Headache Flashcards
What mnemonic can be used to remember different sinister causes of headache?
VIVID
List some conditions that come under each heading of the mnemonic.
Vascular • Subarachnoid haemorrhage • Subdural/Extradural haematoma • Cerebral venous sinus thrombosis • Cerebellar infarct Infection • Meningitis • Encephalitis Vision-threatening • Temporal arteritis • Acute glaucoma • Cavernous sinus thrombosis • Pituitary apoplexy • Posterior leucoencephalopathy ICP raised • Space-occupying lesion • Cerebral oedema • Hydrocephalus • Malignant hypertension Dissection • Carotid dissection
List some red flag symptoms of headache
Decreased level of consciousness Sudden-onset worst headache ever Seizure or focal neurological deficit Absence of previous episodes Reduced visual acuity Persistent headache – worse when lying down and early morning nausea Progressive, persistent headache Constitutional symptoms Past medical history of malignancy or immunosuppression
What cause of headache can also result in a decreased level of consciousness?
Subarachnoid haemorrhage
Subdural/extradural haematoma
Meningitis/encephalitis
What must you consider if someone complains of a sudden-onset worst headache ever?
Subarachnoid haemorrhage
What does a focal neurological deficit along with a headache suggest?
Intracranial pathology
NOTE: migrainous aura can also give neurological signs (either positive or negative)
Which cause of headache is commonly accompanied by reduced visual acuity?
Temporal arteritis
What are the four main features of temporal arteritis?
Headache
Jaw claudication
Reduced visual acuity
Scalp tenderness
What type of headache is associated with causing early morning nausea/vomiting and a headache that is worse when lying down?
Raised ICP
What is likely to cause a headache that is worse when standing up?
Reduced ICP – this is common after an LP and is not considered sinister
What does a progressive, persistent headache suggest?
Gradually expanding space-occupying lesion (e.g. tumour, abscess, cyst)
List some constitutional symptoms. What can cause such symptoms?
Fever, weight loss, night sweats
It may suggest malignancy, chronic infection or chronic inflammation
What are some red flag features of the past medical history of someone presenting with headache?
History of malignancy (headache could be caused by brain metastases)
History of immunosuppression or HIV (increased risk of intracranial infection)
What are some important features of the basic observations that may make you suspect a sinister cause of the headache?
Altered consciousness
Blood pressure and pulse (check for malignant hypertension)
Temperature (suggests infection)
Describe the appearance of 3rd nerve palsy.
The pupil is down and out
Ptosis
Mydriasis (unless it is pupil-sparing 3rd nerve palsy)
What can cause a headache that is accompanied by 3rd nerve palsy?
Subarachnoid haemorrhage
Posterior communicating artery aneurysm
Describe the appearance of 6th nerve palsy.
Inability to abduct the affected eye
The 6th cranial nerve is the most susceptible to compression due to raised ICP. Explain why.
It has the longest intracranial course of any cranial nerve and so is most susceptible to compression by raised ICP
Describe the appearance of 12th nerve palsy.
Protraction of the tongue will make it deviate towards the side of the lesion
What can cause headache that is associated with 12th nerve palsy?
Carotid artery dissection
Describe the appearance of Horner’s syndrome.
Ptosis
Miosis
Anhydrosis
What can cause headache that is associated with Horner’s syndrome?
Carotid artery dissection
List some key features of eye examination and the underlying pathology that each of them is associated with.
Exophthalmos – suggests retro-orbital pathology (e.g. cavernous sinus thrombosis)
Cloudy cornea + fixed, dilated pupil – acute glaucoma
Papilloedema – raised ICP
What age group is most commonly affected by temporal arteritis?
Over 50 yrs old