1.1.2 Elicits the detail and relevance of any significant symptoms. Flashcards
Risk factors for papilledema
How would you manage?
young obese women aged 20-40, children, bilateral
How would you manage? Emergency referral, acetazolamide for AAC if on hand
Decompensated phoria manage:
push screen back, less screen time
H&S - Questions for headaches
- Tell me about them - Open question
- Are these headaches normal for you?
- Have they become worse? Do they become worse when leaning body forwards/during head movement/changing posture? (linked with papilledema)
- Which part of the head is the headache?
- When did they first come on? Any particular time of the day? How long do they last?
- During any particular task? (concentrated task?)
- How painful would you describe them? Sharp or dull, throbbing pain?
- Have you done anything to treat them?
- Any other symptoms (nausea/sickness/vomiting - AAC, Papilloedema,) photophobia, double vision (transient in GCA), blurred vision, visual auras like zig zags (ask one or both eyes), haloes around lights (coloured), shimmering lights (how long do they last?), pain on chewing, flashes?
- Any pain at or around the eyes? Redness? Watering?
- Any head trauma?
- Any FH of migraines?
What else to look for in history?
headaches
- Vision - papilledema, GCA - sudden VA loss (AAION), [amaurosis fugax], shingles (one month gradual onset), AAC, Visual Migraines
- General Health - Inflammation like Rheumatoid artheritis (nagging, morning pain), Ankylosing spondylitis, Herpes Zoster, Malignant hypertension
- Medications - May cause HAs! Painkillers for HA treatment can actually rebound & cause further HAs!
- Ocular History -
- Family History - Migraines
- Lifestyle - VDU (conc task; high use - glare, eyestrain etc), Hobbies
What Part of the Head?
Parts of the head for Each HA Type:
- Refractive Error —> Bilateral, frontal, dull, throbbing
- Papilledema —> Diffuse or unilateral throbbing, usually severe HA
- GCA —> Sharp pain at temporal areas but can sometimes be frontal or occipital
- Migraine —> Unilateral, dull or sharp pain increasing in intensity & spread
- AAC —> Sudden, severe pain within one eye and an ache around your eye
- Tension —> Bilateral, steady (non throbbing) pain, around frontal or occipital region
- Cluster —> Unilateral at oculo-temporal region, sudden, sharp pain
- Pituitary Tumour —> Sudden-onset, severe headache at the front of the head (either located on one side of the head or both) and/or behind one or both eyes.
Tests to do:
For headaches
- Visions Aided & Unaided - if Rx improves vision then potentially refractive error as cause, if not then potentially different cause. If AAION then monocular VA loss. For papilledema, transient visual obscuration’s lasting 30 seconds or more, worsening on bending, coughing, posture change.
- CT at distance & near - diagnose convergence insufficiency, decompensation (questions for decompensation: Cover one eye? Towards end of day?)
- NPC - convergence insufficiency
- Accommodation - Accommodative spasm/insufficiency
- Motility - 6th nerve palsy can follow after papilledema with H diplopia
- Pupils - AAC, Accommodative spasm??,
- PERLA, DCN, RAPD
- IOPs - raised intracranial pressure, AAC
- VFs - enlarged blind spot in papilledema, migraines, brain tumours
- Colour vision - e.g. if complaining of HAs with VF defect, then could be pituitary tumour so desaturated red & colour vision worth checking monocularly (can be acquired - tritan)
- Anterior eye - ipsilateral conjunctival injection, ptosis (cluster), signs of AAC, VHs
- Fundoscopy - observe optic nerve (blurred margins, patton lines, hyperemia), malignant hypertension may mean flame haems/cotton wool spots etc in far periphery
Differential diagnosis:
Worrying Vs less worrying features
Headaches
Worrying features
* Short history
* Continuous
* Worsening
* General malaise (sickness, other things making HA worse)
Less worrying features
* Long history
* Intermittent
* Steady
* Good
* No other problems
Migraines last between 4-72 hours whereas papilloedema is continuous
Differential diagnosis:
Single acute vs acute recurrent
Headaches
Single acute
* Raised ICP
* Subarachnoid haemorrhage
* Referred pain from sinus, teeth, eye
* Herpes zoster
Acute recurrent
* Migraine
* Cluster HE
* Trigeminal neuralgia
Differential diagnosis:
Subacute vs Chronic
Headaches
Subacute
* Temporal arteritis
* Raised ICP
Chronic
Tension
Psychiatric
Ankolysing spondylitis
Causes of Headaches (threatening):
- GCA - AAION
- Acute angle-closure glaucoma
- Increased intracranial pressure
- Ocular ischemic syndrome
- Malignant hypertension
- Infectious CNS disorder (meningitis or brain abscess
- Structual abnormalitiy of the brain (e.g. tumour, aneurysm, arteriovenous malformation
- Subarachnoid haemorrhage
- Epidural or subdural hematoma
GCA - AAION
- Inflamation of arteries, most often affects arteries in head
- Age 55> years, scalp tendernes (combing hair), recent HA (frontal, temporal occipital or more generalized), Jaw claudication (ischaemia of the masseter muscles), thick tender inflammed temporal artery and pulsating.
- Weight loss, fever, malaise depression
- Sudden painless monocular VA loss (on waking), with amarousis fugax attacks
- Potential diplopia
- Pale oedematous disc, flame haemorrhages
- Visual field defect, inferior altitudinal, can be central, paracentral, quadrantic & arcuate
- Ocular motor nerve palsies manifest - 3rd nerve potentially
- TREATMENT - emergency referral, steroids
- If above 48hrs, still refer urgent to stroke specalist and eye unit
DD between AAION + NAAION
- NAAION - associated with small corwded discs, hypertension, diabetes, hyperlipidemia whereas AAION do not normally have same vascular risk factors
- Px with GCA are typically order than those with NAION (i.e. 8th-9th decade vs 6th-7th decade)
- in NAION, patients will usually not note any associated systemic symptoms such as headache, jaw claudication, scalp tenderness, weight loss, anorexia, fever or myalgias/arthralgias
- VA worse in GCA, 1/3rd patients having 6/60 or worse
- Unlike NAION, AAION patients demonstrate a diffuse “chalky” white edema, eventual cupping of the disc, and possible coexistent retinal ischemia. NAION often demonstrates segmental optic nerve edema with eventual sectoral or total flattening & pallor
Acute angle-closure glaucoma
- Caused by iris bulging forward, causing block or narrowing of drainage angle between cornea and iris. Fluid cant escape, resulting in pressure increase
- Pain, blurred vision, haloes around lights, vomitting, frontal headache
- Fixed pupil
- Critial - closed angle in involved eye, acutely raised IOP, microcystic corneal oedema. Narrow or occludable angle in fellow eye if primary eitiology
- Other signs: Conjunctival injection; fixed, mid dilated pupil
Increased intracranial pressure: what does it cause
Papilledema:
* Papillledema is swelling of optic nerve as enters back of eye due to intracranial hypertension.
* Signs: Disc hyperaemia, elevation, indistinct margins, Patton lines, venous engourgement, flame haemorrhages, cotton wool spots.
* Increase in ICP due to space occupying lesion, causes unilateral or diffuse throbbing severe headache, worse in morning, and worse when bending over or coughing, changing posture.
* Causes vomiting, nausea
* In early stages, vision/pupils may not be affected, in later stages may be affected amaurosis fugax
Infectious CNS disorder (meningitis or brain abscess)
- Non-specific HE with neck stiffness
- Pain is severe and throbbing
- Onset can either be gradual or sudden
