Neurological HISTORIES Flashcards
What should you ask for a specific headaches history?
-
SOCRATES
- (site, onset, character, radiation, associated features, time, exac/relieving factors, severity)
-
Associated symptoms
- Fever
- trauma
- falls weakness/visual disturbances
- LOC
- Menigism - photophobia, rash and neck stiffness
- seizures & blackouts
- sentinal headache (precceeds subarach haem)
-
Inflammatory
- pain on combing hair and chewing
- shoulder pain
-
Vision
- eye pain
- N&V
What should you ask for (HPC) in a dizziness history?
-
SOCRATES
- S = SPECIFY in this though
- room spinning
- feel unsteady
- fall (risk)
- (S), onset, character, radiation, associated symptoms, time, exac/relieving factors, severity
- Radiation = ringing in ears
- S = SPECIFY in this though
- Associated features
- ear symptoms
- deafness
- malaise
- earpain
- N&V
- Sensory
- Paresthesia
- Vision and eye pain
- Motor
- weakness
- ADLs
- Speech
- trouble
- headaches
- seizures/blackouts
- Constitutional: weight loss, appetite loss, nightsweats
- ear symptoms
What are the symptoms of temporal arteritis as a DDx of headache?
- temporal arteritis = severe headache located in the temple area
- jaw claudication
- scalp tenderness
- often polymyalgia rheumatic symtoms –> pain and stiffness in shoulder muscles, developed quickly over a few days or weeks (if suscpecting temoral arteritis)
- sudden blindness in one eye if not treated promptly
Tx: high dose oral prednisolone
NB:About 15% of people with polymyalgia rheumatica also have temporal arteritis (giant cell arteritits) and about half of people with temporal arteritis also have polymyalgia rheumatica. Tempoatica (PMR) is a chronic, inflammatory disorder of unknown cause, almost exclusively occurrinral arteritis causes inflammation that damages large and medium-sized arteries. Polymyalgia rheumg in people aged over 50 and often associated with giant cell arteritis. Several infectious agents have been investigated as possible triggers of PMR even though the results are inconclusiv
What are important points to consider with a headache history?
- characterise into if headache is uni- or bi-lateral
- is the headache recurring or happening for the first time?
- e.g. recurring could still be migraine, cluster or tension but try to rule out sinister causes
- what is the pain scale involved and then assoicated symptoms to help direct line of questioning
- as red flag symptoms to excule potential life threatening causes
- emergencies can be broken into:
- brain parenchyma (tumour, can cause raised ICP)
- vessels (haemorrhage: subarachnoid, subdural and extradural, clots: venous-sinus)
- meninges (meningitis)
- extracranial arteries (temoral arteritis)
- eye (glaucoma)
- emergencies can be broken into:
What are the symptoms of migraine as a DDx of headache?
- severe, pulsating, recurring, unilateral headache that lasts around an hour
- often has visual or sensory aura occuring shortly before onset
- photophobia/phonophobia when headache starts
- patient seeks dark quiet room
- triggers: changes in diet, oral contraceptives, exercise, caffeine and alcohol
Tx: avoid precipitants; triptan e.g. sumatriptan (inhib serotonin vasc narrowing) when headache starts
What are the symptoms of cluster headaches as a DDx for headaches?
- Excruciating,
- recurring,
- unilateral headache
- normally localised around one eye
- lasts only for a few hours, often twice in 24 hours and most common at night
- headaches occur in clusters for weeks, then headache free for months
Tx: 100% O2 and sumatriptan (inhibs sero) for acute attacks; verapamil (Ca antag) or prednisolone for prophylaxis
What are the symptoms of a tension headache (ddx of headache)?
- Bilateral
- associated with stress and visual strain e.g. reading, watching TV
- Typically described as a tight band across the head that lasts minutes-hours
- no other signs or symptoms
What are the symptoms of sinusitis? (DDx of headache)
- Pain over sinuses
- e.g. behind eyes or deep behind nose
- constant dull ache associated with coryzal symptoms (viral e.g. sneezing and coughing), fever and congestion
- worse on bending forward
What are the symptoms of menigitis? (DDx: headache)
- Classical presentation : Headache, fever, neck stiffness and photophobia
- non-blanching purpuric rash indicates menigococcal speticaemia
- later presentation includes: seizures, decreased consious level and even coma
Tx: IV antibiotics e.g. cefotaxime (3rd gen cephalo, interferes w/bact cell wall)
What are the syptoms of extradural haemorrhage? (DDx of headache)
- typically due to trauma to the temple- damaging middle meningeal artery
- there maybe a lucid interval with increasingly severe headache,
- associated raised ICP symptoms and gradually decreasing consciousness… until complete LOC
- bleed = lemon shape on CT head
What are the symptoms of subdural haemorrhage? (DDx of headaches)
- Common in elderly after falling/banging their head in previous weeks/months
- worsening pain, decreasing consciousness, increased sleepiness and ataxia
- ICP gradually increases until it causes ICP symptoms
What are the symptoms of subarachnoid haemorrhage? (DDx: Headaches)
- Sudden, severe “thunderclap” headaches,
- sometimes with a sentinel headache of less severity within the weeeks prior to the current headache
- Sentinel bleed = in which a small leak of blood from an aneurysm occurs some days or weeks prior to a larger bleed
- linked to polycystic kidney disease and Elhers-Danlos syndrome (connective tissue disorder)
What are the symptoms of raised intracranial pressure? (DDx of headache)
- often described as the worst headache ever
- morning headache
- worse on coughing, lying down or any valsalva manoeuvre (e.g. anything ic pressure ontop)–>
- valsalva manouvre: performed by moderately forceful attempted exhalation against a closed airway, - closing mouth, pinching nose shut & pressing out air squeeze
- may have visual disturbances, seizures and other neurological symptoms
Tx: Elevate head of bed to 30 degrees: sedation, CSF drain, mannitol [ic plasma osmol], neuromuscular blockade and hyperventilation lower ICP
What are the other DDx for headache?
- Angle closure glaucoma
- acute painful red eye
- visual halos
- reduced vision
- medication
- mixed analgesics may cause a headache themselves
- trigeminal neuralgia
- short, intense “electric shock” pain in trigeminal nerve distribution triggered by touching affected area (e.g. shaving or brushing hair)
What investigations should be done into headache?
- Bedside
- neurological examination and examination for tender areas over the skull
- opthalmology (evidence of papilloedema from ic ICP)
- Blood
- FBC
- U&E
- CRP
- ESR
- Scans
- CT/MRI scan
- Procedures
- temporal artery biopsy if temproal arteritis suscpected
- lumbar puncture if not contraindicated
