Headache workup Flashcards
What are features of a Migraine?
- With/without visual aura
- Lasts 4-72 hours
- Unilateral
- Pulsating quality
- Moderate to severe intensity
- Aggravation by routine physical activity
- Association with nausea and/or photophobia/phonophobia
What are featured of a Tension headache?
- Lasts 30 mints to 7 days
- Bilateral
- Pressing/tightening quality
- Mild to moderate intensity
- Not aggravated by routine physical activity
- No nause/vomiting/photophoia/phonophobia
What are features of Cluster headaches and other trigeminal autonomic cephalgias?
- Lasts 15 mins to 3 hours
- Occurs every second day to 8 times a day
- Severe unilateral pain
- Orbital, supraorbital, temporal
- Ipsilateral conjunctival injection, lacrimation, nasal congestion, rhinorrhoea, forehead and facial sweating, mitosis, ptosis and/or eyelid oedema
- With/without restlessness or agitation
What are the associated symptoms of patients who have headaches secondary to a stroke?
- New and acute onset of headaches
- Loss of VF
- Muscle weakness (face, limbs etc)
- Slurred speech
What are the associated symptoms of patients who have headaches secondary to a Giant Cell Arteritis?
- Swollen, tender scalp artery
- Jaw claudication (pain on chewing/speaking)
- Polymyalgia rheumatica (neck/shoulder stiffness)
- Scalp tenderness
What are the associated symptoms of patients who have headaches secondary to Optic neuritis?
- Unilateral or bilateral retro-orbital, orbital, frontal and/or temporal pain
- Aggrevated by eye movement
What are the associated symptoms of patients who have headaches secondary to Hepes Zoster (ophthalmic)?
- Unilateral facial pain along ophthalmic and maxillar division of trigeminal nerve
- Lasts < 3 months
- Burning, stabbing/shooting, tingling or aching
- Accompanied by cutaneous alllodynia (condition where non-painful stimulus e.g., light touch or temperature changes auses pain on the skin)
What may be associated features of headaches?
- Relieving: closing eyes, analgesic or other medication
- Exacerbating or triggers: bright lights, touching, moving, alcohol, shaving, reading, stress, foods, exercise
- History of neck injury
- Personal or family history of migraines
- Migraines: nausea, photophobia, phonophobia
- GCA: jaw claudification, weight loss, anorexia, malaise
- Systemic autoimmune disease
- Medication causing angle closure glaucoma
- Autonomic features: tearing, nasal congestion, red eye, ptosis
What questions should you ask a patient presenting with headaches (think LOFTSEA)?
- Location/site
–> where does it hurt? eye, temple, face, where on head?
–> Same place each time - Onset (and duration)
–> when did it start?
–> how did it start? sudden, slowly, insidiously
–> How long does it last? seconds, minutes, hours days - Frequency
–> How often does it occur? continuously, hourly, daily, weekly? - Type
–> What does it feel like? Deep, shotting, stabbing, pounding, aching, throbbing?
–> How severe is it? Scale of 0 to 10 - Self-treatment and effectiveness
–> What has helped? Medication, rest, exercise - Effect on vision or patient
–> Blurred vision, double vision
–> Unable to work, study, function
What tests should you perform on a patient presenting with headaches?
- Ocular motilities/excursiomns
- Near point of convergence
- Cover/uncover test
- Visual fields (begin with confrontation field and then more sensitive testing if needed)
- Red cap test
- Amplitude of accommodation
What is the signifcance of doing a Red cap test on a patient with a headache?
- Red cap test differentiates between retinal and visual pathway pathology
- If there is a neurological disease causing the headaches, there would be an abnormal result
What clinical test/procedures should you perform on a patient with presenting complaint of headache?
- Targeted case history
- Habitual V/VA/pinhole
- Ocular motility, NPC, cover test
- Visual fields (confrontation and automated perimetry)
- Red cap test
- Pupils
- Objective/subjective refraction
- Amplitude of accommodation (near addition)
- Ophthalmoscopy
- IOP
