Head Pain

Question 1

List tentative diagnoses of non-emergencies presenting with ocular pain;

Answer 1

cornea: abrasion, FB, RCE, EKC, dry eye, trichiasis, dystrophy, etc.
Scleritis, a red, painful eye

Question 2

List tentative diagnoses of non-emergencies presenting with peri-ocular pain

Answer 2

near point stress
orbital mass 
eyelid mass
sinusitis
Neuralgia
H zoster

Question 3

Near point stress - diagnosis

Answer 3

a reliable trigger for the symptom?
Tend to affect both eyes. Most other ocular conditions more likely to involve just one eye
Headaches tend to be frontal
Headaches tend to be worse at the end of the day
gritty,” “burning” feeling in the eyes
generalized “eye strain”
“Redness” but not very red
Also: general fatigue, tiredness, need to take frequent breaks

Question 4

orbital mass-diagnosis

Answer 4

Seeing it or feeling it by touch or asymmetrical resistance to retropulsion makes the dx

Question 5

Chalazion / hordeolum

Answer 5

Orbital mass lesion - need imaging

Question 6

sinusitis-diagnosis

Answer 6

Pain usually at the sinus
Tender to pressure over the sinus
Associated with rhinorrhea, nasal congestion, recent cold
Failure to transilluminate the sinus
Sinus xray

Question 7

List the distinguishing characteristics of TACs

Answer 7

The pain is neuralgiform (ice pick pain)

The pain is accompanied by autonomic hyper- or hypo-activity

Question 8

List tentative diagnoses of non-emergencies presenting with cranial pain; specific primary Headache Syndromes

Answer 8

Migraine
Tension-type
TACs
Chronic daily

Question 9

3 major groups of HA

Answer 9

Primary (4 sub-groups)
Secondary (8 sub-groups)
Cranial neuralgias & “other” (2 sub-groups)

Question 10

Trigeminal Autonomic Cephalalgias (TAC) encompasses;

Answer 10

Cluster
paroxysmal hemicrania
SUNCT

Question 11

What distinguishes the TACs from primary trigeminal neuralgia?

Answer 11

autonomic

Question 12

Cluster

Answer 12

Males»females (9:1), esp large men
Onset age 20-40
During HA, they pace the floor.
Being still makes the pain worse.

Question 13

Migraine

Answer 13

migraine is a recurrent and episodic type of HA,1 per year to 5 per week,
Fairly common
Females > males by about 2:1
Often runs in families
Onset: often start in childhood or late teens
Duration: typically 24 hours

Question 14

Migraine -Description of the Pain

Answer 14

Unilateral (esp. temple and around eyes)
Pulsating or Throbbing
Severe (to moderate)
Exacerbated by routine physical activity

Question 15

Migraine associations

Answer 15

gastrointestinal upset, nausea

photophobia / phonophobia

Question 16

Migraine with aura

Answer 16

Just like any other migraine, but the HA is preceded fairly reliably by an aura,
DURATION: 30 (10 to 60) minutes!
Transient ischemic attack (TIA): 3 to 10 minutes
flashes of RD: 5 to 30 seconds

Question 17

Visual migraine auras

Answer 17

Fortification spectrum

Typically on opposite side of head from HA

Question 18

Tension-type

Answer 18

Duration: 0.5 hours to 7 days , but
Typical duration is 2 to 16 hours
Steady “pressing” or “vice-like” pain
Severity: mild to moderate, worse @ end of day
Bilateral, typically: wide-spread location
Triggers: stress, fatigue, not eating

Question 19

Tension-type were once called

Answer 19

“muscle-contraction” headaches

Possibly related to tension or isometric contraction in the neck &/or scalp muscles

Question 20

Daily-persistent

Answer 20

Typically present upon awakening or
begin during the MORNING.
Duration: 1 hour to all day, typically around 4 - 6 hours, but less than 24 hours
Gradually get worse or better
Description: dull, steady, bilateral (like tension)

Question 21

Pseudotumor cerebri

Answer 21

“benign intracranial hypertension.”
Onset of headache: gradual
Location of headache: generalized, bilateral
Description of headache: dull, steady
Accompanied by:
blurry vision, (because of papilledema)
visual “obscurations” 2° papilledema (cloud passing front of vision, confused with TIA)
Diplopia 2° CN6 palsy
Opening” cerebrospinal fluid pressure >200

Question 22

Pseudotumor differential

Answer 22

The diagnosis of pseudotumor cerebri can only be made if there has been a lumbar puncture accompanied by a measurement of the opening pressure.

Question 23

space occupying lesion

Answer 23

Brain tumor (1 of the 2 ‘B’ words)
Aneurysm
Epidural or Subdural hematoma

Question 24

Brain tumor

Answer 24

Focal neurological signs or seizures usual presenting indication (not HA)
Onset: subacute or chronic
When advanced (very high ICP): nausea, vomiting, impaired mental status
Look for: papilledema, CN6 palsy, SVP

Question 25

Subdural hematoma

Answer 25

Slow (weeks to months) onset of sx, after blunt trauma or a fall.
HA, if present, starts as mild, but…
HA and focal neuro si gradually escalate
Often first si (signs) = change in mental status,
Usually not associated with papilledema
Must be imaged

Question 26

elevated intracranial pressure

Answer 26

Headache is due to elevated intracranial pressure
Location: global or diffuse
Made worse by: valsalva maneuver

Question 27

Ruling out elevated ICP

Answer 27

Look for:
papilledema,
CN6 palsy,
SVP

Question 28

list diagnosis of emergencies presenting with cranial pain

Answer 28

Anuerysm
Subarachnoid hemorrhag
Meningitis/Encephalitis
GCA