In this episode of PodMD, neurosurgeon Dr Jeremy Russell will be discussing the topic of neurosurigical causes of headaches, including what are the neurosurgical causes of headaches, treatment, when a GP should refer and more.
- Transcript
Please note this is a machine generated transcription and may contain some errors.
*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Today I’d like to welcome to the PodMd studio Neurosurgeon, Dr Jeremy Russell.
Dr Russell’s speciality involves expertise in cerebrovascular surgery, skull base neurosurgery and spinal surgery.
Today, we’ll be discussing the topic of neurosurigical causes of headaches.
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.Jeremy, thanks for talking with us on Pod MD today.
Jeremy: Thank you for having me
Question 1
The topic of today’s discussion is on neurosurgical causes of headaches. Jeremy, can you describe for our listeners what a neurosurgical cause of headaches is?Jeremy: So, today I was just going to touch on neurosurgical cause of headaches as headache is one of the most common presentations to GPs, and obviously there’s, hundreds of different causes of headaches, of which I’m only going to touch on a few that are relevant to the neurosurgical specialty. so within those, there are a few headaches that will place a certain amount of fear into most doctors and especially GPs or non-neurosurgeons. and they would typically be either from a subarachnoid haemorrhage or from raised intercranial pressure will be the two that would, I guess, garner the most excitement for people. now, aside from that, there are a variety of other causes, that we deal with in one shape or other. but I was going to probably focus on those first two mostly because I think they’re the ones that will cause the most concern.
Question 2
How would a patient initially present with neurosurgically caused headaches?Jeremy: So if, if patients coming into your, into the GP office with a headache, trying to discern whether or not it’s something you’re a surgical, such as discussed a separate known haemorrhage or a brain tor or the like, can be incredibly difficult first up, subretinal haemorrhage is typically a little more straightforward. So it’s got a very classical presentation of Thunderclap headache it’s often referred to and it is a sudden onset, severe headache. And the way I ask patients about it it’s as if I got a bit of two by four, walked up and clocked you over the back of the head, it’s that rapid onset, literally bang. And it is almost always the worst headache you’ve ever had. So it’s not something you go, Oh, what was that?
And then keep on doing your thing, often associated with nausea and or vomiting and, you know, w when it gets worse than that loss of consciousness, seizures, et cetera, then it becomes a little more obvious than that. Generally, they’re going to the emergency department anyway. but it’s really it’s in the history. So it’s in the timing, especially. So the temporal nature of the headache is by far and away, the most important it does not come on over a minute or five minutes or 30 minutes from nothing to hitting its maxim. It is literally bang, sudden onset nought to 10, any headache like that should raise your concern significantly. similarly, subretinal haemorrhage headaches, as I said, they are almost always described by the patient as the worst headache they’ve ever had. they don’t look well, I don’t know how to describe it, but you can kind of just picks up our patients, looking at them, they look miserable. The headache does not go away. It lasts typically for days or even weeks. So again, if they’ve come back and their headache went five minutes after or 30 seconds after it’s highly unlikely to be a suburb. The reason why everyone gets so worried about it is if it is a separate non haemorrhage, there is a 30 to 40% mortality and of those that survive only one third ever go back to their day-to-day life. So it has severe consequences. And the first treatment is to fix the, the aneurysm, which is typically the cause of it, which is a neurosurgical thing. So that’s why it garners so much fear associated with a headache is often, nuclear for rigidity. So a stiff neck or meninges MIS it can be known as a stiff neck, a avoidance of bright lights. And so there’s photophobia avoidance, loud noises, phonophobia, nausea, vomiting, et cetera.
, if you are concerned about this, I would suggest that the patient be referred to the nearest emergency department immediately. I don’t think there’s any point in trying to send them off for a CT and see them again later that day. Like, I think you’re better off just to get them to the nearest emergency department and have it excluded due to the seriousness of the condition. so I won’t really touch more on the after treatment once they get to the hospital. I think we’re more at the point of today’s module, discuss how to pick them. so that will probably be the one that I think causes the most fear to GPS. other causes of headaches that do make people concerned, raised ICP headaches. So by ICP, I mean intracerebral pressure. they tend to be headaches that wake the patient up early or worse in the morning, rather than the evening.
The reason for this is that a lot of people, when you go to sleep, you don’t protect your airway as well. You tend to not breathe as well. And thus, you tend to raise your carbon dioxide levels. Carbon dioxide is a natural vasodilator of the brain. So, it causes the blood vessels to increase in size. Therefore, if they increase in size, they increase in vole. And if you’ve already got a tight brain, then it makes it even tighter. And that’s why wake up worse as they were a couple, they tend to start breathing properly. They blow the CO2 off and then the headaches subside a little bit. So that’s the rationale for the early morning headache. They tend to be frontal or by temporal in nature, throbbing pulsating, rather than sharp shooting electric, et cetera, they get worse with things that increase your ICP, such as coughing, sneezing, leaning down to put, you know, tie your shoelaces on straining on the toilet, et cetera. Cause all those things involve a degree of Vel Silva and increase the Venus or reduce the venous drainage and hence increase your intercranial pressure. yeah, they get worse when lying down for the same reason. They’re partially resolved by standing up for the same reason. And if it’s due to a tor or something, they tend to just progressively get worse as the tor gets bigger, et cetera. there is the, the initial symptoms is just a headache. And at this point it’s incredibly difficult to discern and there’s really nothing special at that point. Next tends to be nausea followed by vomiting. Interestingly vomiting often helps relieve the headache so they can have a nasty bout of vomiting and retching and then immediately thereafter the, Oh my headaches actually. Yeah. So that’s really until atypical of other headaches and he’s certainly seen more in raised ICP headaches.
The next thing to happen is then more obvious. So drowsiness confusion, mental change, and it really depends where the lesion is. So if it’s frontal, or certainly by frontal, they lose their executive function. They often become more dis-inhibited, impulsive often, angrier, shorter fuse, et cetera. And very often when you ask the partners about this, they go, Oh yeah, nber, all that. and then it really depends. So if it’s an, a parietal area, you may get a, it’s called a Gerstmann syndrome. We have a, so it’s a dominant hemisphere parietal and you get a calculator. So you can’t do mathematics a graph. You can’t right. You forget, which is, which has left in, which is right. And then interestingly, you can’t remember what your fingers are called. So you hold your thumb up and ask them, what’s this one called and they go finger. So that’s very classic of, it’s called Gerstmann syndrome. and I, I won’t go through all the rest of them. It depends what part of the brain is, is, and then on examination, the most important thing is to do a formal eye exam. And fundoscopy, now I realize that people who don’t do this very often, it can be very challenging. And I would not asking the GP to dilate the eyes because then we lose information as to what’s going on with the patient. some of the newer ophthalmoscopy to the Panopto Alma scope is actually really, really good to get a decent look at the funders. But at the end of the day, if you’re not doing this very often and you’re not comfortable discerning what is or is not pebble DEMA, there’s probably no point in doing it. And then I would just refer them to an eye doctor who is more, happy making that diagnosis.
, but there are certainly the, the features of the headaches that are concerning, if they are drowsy or towards the latter end of the spectr, if there’s mental, cognitive changes, drowsy, obviously a specific neurological deficit, such as weakness or nbness or whatever the case may be. then if you happen to know when you’re a surgeon, you, I will call them directly. I’m certainly happy to be called directly on my mobile. And now we have, access to radiology from wherever. So by this point you’ve often done, at least a con a non-contrast CT, happy to take a look at it and offer advice. Not all of them need to be rushed to the emergency department. Sometimes I’ll look at it and go, yeah, I’ll see them tomorrow or in a couple of days. Or sometimes you might look at and go, I’ll see you in a week. Other times you will say get them to the emergency department immediately. so they’re more the features of raised ICP.
Question 3
Tell me about any incidental findings when patients have been sent for brain scans?Jeremy: I actually see this quite often nowadays patients are referred for an MRI brain for the headache may be more often than not. It’s just a primary headache and the scan is normal with respect to the etiology, the headache, three to 40% of MRI brains will find an abnormality. And unfortunately, then you have to do something about it. one of the more common ones is incidental, small aneurysms or brain aneurysms. and I probably see one every couple of weeks of these, more often than not they’re innocuous and nothing to worry about three or 4% of the population have a cerebral aneurysm. I think if you do see one, it is then reasonable to refer on to a neurosurgeon, rather than a neurologist. and even within neurosurgery, there’s only a few of us who have a particular expertise in this kind of thing.
So, most neurosurgeons probably are not adept to then make, all the, all the appropriate choices. So if you do happen to know someone who has a cerebral vascular interest, but just as a rough guide, if the enter ism is less than three millimeters, or really less than four millimeters, we’re almost always not gonna do anything about it. Just monitor it with repeat imaging, if it’s more than seven millimeters, and they’re a young ish patient, I at least got five or more years to live. then we would tend to treat it. And then in between really comes down to their risk factors, which include family history of aneurysms, personal history of subretinal hemorrhage, or aneurysms smoking and high blood pressure, the main ones, we will then make a decision based upon the risk factors, the size of the end reason, the shape of the end result and the location as to whether or not it mandates treatment. but certainly I think a referral, is appropriate. And then from there on the bonuses that we will over see their ongoing management and then you don’t have to worry about it anymore.
Question 4
What is the treatment like?Jeremy: Sure. So, with respect to a subretinal hemorrhage, that’s getting them to a tertiary and I would suggest public hospital, private hospitals are not really geared for ruptured aneurysms. so calling triple zero, getting them to an appropriate tertiary hospital immediately for ongoing management. I won’t go into what happens once we get there as to raised. ISEP, it’s really recognizing these flags considering it is a secondary headache rather than a primary headache and then ordering a scan. I think ultimately an MRI brain is always more useful than a CT, but I am aware that it can be expensive for patients, and thus they may opt not to, but you certainly do get a lot more information from an MRI, but either way, some form of scan, it really, if you are concerned about raised ICP, I think it really should involve contrast they a CT with them without contrast or an MRI with them without contrast as it is.
It is certainly possible, especially on CTS, probably less. So an MRI that patient may have something going on and you just don’t see it without the administration of a contrast . And then obviously once the scan has been done, if something is found, then are appropriate referral from there. I would suggest that if there is evidence of a brain tor, that they either contact a neurosurgeon, fairly rapidly the same day, for an opinion as discussed, we can often log in from wherever, have a look at the scan and triage it accordingly. If we are particularly concerned, we may ask you to administer something such as dexamethazone to reduce the swelling in the brain, in conjunction with the PE a proton pp inhibitor, or refer to the local emergency department or whatever the situation may be
Question 5
Other conditions that may be neurosurgical causes of headaches?Jeremy: Aside from what we’ve already touched on? , there are, quite a nber of other things that can be associated and I’m not gonna run in really any detail at all, more to mention that they exist. And again, to highlight you to think about them. so within the vascular cohort, one of the more common ones we speak, especially in females, and people have risk risk factors of thrombosis such as smokers or on the pill, or, various genetic conditions is cerebral venous thrombosis. so this can be with them without neurological deficit, but often it is the cause of significant headaches, and mandates appropriate imaging. it can be quite a dangerous condition, otherwise vasculitis, including giant cell arteritis. so this is often people who complain of significant pain on touch or pressure around their, temple region, just near where the hairy temple here or near the temporal region, where the hair meets the, the ear or the forehead there.
And that’s the superficial temporal artery runs there. And that can be inflamed in this condition and be a marker of stroke and people can lose their vision. So if they’re saying it’s particularly to touch, especially if you can feel a thickened artery running through there, then this is a true emergency and the treatment is under a neurologist or a rheatologist. And often we will then obtain a biopsy, but start the patient on very high dose steroids. As I said, because loss of vision is a real concern in this setting, stroke or Tia, not so much, much presenting with headache, but may so again, just think of it. One that can more present with headache in this setting is dissection of typically the carotid artery, or it may be the vertebral artery as well. So these people patients often present with really quite severe neck pain, associated potentially with headaches often radiates into the back of the eye and with any neurological deficit, it may be associated with traa.
So I’ve seen this from, aggressive neck manipulations by, some allied health team, okay. Car accidents, you know, bike accident, those sorts of things, more obvious, but they don’t have to, it can just be someone has a collagen disorder such as fibromuscular dysplasia, et cetera, but it’s that really sudden onset of nasty. And they often describe it as a tearing pain, which is kind of a hint, in the neck or base of the skull and obviously associate with anybody neurological deficit, brain infection, really the, the features of raised ICP, but in conjunction with temperatures, and re , concerns of, meningitis, et cetera, or encephalitis, they all present fairly similarly. And I think that would, if you’ve got concerned about that, that’s, mandates the new nearest emergency center finally hydrocephalus, which is a communication of fluid in the head.
, fear really uncommon without a precipitant, such as traa. you can occasionally see it with things such as the colloid cyst, but they will present with ICP features. pituitary apoplexy is where you have a sudden bleed into pituitary gland. They will present with loss of function of their pituitary system, sudden severe headache, often the rates as a subretinal hemorrhage. And then on imaging, you see blood in the pituitary fossa, that is a potentially life-threatening emergency, and they can lose their vision instantaneously, benign intracranial hypertension or idiopathic intracranial home potential, is typically middle-aged, women who are carrying a bit of extra weight on the pill is the classic. and they, on their scans, they have actually quite small ventricles, but they have, or raise pressure. We’re not really too sure of the etiology. Often it’s due to impaired venous outflow from the brain.
, you must check their vision because if they’re having visual loss, then that can be a surgical emergency as well. Arnold Chiari headaches. So these are people who have the cerebellar tonsils too low, and they get these particular headaches, typically in the back of the head, the occipital region they’re exacerbated by anything that raises ICP. So Val Silva nerve is coughing, sneezing, light leaning down, straining on the toilet, et cetera. And that is a fixable one. It’s not a life-threatening one, but a fixable one. and then finally, a bit of an odd duck is intracranial hypotension. people can develop a spontaneous CSF leak or sometimes after a lbar puncture. And they complain to the headaches when they sit up. So lying down, takes the headaches away and then sitting up brings the headaches on, which is the opposite to almost every other headache there is.
So if you do see that unusual, situation, then you should think about that. And probably an MRI brain, looking for a cure, looking for it’s a brain, herniation again, and that would then be referral to emergency department. And then finally, I should say very, very common cause of headaches, typically a separate or headaches, but they can rate out in the retro-orbital regions through the base of the skull is just degenerative spinal disease associated with referred pain via the facets, et cetera. And that’s known as a separate of cervical headaches. management is physiotherapy, but having said that there’s only a few physiotherapists who really know what they’re doing in this scenario, and you really need to find the right ones otherwise more often than not, they don’t work. so that pretty much ss up most of them, but it’s really the first two that I wanted to bring people’s attention to today.
Question 6
When should a GP refer?Jeremy: GP referral, obviously subretinal hemorrhage. That’s straight to emergency department. That’s fairly straightforward, raised ICP. If the scan does show something, then a referral would be mandatory. obviously it depends on what is seen. If it’s a, you know, a huge brain tor, then, a phone call that day is probably appropriate for referral to the emergency department. but more often than not, you might find, you know, a small incident or meningioma or pineal region cyst. And that is a very elective situation and, you know, reviewing rooms, et cetera. but ultimately if you really concerned, that it could be something nasty. My suggestion is you’re better off being more cautious than otherwise. and in that setting more often than not, it would referral to emergency department further workup.
Concluding Question
Thank you for your time here today in the PodMD studio. To s up for us, could you please identify the three key take home messages from today’s podcast on neurosurgical causes of headaches?Jeremy: Okay. take home messages for this. It’s a little harder to define these, really
1. I guess, with any, because headaches are so common, but anyone who presents with a sudden onset severe Thunderclap headache, please consider separate not hemorrhage, take it seriously.
2. , and if there’s any concern that are truly, could be one referred to the emergency department immediately, if you’re more concerned about a slowly progressive headache with features of raised intracranial pressure, I think a scan is warranted.
3. , I would suggest an MRI offers a much higher yield than a CT, but I’m aware of the cost implications of this, but at least some form of imaging and preferably with and without contrast, And then finally, unfortunately there is a list as long as my arm or various kinds of headaches, and it can be incredibly difficult to try and discern between those.So if, if you are not, if you are concerned that it’s not just a straightforward migraine or cervicogenic headache or something really quite simple to deal with, I’ll, I would have thought a referral to either a neurologist or neurosurgeon for further opinion is more often than not mandated. And if you get to this point, then often with an accompany MRI,
Thanks for your time and the insights you’ve provided.
Jeremy: Absolute pleasure I hope that helps
