Common Neurological Presentations: Headache Flashcards
What are the exploding symptoms for headache
SOCRATES explosion
Site
- unilateral - migraine?
- bilateral - tension?
- temples, jaw - GCA?
- trigeminal distribution - trigeminal neuralgia?
Onset
- sudden - SAH
- gradual - SOL?
Character
- baseball batlike - SAH
- all around head - tension
- throbbing, pulsating - migraine
- sharp, burning, piercing - cluster
Radiation
- neck => meningitis?
- face => TN
- eye => ACAG
Associated symptoms - systems review
Time course -changed over time? Pattern -worse in morning => high ICP (SOL?) -worse at night => low ICP
Exacerbating
- triggers - caffeine, excess analgesia, stress
- relieved by hydration, relaxing
- worse when coughing, straining, better when upright => ICP
- worse when standing, better when supine => low ICP
- worse when bending down => sinusitis?
Severity
-10 - cluster, SAH
Systemic review
Neurological
- N+V - migraine, ICP
- visual changes - migraine aura, SOL, glaucoma
- photophobia - meningitis, migraine
- focal neuro deficits - migraine, SOL, infection, ICH?
- RECENT HEAD TRAUMA?
MSK
- neck stiff - SAH, meningitis
- temporal pain and hypersensitivity - GCA
- proximal arm weakness - PR
- rash - non blanching => meningitis
Resp
-SOB, cough - lung cancer signs
GU
-reduced urinary frequency - dehydration
GI
-dysphagia, dyspepsia, N+V, abdo pain - signs of GI malignancy
Systemically unwell
- fever - infective (HSV encephalitis, cerebral abscess, meningitis)
- weight loss - brain tumour/mets?
Red flags you don’t want to miss
Meningism => meningitis, SAH?
-rash, fever, neck stiff, N+V, photo/phonophobia
Temporal arteritis
-scalp tenderness, reduced vision, jaw pain
Glaucoma
- red, hard, painful eye
- N+V, reduced vision, haloes
Sudden onset, immediate climax => SAH
Head trauma => SDH
Neural focal deficit => ICH, SOL, enceph/meningitis?
- personality change
- seizures
- memory issues
Posture dependent - ICP
Past medical history
Any medical condition?
- medications? - AC/AP
- surgeries, procedures, hospital visits
Allergies and reaction
Medications to treat headache
-frequency - 15+ days/month => overuse headache
-contraceptives?
-
Family history
History of headaches, cancer, bleeds in the brain?
-age and death?
Social history
Living
- accommodation type
- stairs, lifts?
- use of a gas fire or boiler or CO detector => headache, drowsy
People
-who they live with, social network, carers?
ADLs
-shopping, cooking, cleaning, dressing, self care
Smoking - cancer risk
Alcohol - withdrawal headaches?
Rec drugs - cocaine, amphetamines, cannabis headaches
Work
- impact on work
- CO exposure?
Tension headaches
- risk factors
- core features
- management
Risk factors
- stress
- dehydration
- lack of sleep
- caffeine
Core features
Band like, gradual onset
Management Conservative - address triggers -hydration -sleep hygiene -stress management Analgesia - paracetamol
Cluster headache
- risk factors
- core features
- management
Risk factors
- smoking
- FHx
Core features
Multiple short attacks (30mins-hours) with a clustering pattern at the same time of day, rapid onset
Intense eye pain, crying, runny nose
High agitation due to pain
May have triggers
Management - REFER TO NEURO
Symptoms - INH or SC triptan + 100% O2 NRM
Prevention - verapamil + avoid triggers
Migraine
- risk factors
- core features
- management
Risk factors
-FHx
Core features
Triggers - hormonal, stress, dehydration/hunger, caffeine, sleep
Aura - 30mins-1hr
-positive focal neuro symptoms that progress
Headache - unilateral, pulsing, throbbing pain, lasts hours
- worse on mv
- better in dark quiet room
Post-migraine fatigue - lasts hours-days
Management Avoid triggers Symptomatic - simple analgesia => sumatriptan -take when attack starts Prevention - topiramate/propanolol
Trigeminal neuralgia
- risk factors
- core features
- management
Risk factors
-older age
Core features
Hypersensitivity within unilateral trigeminal region => shooting, electrical, burning pain
Presentation suggesting underlying cause
- malignancy?
- MS?
- hearing loss/dizzy => acoustic neuroma
Management - carbemazepine
-once attacks controlled => wean down
Meningitis
- risk factors
- core features
- management
Risk factors
- not being vaccinated
- IC, head trauma/infection
- recent contacts
Core features
Headache, fever, neck stiffness, N+V, blanching rash, photophobia, phonophobia
Management
GP - benzylpenicillin => A&E!
A&E - cefotaxime or ceftriaxone empirically
-blood culture, LP and CSF culture and PCR
Giant cell arteritis
- risk factors
- core features
- management
Risk factors
- PR
- older female
Core features
Unilateral throbbing in temples
-worse when speaking, eating, on contact
Visual loss/blindness - one or both eyes
PR signs
- bilateral proximal limb weakness with prolonged morning stiffness
- low grade fever, loss of appetite, fatigue, weight loss
Management - ESCALATE => PO pred
-assess for signs of stroke
Brain bleeds
- risk factors
- core features
- management
Extradural - head trauma => LOC => lucid => deteriorate
Management - Head CT => neurosurgery referral
Subdural - fall/alcoholic/elderly => gradual deterioration over time (neuro signs)
Management - Head CT => neurosurgery (relieve ICP)
Subarachnoid - trauma/AVM/APKD => thunderclap headache at back of head
Management - Head CT => neurosurgery
-nimodipine, antiseizure prophylaxis, analgesia, antiemetic
Raised intracranial pressure
- risk factors and causes
- core features
- management
Causes of high ICP
- Idiopathic => overweight women, endocrine conditions, COCP
- SOL => tumour, abscess,
- Brain bleeds
- Encephalitis, meningitis, hydrocephalus
Core features
Throbbing headache, temp visual loss
-worse in morning, coughing, straining
-better when standing
N+V
Sleepy, irritability
Management - assess for underlying causes
-neuro, cranial nerves, eye exam
-CT, MRI brain, LP
Idiopathic
Conservative - weight loss, optimise endocrine conditions,
Medical - diuretics, short dose steroids, regular LPs
Glaucoma
- risk factors
- core features
- management
Risk factors
- Asian, older female
- Long sighted
- High IOP
Core features
Red, hard, painful eye
N+V
Blurry vision, haloes
Management - A&E!
Symptomatic - eyedrops (aAg, Bb, CAinh, CholinergicInh, prostaglandin analogue)
Definitive - laser iridotomy
