Headache

Question 1

Sequence of events

Answer 1

Open question
Timeline- how did it start, how have symptoms progressed

Question 2

Symptom analysis

Answer 2

SOCRATES

Site- point to area
Onset- come on suddenly, any warning
Character- describe it,one episode or multiple
Associated features- see systems review
Timing- when did it start, continuous or intermittent, how long do they last, when was last time you had one
Exacerbating or relieving factors- coughing, bending forward, night time, early morning, any particular activities or movements etc.
severity- how bad on scale of 1-10, how about now, is it painful to press or touch anywhere

Question 3

Systems review

Answer 3

Trauma- hit head recently

Constitutional- FWARJNLC

Meningism- sensitive to light, neck stiffness, rash anywhere

NS- arm or leg weakness, visual disturbance, sensory disturbance, preceding aura (vision, numbness or otherwise), vision and hearing changes, vertigo (n and v)

Seizures or blackouts

Sentinel headache- have you had less severe headaches recently

MSK- painful to comb hair or chew, vision changes, pain or aches in shoulders

Question 4

Red flags for headaches

Answer 4

Meningism
Non blanching rash
Systemically unwell
Weight loss
Neurological symptoms
Seizures
Over 65 and unilateral
LOC

Question 5

Patients perspective

Answer 5

Effect on life and feeling
ICE

Question 6

Background information

Answer 6

PMH- headaches in the past, other conditions
DH- any changes, OTC, allergies
FH
SH

Question 7

Meningitis

Answer 7

Classic- headache, fever, neck stiffness, photophobia
Non blanching rash- meningococcal septicaemia
Late presentation- seizures, decreased consciousness, coma

Question 8

EDH

Answer 8

Temple trauma
Lucid interval, increasingly severe headache, raised ICP Sx
Decreasing consciousness

Question 9

SDH

Answer 9

Elderly and alcoholics after hitting head weeks or months ago
Worsening pain, decreasing consciousness, increased sleepiness, ataxia
ICP gradually increases until it causes Sx

Question 10

Raised ICP

Answer 10

Morning headaches, worse on bending or coughing, lying down, any valsalva
Visual disturbance, seizure, neuro symptoms

Question 11

Temporal arteritis

Answer 11

Severe headache in temple
Jaw claudication, scalp tenderness, poly myalgia rheumatica Sx

Question 12

Acute sinusitis

Answer 12

Full ache worse on bending forward
Associated with Coryzal Sx
Purulent rhinorrhoea or productive cough

Question 13

SAH

Answer 13

Thunderclap headache
Meningism
Can have less severe headaches in weeks prior
Linked to ADPKD, Elhers Danlos

Question 14

Other Causes of first headache

Answer 14

Acute angle closure glaucoma headache
Medication induced headache
Trigeminal neuralgia

Question 15

Migraine

Answer 15

Severe pulsating recurring unilateral headache
Often visual or sensory aura occurring shortly before onset
Photophobia phonophobia when headache starts patients want a dark room
Triggers- changes in diet, oral contraceptives, exercise, caffeine, alcohol

Question 16

Cluster headaches

Answer 16

Excruciating recurring unilateral headache localised around one eye
Lasts for few hours often twice in a 24 hour period and most common at night
Headaches occur in clusters for weeks, then headache free for months
Profuse eye watering and nasal secretions on affected side

Question 17

Tension headache

Answer 17

Bilateral and associated with stress and visual strain (reading and watching TV)
Tight band across head that lasts minutes to hours
No other signs or symptoms

Question 18

Investigations

Answer 18

Neurological examination and examination for tender areas over skull
Ophthalmoscopy for evidence of papilloedema
Bloods- FBC UE CRP ESR
Temporal artery biopsy
CT or MRI head
Lumbar puncture (AS LONG AS IT ISNT CONTRAINDICATED eg. ??