Headache

Exploring symptom

• Pain
  • Site
  • Onset
  • Character
  • Radiation
  • Associated symptoms
  • Timing
  • Exacerbating/relieving factors
  • Severity
• Red flags
  • Intracranial bleed: thunderclap headache, recent trauma
  • Raised intracranial pressure: posture/Valsalva-related
  • SOL: immunosuppression, malignancy, focal neurology, onset >50 years
  • Meningitis: rash, fever, neck stiffness, photophobia
  • Giant cell arteritis: visual problems, jaw claudication, scalp tenderness
  • Glaucoma: visual blurring, red eye, halos

Relevant system reviews

• General
  • Fever, skin rashes/bruising
• Neurological
  • General: fits/falls/LOC, dizziness, vision/hearing, memory loss, neck stiffness/photophobia
  • Motor: weakness/wasting, incontinence 
  • Sensory: pain, numbness, tingling

Differential diagnoses and clues

Primary:

Tension headache	-Bilateral tight band sensation -Recurrent -Occurs late in day -Association with stress
Cluster headache	-Short painful attacks around one eye-Last between 30 minutes – 3 hours  -Occur multiple times a day for 1-3 months -May have lacrimation and flushing
Migraine	-Unilateral throbbing headache in trigeminal nerve distribution -Last between few hours – days   -May have aura (usually visual) -Need to lie down in dark room (photophobia)
Trigeminal neuralgia	-2 second paroxysms of stabbing pain in unilateral trigeminal nerve distribution -Face screws up with pain

Secondary – intracranial:

Meningitis	-Photophobia -Neck stiffness -Systemic symptoms, e.g. fever, non-blanching rash
Giant cell arteritis	-Unilateral throbbing pain -Scalp tenderness and jaw claudication ->55 years -May have visual involvement
Subarachnoid haemorrhage	-Very sudden onset severe headache -‘Like someone hit me with a brick over the head’ -Meningism
Raised intracranial pressure (e.g. tumour, idiopathic intracranial hypertension)	-Worse in morning and with coughing and bending -Vomiting and reduced GCS  -May have neurological symptoms/seizures -History of malignancy/immunocompromise

Secondary – extracranial:

Glaucoma	-Pain around one eye -Swollen red eye -Visual blurring and halos
Sinusitis	-Facial pain exacerbated by leaning head forward -Rhinorrhoea

Others:

Other differentials

Venous sinus thrombosis Intracranial haemorrhages (intracerebral, subarachnoid, subdural) Infections (abscess, encephalitis, meningitis, viraemia) Hypertensive headache Spontaneous intracranial hypotension  Hypoxia/hypercapnia Pituitary apoplexy Cervical spondylosis Pre-eclampsia Drugs (e.g. nitrates, PPI, caffeine, analgesia overuse, hormones)

Vertigo

Exploring symptom

• Timeframe
  • Duration
  • Onset (sudden or gradual)
  • Progression
  • Timing (intermittent or continuous)
• Background to attacks
  • e.g. Previous attacks, frequency, impact on life

Relevant system reviews

• General
  • Fever
• ENT
  • Ear: hearing loss, tinnitus, otalgia
  • Nose: rhinorrhoea, epistaxis
  • Throat: sore throat, odynophagia
• Neurological
  • General: fits/falls/LOC, headache, dizziness, vision/hearing, memory loss, neck stiffness/photophobia
  • Motor: weakness/wasting, incontinence 
  • Sensory: pain, numbness, tingling

Differential diagnoses and clues

Peripheral (vestibular):

Benign positional vertigo	-Attacks of sudden rotational vertigo -Evoked by head turning -Lasts ~30 seconds
Vestibular neuritis(e.g. Herpes virus)	-Often preceded by URTI -Sudden rotational vertigo and vomiting -Lasts several days but imbalance may persist -May re-occur several times per year
Viral labyrinthitis	-Often preceded by URTI  -Severe vertigo and hearing disturbance -May have tinnitus, otalgia, nausea, fever
Ménière’s disease	-TRIAD: vertigo + tinnitus + hearing loss -Attacks last minutes-hours

Central:

Vertebrobasilar insufficiency

-Momentary vertigo attacks precipitated by neck extension  -Elderly with cervical osteoarthritis

Others:

Peripheral	– Acoustic neuroma (vestibular schwannoma) – Chronic otitis media – Eustachian tube dysfunction – Ramsay-Hunt syndrome (vertigo, facial palsy, otalgia, zoster rash) – Cholesteatoma
Central	– Vertebrobasilar stroke  – Cerebellar stroke – Neurological conditions (e.g. MS, epilepsy, brain tumour, migraine) – Head injury
Drugs	e.g. alcohol, salicylates, quinine, aminoglycosides, metronidazole, co-trimoxazole, diuretics

Fit / fall / syncope

Exploring symptom

• Attack
  • Before: warning, circumstance
  • During: duration, LOC, movements (floppy/stiff/jerking), incontinence/tongue biting, complexion (get corroboration)
  • After: amnesia, muscle pain, confusion/sleepiness, injuries from fall 
• Background to attacks
  • e.g. Previous attacks, frequency, impact on life

Relevant system reviews

• General
  • Fever
• Cardiorespiratory
  • Chest pain, palpitations, SOB/wheeze, leg swelling
• Neurological
  • General: fits/falls/LOC, headache, dizziness, vision/hearing, memory loss, neck stiffness/photophobia
  • Motor: weakness/wasting, incontinence 
  • Sensory: pain, numbness, tingling

Differential diagnoses and clues

Cardiovascular:

Arrhythmia	-Fall after transient arrhythmia -May have had palpitations or felt strange before collapse -Cardiac history or family history of sudden death -May have occurred during exercise or when supine
Aortic stenosis	-Collapse on exertion -SOB worse on exertion

Neurological:

Seizure	Partial –Simple partial: focal motor seizure, no LOC – Complex partial (e.g. temporal lobe epilepsy): strange actions with impaired awareness Generalised –Tonic-clonic (grand mal): sudden LOC, limbs stiff then jerk, may become incontinent, bite tongue, feel awful with myalgia and confusion afterwards –Absence (petit mal): unresponsively stare into space for ~5 seconds (in childhood) –Atonic: all muscles relax and drop to floor –Tonic: all muscles become rigid –Myoclonic: involuntary flexion
Parkinson’s disease	TETRAD = rigidity + tremor + bradykinesia + postural instability
TIA/stroke	-Neurological symptoms, e.g. limb/face weakness, slurred speech, hemianopia -LOC/syncope very uncommon

Reflex:

Vasovagal	-Occurs in response to stimuli, e.g. emotion/pain/fear/prolonged standing -Preceding nausea, pallor, sweat, closing visual fields -Then LOC for ~2 minutes
Postural hypotension	-Dizziness ± LOC on standing from lying -Recently medication changes (e.g. antihypertensives)

Others:

Cardiovascular	-Structural e.g. hypertrophic obstructive cardiomyopathy, arrhythmogenic right ventricular dysplasia -PE -Vertebrobasilar insufficiency (elderly with cervical osteoarthritis)
Neurological	-Neuropathy e.g. MS-Intracranial haemorrhage (extradural, subarachnoid, subdural) -Drop attack (sudden leg weakness without warning/LOC/confusion)
Reflex	-Situation syncope (e.g. cough syncope, effort syncope, micturition syncope) -Carotid sinus hypersensitivity (precipitated by head turning/shaving)
Mechanical	-Mechanical fall/postural instability
Alcohol/drugs use	-Alcohol excess -Polypharmacy -Recreational drugs
Abdominal	-Ectopic pregnancy -Ruptured AAA
Miscellaneous	-Delirium (secondary to infection) -Any cause of vertigo above  -Anaemia -Hypoglycaemia -Eyesight problems -Arthritis

Try some questions

What are the red flags when assessing a patient with a headache? And which conditions would you worry about if each were present?

Time to test yourself! Try some stations.

1. Headache history
2. Stroke
3. SAH
4. TIA
5. There’s lots more to do…