Céphalées Flashcards
Tension headache
Episodic or chronic (>15 days per month)
Associated with emotional stress
Generalised pressure/tightness around head
Radiation to or from neck
Normal neurological examination
Exclude musculoskeletal problems (e.g. cervicogenic headache)
Migraine
age et ratio H:F
Late teens to 50s
M:F ratio:: ≈1:3
Normal examination between attacks
Classical migraine
Aura present
Unilateral throbbing headache
Aura precedes headache
Visual aura:
Homonymous hemianopia
Scintillating scotoma
“Zigzag” of flashing lights (fortification spectrum)
Aura can be visual, sensory, involve speech or limbs
Stop COCP (i.e combined oral contraceptive pill)
Common migraine
Aura absent
No aura
≥5 headaches lasting 4–72 h
Nausea/vomiting or Photophobia and phonophobia
Plus ≥2 of the following: Unilateral headache Pulsating nature Affects QoL Aggravated by routine activity Look for triggers (e.g. diet, stress)
Acute sinusitis (Rhinosinusitis)
Paranasal sinus inflammation
Nose frequently involved
Acute bacterial infection lasts between 10 and 30 days
Common causes: Haemophilus influenzae and Streptococcus
Common risk factors: URTI, smoking, asthma, allergy, DM, swimming, dental infection
≥2 of the following lasting <12 wks: Blocked nose Nasal discharge/post-nasal drip Facial pain or pressure Reduction or loss of smell ± Headache ± Malaise ± Upper toothache
Tenderness over sinuses Normal respiratory examination Facial pain worse on stooping ± Fever
Post-concussion syndrome
Common causes: RTA, sports injury, fall, assault
Full recovery should be achieved within 2 wks
Onset symptoms days after minor head trauma
Persistent mild headache Not getting worse Dizziness
Memory loss (retrograde or
anterograde)
Low mood
Poor concentration Irritability
Nausea with no vomiting
GCS 15/15 No confusion Normal gait and balance No visual problems No focal neurology (e.g. limb weakness)
Discharge from nose or ear suggests CSF leak from basal skull fracture
Refer immediately
Medication
Chronic analgesia use: NSAID, paracetamol, codeine, ergotamine
Medication side-effects: GTN, nifedipine, substance withdrawal
Onset symptoms after taking medication
Normal neurological examination
Temporal arteritis (Giant cell arteritis)
Age >50 yrs
≥25% also have polymyalgia rheumatica
Unilateral headache Worse at night Jaw claudication Acute visual disturbance in one eye Malaise
Scalp tenderness
± Optic neuritis (swollen optic disc, painful eye movements, visual field defect)
± Retinal artery thrombosis (pale retina, red fovea and arteriolar narrowing)
Requires immediate high-dose steroids
Refer to ophthalmology if visual symptoms
Cluster headache
Age >20 yrs M:F ratio: ≈6:1 Recurrent annual event Daily symptoms for 6–12 wks Severe unilateral headache Retro-orbital pain Worse at night Unilateral Red watery eye Ptosis Rhinorrhoea or nasal blockage
Malignant hypertension
BP >200/130 mmHg Young adults Commonly Afro-Caribbean Other risk factors include: Obesity, smoking, DM
Visual disturbance
Bilateral retinal haemorrhages
Encephalopathy
Abnormal urinalysis: Proteinuria
Admit for BP control
Intracranial tumour
<1% of all headaches Age >50 yrs New onset headache Worse in the morning Progressively worsening Nausea/vomiting Personality change (e.g. disinhibition) ± Seizures (≤50%)
Drowsiness
Falling pulse and rising BP (Cushing’s reflex)
Papilloedema (≈50%)
Focal neurology
Refer for urgent neurology review
Subarachnoid haemorrhage
M
Meningitis
Common viruses: Echovirus, herpes simplex and zoster, coxsackie, HIV, measles, influenza
Common bacteria: Streptococcus pneumoniae, Neiserria meningitidis, Haemophilus influenzae type B, Listeria
Elderly and young age <2 yrs are particularly susceptible
Acute onset of symptoms Frontal headache Nausea/vomiting
Severe leg pains
Neck pain
± Non-blanching purple skin rash
Fever
Cold peripheries
Drowsiness
Irritability
Neck stiffness Photophobia Papilloedema (raised ICP) ± Petechial rash
Positive Kernig’s sign: Pain and resistance on passive knee extension with hips flexed
Positive Brudzinski’s sign: Hips flex on bending head forward
Notifiable disease
DO NOT delay antibiotic treatment
Petechiae suggest meningococcus or pneumococcus meningitis
Benign intracranial hypertension
Commonly young women
Typically obese
Often self-limiting
Blurred vision or diplopia
Papilloedema
VI nerve palsy (lateral rectus):
Eye is medially deviated Lateral eye movement not possible
Horizontal diplopia on looking out
Carbon monoxide poisoning
Risk of fits and coma if prolonged exposure
Nausea/vomiting
Dizziness
Worse when heater or cooking appliance in use
Relieved when away from house
Pink skin and oral mucosa
Tachypnoea
Tachycardia
Check gas appliances and flues
