COmmon cerebral histories - Headache

Question 1

What would you want to ask about a presentation of headache?

Answer 1

• SOCRATES
• Red flags
• General symptoms
• Neurological symptoms

Question 2

What are red flags to ask about when someone is presenting with a headache?

Answer 2

• Intracranial bleed - thunderclap
• Raised ICP - increases with posture change
• SOL - immunosuppression, malignancy, focal neurology, onset > 50
• Meningitis - neck stiffness, phtophobia, fever, rash
• Glaucoma - red eye, visual disturbance, halos
• Trauma
• GCA

Question 3

What neurological symptoms would you ask about in someone with a headache?

Answer 3

• Dizziness
• LOC
• Fit/Seizure
• Weakness
• Tingling/paraesthesiae/numbness
• Visual disturbance
• Hearing loss
• Speech changes
• Neck stiffness
• Photophobia
• Memory loss

Question 4

What general symptoms would you want to ask about in someone with a headache?

Answer 4

• Fevers
• Rash/bruising

Question 5

What features would distinguish a tension headache?

Answer 5

• Bilateral tight band sensation
• Recurrent
• Occurs late in the day
• Association with stress

Question 6

What features would suggest a cluster headache?

Answer 6

• Short painful attack around one eye
• Last between 30 mins - 3 hours
• Occur once/twice per day for 1-3 months
• May have lacrimation and flushing

Question 7

What features of a headache would suggest a migraine?

Answer 7

• Unilateral pulsating headache around one eye in trigeminal nerve distribution
• Last between few hours to days
• May have aura
• Need to lie down in dark room - photophobia

Question 8

What features of a headache would point towards trigeminal neuralgia?

Answer 8

• Short sharp stabbing pain in unilateral trigeminal nerve distribution
• Face screws up in pain
• Can be triggered by touch

Question 9

What features of a headache may indicate meningitis?

Answer 9

• Photophobia
• Neck stiffness
• Fever
• Rash - non-blanching

Question 10

What features of a headache may indicate a temporal arteritis as the cause?

Answer 10

• Unilateral throbbing pain
• Scalp tenderness
• Jaw claudication
• > 55 years
• May have visual involvement

Question 11

What features of a headache would indicate a subarachnoid haemorrhage as a cause?

Answer 11

• Very sudden onset severe headache - thunderclap
• Meningism

Question 12

What features of a headache may indicate raised ICP as a cause?

Answer 12

• Worse in morning and with coughing and bending
• Vomiting
• Reduced GCS
• Focal Neurology
• Seizures
• History of malignancy/immunocompromise

Question 13

What are common causes of a headahce (try to think of distinguishing features of each)?

Answer 13

• Primary - Tension, cluster, migraine, TN
• Seconary intracranial - Temporal arteritis, Subarachnoid, SOL, Raised ICP
• Secondary extracranial - Glaucoma, Sinusitis
• Venous sinus thrombosis
• Intracranial haemorrhage
• Infections - abscess, encephalitis, meningitis
• Malignant hypertension
• Hypoxia/hypercapnia
• Viraemia
• Cervical spondylosis
• Pre-eclampsia
• Drugs

Question 14

What features would point towards glaucoma as a cause of a headache?

Answer 14

• Pain around one eye
• Swollen red eye
• Visual blurring and halos

Question 15

What features would indicate sinusitis as a cause of a headache?

Answer 15

• Facial pain exaggerated by leaning forward
• Rhinorrhoea