Session 9 - Lecture 2 - Headache Flashcards
1 - Headache
Headache
“Headache is probably the most common neurological problem.”
2 - Contents
Contents • Case • History • Examination • Types of headache • Red Flags https://www.fotosearch.com/CSP992/k13365758/
“So, we’re going to talk you through hx, examination, diff types of headaches, focusing primarily on primary headaches (more benign) – talk through red flags, use a case history to discuss these.”
3 - Patient Case
Rachel, a 24 year old female comes to you, as her GP, with headaches.
What are you going to do?
Patient Case
Rachel, a 24 year old female comes to you, as her GP, with headaches.
- What are you going to do?
- First, always history and examination to get DIFFERENTIAL DIAGNOSIS
“First question always what are you going to do? As always, history and examination for DDx and then work out what you have to do next.”
4 - Differential Of Headaches
[speech]
Differential Of Headaches
ACUTE
• VASCULAR: Haemorrhage: SAH, intracranial bleed, sinus venous thrombosis
• INFECTION/INFLAMMATION: Meningitis, Encephalitis, Abscess
• OPHTHALMIC: Acute glaucoma
• SITUATIONAL: cough, exertion, coitus
CHRONIC • MIGRAINE • CLUSTER HEADACHES • DRUGS: Analgesics, Caffeine, Vasodilators (i.e. side effects of other drugs) • TENSION HEADACHES • NEURALGIA (TRIGEMINAL) • ICP ↑: tumours • GIANT CELL ARTERITIS • SYSTEMIC: HTN (pheochromocytoma, pre- eclampsia)
“So DDx for headaches can be split into Acute and chronic- acute: vascular, e.g. subarachnoid haemorrhages; infections like meningitis; Opthalmic thinking about acute closed-angle glaucoma; situational, most common is post-coital headache. And Chronic headache thinking about more primary benign headaches like migraines, cluster headaches, tension headaches and trigeminal neuralgia, medication-overuse headaches, raised ICP, giant cell arteritis and systemic causes of headaches – things that can caused raised BP, things like pheochromocytoma and pre-eclampsia in pregnant ladies.”
5 - Primary vs Secondary Headache
Primary vs Secondary Headache
Primary
• Due to the headache condition itself, not due to another cause
• E.g. migraine, tension, cluster
Secondary
• Headache that is present because of another condition
• E.g. headache in meningitis/sinusitis/SAH
• Medication overuse is in this category
“So, you can also categorise headaches into primary & secondary headaches. Primary headaches due to condition itself not due to another cause e.g. migraines, tension, cluster headaches. Secondary headaches to do with different presentation, so a diff condition, so secondary to a haemorrhage or infections like meningitis, and medication-overuse is also classed as secondary.”
6 - Most important thing to know by the end of the assessment:
Most important thing to know by the end of the assessment:
• How worried you are about the cause of the headache?
• What you are going to do next?
• Investigations?
• Start some treatment?
• Send to specialist?
• Send straight to A+E?
“So point of hx and exam, is you want to know how worried are you about cause of headache, and what are you going to do next – investigations, treatment or straight to A&E/specialist for urgent referral?”
7 - Headache History and Examination
Headache History and Examination
History • HPC: SOCRATES/ SQITARS • Causal factors/ triggers • PMHx: problems related to headaches i.e. previous history • DHx: analgesia/ drugs that give headache as a side effect • FHx • SHx: stress, eating, dehydration • Red Flags
Examination
• Observations
• Neuro (peripheral and cranial)
• Any related system depending on what you are worried about
“So, hx always the same, pain hx – with headache, want to know where it is, does it go anywhere, what does it feel like, how intense is the headache – timing of headache how long does it last anything makes it better or worse for the headache/in general and any associated symptoms. Also with headaches think about causal factors, lots of triggers for headaches, common ones include sleep disturbance, stress, certain foods e.g. cheese, coffee, wine etc. v common causes of headache. You want to know is this the first time or something they’ve had chronically over a number of years. If getting headaches how much medication they’re taking – are they straying into medication over-use side of headaches - or started medication a few months ago and actually a side effect? If it runs in the family? Any social history: causal factors and triggers. And also red flags we’ll come back to in a lil while. For Eeaminations of headaches – do obs, do temp for any signs of infection, any neurological deficit do full neuro exam (peripheral and cranial nerves) – and if cause involves diff system then examine that system as well, but most commonly just do neurological examination.”
8 - Differential Of Headaches
[slide]
Differential Of Headaches
ACUTE
• VASCULAR: Haemorrhage: SAH, intracranial bleed, sinus venous thrombosis
•INFECTION/INFLAMMATION: Meningitis, Encephalitis, Abscess
• OPHTHALMIC: Acute glaucoma
• SITUATIONAL: cough, exertion, coitus
CHRONIC • MIGRAINE • CLUSTER HEADACHES • DRUGS: Analgesics, Caffeine, Vasodilators (i.e. side effects of other drugs) • TENSION HEADACHES • NEURALGIA (TRIGEMINAL) • ICP ↑: tumours • GIANT CELL ARTERITIS • SYSTEMIC: HTN (pheochromocytoma, pre- eclampsia)
9 - Differential Of Headaches
A+E
Differential Of Headaches
Go to A+E/ for emergency assessment (*)
ACUTE
• *VASCULAR: Haemorrhage: SAH, intracranial bleed, sinus venous thrombosis
• *INFECTION/INFLAMMATION: Meningitis, Encephalitis, Abscess
• *OPHTHALMIC: Acute glaucoma
• SITUATIONAL: cough, exertion, coitus
CHRONIC • MIGRAINE • CLUSTER HEADACHES • DRUGS: Analgesics, Caffeine, Vasodilators (i.e. side effects of other drugs) • TENSION HEADACHES • NEURALGIA (TRIGEMINAL) • *ICP ↑: tumours • *GIANT CELL ARTERITIS • *SYSTEMIC: HTN (pheochromocytoma, pre- eclampsia)
“The ones that we’re flagging up now in orange = acute headaches: ones to be super worried about and ruling out with history. Things like bleeds or infections and acute-angle glaucoma: need to go straight to A&E. RICP if stable for a number of weeks then potentially just 2-week wait referral but any new seizures, changes in consciousness level for example, send them straight to A&E. GCA but generally can start some treatment acutely, acute corticosteroids, but need to be seen by a specialist in hosp within 24-48 hrs. Systemic – depends on what you think the cause is whether you do a 2-week wait or straight to hospital e.g. straight to hosp for pre-eclampsia.”
10 - Red Flag symptoms of Headache
[speech]
Red Flag symptoms of Headache
• Aimed at picking up emergencies and malignancies
Box 1. The SNOOP mnemonic may catch potentially life-threatening headaches
Systemic signs and disorders 50 years old 50 needs to be a BIG RED FLAG: we’ll talk about epidemiology of common benign headaches, you’ll see that 50 y/o quite late for these headaches: even if PMHx of headaches if this is NEW and DIFFERENT be worried about MALIGNANCY. Onset in Thunderclap presentation, vascular presentation, get a SAH lecture later on, we mean sudden onset, reaches intensity within a couple of seconds, worse headache they’ve ever had – patient commonly says things like “feel like I’ve been whacked over the back of the head” – quickness of headache. And then thinking about any symptoms of RICP such as papilledema, do you need to check the eyes as part of your neurological examination. So again you’ve got a future lecture on RICP but we’ll just”
11 - Red Flag symptoms of Headache
[slide]
Red Flag symptoms of Headache
• Aimed at picking up emergencies and malignancies
Box 1. The SNOOP mnemonic may catch potentially life-threatening headaches
Systemic signs and disorders 50 years old
12
Space occupying lesion symptoms • Gradual onset • Progressive • Associated neurology • Change in vision • Features of increased ICP • Early morning headache • N+V • Worse on coughing or bending https://www.fotosearch.com/CSP992/k13365758/
13
Patient Case Rachel, a 24 year old female comes to you, as her GP, with headaches. They have been going on for 2 months on and off. She gets about 1 a month. She gets a throbbing in her head and fuzzy lines in her vision. She vomits and light hurts her eyes. They go after about 6 hours. The pain relief she had tried isn’t helping very much. Think for a moment about your differential diagnosis Any red flags from that history? Any other questions you would ask?
14
Patient Case Rachel, a 24 year old female comes to you, as her GP, with headaches. They have been going on for 2 months on and off. She gets about 1 a month. She gets a throbbing in her head and fuzzy lines in her vision. She vomits and light hurts her eyes. They go after about 6 hours. The pain relief she had tried isn’t helping very much. Think for a moment about your differential diagnosis Any red flags from that history? Any other questions you would ask? Other questions: - Other red flags e.g. worse in the morning - How much medication she is taking/ new medications - Precipitants to headache
15
Patient Case Rachel, a 24 year old female comes to you, as her GP, with headaches. They have been going on for 2 months on and off. She gets about 1 a month. She gets a throbbing in her head and fuzzy lines in her vision. She vomits and light hurts her eyes. They go after about 6 hours. The pain relief she had tried isn’t helping very much.
