Non-drug treatments


  • Herbal: feverfew - no, butterbur - possibly

  Manual therapies: physiotherapy - caution, acupuncture - no

  Electrical occipital nerve stimulation: possibly

  Closure of hole in heart - no
• We are trialling a non-drug electrical therapy for tension-type headache, a completely new drug approach to medication overuse headache, and may be trialling new agents for migraine in the near future
• A tool for detecting secondary headaches was proposed as a red flag detection tool for secondary headaches

  
• Head injury can cause secondary headaches
• Objectives for head injury


  • Describe basic intracranial physiology

  Recognize the importance of limiting secondary brain injury

  Perform a focused neurologic exam

  Stabilize and arrange for definitive care
• Skull base fractures can occur with head injury
• Glasgow Coma Scale (GCS)


  A tool for assessing the level of consciousness after a head injury
• A motor score of M3 or M2 on the GCS indicates a poor prognosis
• Holistic view


  Don't look for head injury alone, also look for neck, chest, abdomen, and limb injuries
• Hypotension after head injury, except in 3 rare situations, is usually due to extracranial causes, so always check the chest, abdomen and limbs
• Types of intracranial hemorrhage

  • Epidural hematoma (EDH) - arterial, lens-shaped, with a lucid interval

  Subdural hematoma (SDH) - venous, crescent-shaped

  Subarachnoid hemorrhage (SAH) - meningitis-like, risk of vasospasm and seizures

  Intracerebral hemorrhage (IPH)

  Diffuse axonal injury (DAI) - shear injury, sudden rotation, grave prognosis
• Intracranial anatomy and physiology


  Rigid, nonexpansile skull filled with brain, CSF, and blood, CBF autoregulation, Autoregulatory compensation disrupted by brain injury, Mass effect of intracranial hemorrhage
• EDH


  Arterial, lens, lucid interval
• SDH


  Venous, crescent
• SAH


  Meningitis like, risk of vasospasm & fits
• DAI


  Shear injury, sudden rotation, grave prognosis, low GCS/coma with negative CT
• Rigid, nonexpansile skull filled with brain, CSF, and blood