Headache in General Practise Flashcards
How do you diagnose headaches in primary care?
- Good history taking
- Exam the pt well - esp neurologically
- Check for red flags
- Avoid over investigation
What are the 4 C’s of socrates in history taking?
Circumstances
Character
Causes
Co symptoms
What are the questions would you ask in circumstances ?
How long you suffered?
How long it lasted ?
How often ?
How constant ?
Episodic ? When ?
Any pattern ?
Have they changed ?
What are the questions would you ask in character ?
The nature
Site & severity
Pain ? throbbing, stabbing, global, one-sided, neck , back/front of head, band like, facial ?
What are the questions would you ask in causes ?
is there anything that trigger ?
Aggravate or relieving factors ?
Periods
What are the co-symptoms ?
Nausea
Vomiting
Visual
Photophobia
Neurological ?
Is there any different types of headaches between headache
also make sure to ask for ICE
Classify the headaches accordingly to chronically ?
Acute new headache
Acute recurrent headache
Subacute headache
Chronic headache
What are the causes of acute new headache ?
Meningitis
Subarachnoid haemorrhage
Viral UTI
Sinusitis
Dental problems
Tropical illness e.g malaria
What are the causes of acute recurrent headache ?
Migrane
Cluster headache
Exertional headache
Trigeminal headache
glaucoma
What causes subacute headache ?
Temporal artheritis
What causes chronic headache ?
Tension type
Cervicogenic
Medication overuse
Raised intracranial pressure
What would you ask in PMH/Surgical history?
Sinus problems
Dental problem
Migrane
Hypertention / Intracranial bleeding
Recent head injury
Malignancy
HIV
Depression /Mental illness
What would you ask in Social history?
Job
Recent travel
drugs
alcohol
Home situation
Stress with work, bills, relationship
Family problems, children, parents , illness
How would you keep a headache diary?
If the cause is not known yet then keep a headache diary
What would you record on Headache diary ?
Frequency, duration, severity
associated symptoms
Medication used
possible precipitations
Relationship to periods
What are the red flags in headache?
Fever , purpuric rash, meningism ?
- Meningitis
Thunderclap headache
- Subarachnoid headache
Worsening over few weeks or change in chronic headache - SOL
Headache with change in posture, coughing, sneezing, exercise - vomiting ? Increased Intracranial Pressure
Furthermore red flags ?
Are they new onset + h/o , cancer, HIV, immunosuppressant - infection /met
Recent head injury (<3cm ) - Bleed
Any changes in personality, cognition, new neurological defecit - SOL
What are the Atypical aura in migraine?
Motor weakness
double vision
unilateral vision symptoms
Poor balance
Reduced consciousness
What do you look during Inspection of the examination ?
Neuro signs
Rash ? purpura , the glass test
In eyes - look for red, pupils PERLA, Cornea and photophobia
injury
Mood
What do you look during palpation of the examination ?
The temporal area
Tender Scalp
Sinuses for tenderness
Examine the neck to exclude neck pain as a factor
What would you look for in Neuro examination ?
Include Fundi ( papilledema )
Visual acuity
Gait
cranial nerves/ full neuro exam
What would be your investigation ?
Not needed in GP
-If the cause is acute- they’re admitted
-if the cause is serious - they’re referred
-Temporal arteritis - ESR raised
What more investigations would you consider for pts with lethargic, pallor and jaundice?
FBC
U & E
TFT
LFT
What is tension type of headache ?
- 2 % prevelance
- 2 F : 1M
- Pts that present with stress/anxiety
- FH of 40%
- often comes during the day
and gets worse at the end of the day - It lasts few hrs
-it does not disturb sleep
-it also doesn’t affect physical activity
What is the management for Tension headache?
- Aspirin ( but not for under 16s)
or NSAIDS +/- Paracetamol
- Reassurance
- Explanation
- NOT OPIODS
What is Migraine ?
15% of prevalence
3F :1M
Disturbance of cerebral flow which lead to
Headache
- ( 4-72 hrs debilitating)
- Nausea/vomiting, sensitivity to light/noise
With aura
- 5- 60 mints visual symptoms - flickering lights, spot lines, loss of vision
- Sensory symptoms include - numbness and parasthesis
- speech symptoms include - FULLY REVERSIBLE
What are the triggers of the MIgrane ?
- Stress/ anxiety
- Environment ( nose, flickering light, perfume, cold
- Foods eg caffeine
- Lack of sleep
- Periods
Severity can be assessed by the migrane, disability assessment score - MIDAS
What is the management of Migrane ?
Acute Migrane
- treated with triptan , +/- nsaid ,paracetamol
Prophylaxis Migrane
- treated with Propranolol/ Toparimate
What is Cluster Headache ?
1 in 1000 people
6M: 1F
Severe pain comes unilaterally and around one eye
Ptosis, miosis, red watery eye, stuffy nose,
May wake you up at night sometimes or after alcohol
It lasts usually one hour
Cluster attacks over days/ weeks months then periods of remission
What is the management of cluster headache ?
Refer to neurology with 1st attack to confirm the diagnosis/ scanning
What is the treatment of acute cluster headache?
100 % O2 , 12 L minimum with non - rebreather mask and reservoir bag
Triptan
What is the prophylaxis of cluster headache ?
- Verapamil or prednisolone
- specialist advice
What is Temporal arthritis ?
Chronic vascular disease
Age > 50 years
Inflammation in the wall ( medium size and large arteries - branches of carotids )
overlap with polymyalgia rheumatica
What type of headache would you experience with temporal arthritis ?
Unilateral temporal, can be diffuse or bilateral
What would you find on examination for temporal arthritis ?
Temporal artery tenderness on palpation
What is the Investigation of Temporal arthritis ?
ESR >50 USUALLY HIGHER ( 2- 8.7% can be normal)
Biopsy temporal artery - vasculitis,
