So that's the low pressure
headaches, intracranial hypotension.
What about high pressure?
Let's learn a little bit more about
that by also considering a case.
This is a 38-year-old obese woman
with a 3-month history of headaches.
She reports by temporal
They're worse in the early morning
and they've been awakening her
out of sleep at 4am
over the past 2 weeks.
There's mild nausea,
but no photo or phonophobia
like we would see with migraine.
She also reports mild vision
complaints, difficulty seeing cars,
particularly from the lateral sides
when driving and that's worse at night.
Her current medications
include oral contraceptives,
which in some people can increase risk
of coagulation, hypercoagulability.
On exam, she has difficulty with finger
counting in the far peripheral fields.
She has a far peripheral field
abnormality or homonymous hemianopia,
bilateral reduction in adduction
of the extraocular movements,
bilateral reduction in abduction
with extraocular movements.
So what type of headache
syndrome does she have?
Well, there's some key clinical
features that would tip us off here.
The first is this
She has early morning awakening.
Many people's headaches will
present in the early morning.
But the difference
in this patient
is that these headaches are
awakening her up out of sleep.
We all get up and may feel a
headache from obstructive sleep apnea
or medication overuse
headache or just a migraine.
But few headaches wake
us up out of sleep.
And that's the
characteristic feature here
which is pointing us in the direction
of a high pressure headache.
In addition, we see some
other key associated features.
We have the clinical description
that makes us concerned
for bilateral sixth nerve palsies,
difficulty with looking laterally,
reduction of gaze,
peripheral fields laterally,
and then ultimately on exam, we find
that reduction in sixth nerve activation,
bilateral sixth nerve palsies.
So is this a primary or
secondary headache syndrome?
Well, this is a secondary
and requires evaluation for the cause
before we proceed forward with treatment.
This patient underwent
MRI of the brain
and here we're looking at MRI post
contrast after gadolinium contrast.
And we're looking down at
the level of the sinuses.
We're seeing the
over the the superficial
aspect of the cerebellum here
and we see a good sinus an open
clear paitent sinus on the right,
there's white contrast filling
the sinus on the right.
On the left we see
We see a blockage to flow, in fact, we can
see a clot in the left transverse sinus
that may be contributing this
patient's high pressure headaches.
And here we can see that pointed
out on the left transverse sinus
a venous sinus thrombosis.
So what's the treatment
for this headache?
Should we start anticoagulation,
for headache treatment
refer to ophthalmology,
given the vision complaints
or recommend weight loss and
send to a personal trainer?
Well, weight loss and personal trainers
can be very important for managing patients
with high pressure headaches,
particularly pseudotumor cerebri.
And they're a part of the multifactorial
component of management of those patients.
But this patient has a
venous sinus thrombus
and weight loss is not going to fix
that blood clot in the venous sinus
and so is not the optimal treatment or
initial step for managing this patient.
Prescribing topiramate for headache
can be a great medication for migraine
but this patient does
not have migraine,
and topiramate will not fix
this venous sinus thrombus.
Referral to ophthalmology is something
that we think about in patients
who have vision deficits and this patient
does have peripheral visual field deficits
that are reminiscent of
a homonymous hemianopia
which could localize
to the chiasm.
But the imaging confirms
venous sinus thrombosis
and the patient's
symptoms really suggest
a high pressure headache and
possible venous sinus thrombus.
And so in this patient the appropriate
treatment is to start anticoagulation
and that's the treatment of choice
for patients who have a blood clot
in the venous sinuses or
a venous sinus thrombus.