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Common cerebral histories

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

Primary headache

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

Subarachnoid haemorrhage

  • Very sudden onset severe headache
  • ‘Like someone hit me with a brick over the head’
  • Meningism

Raised intracranial pressure

Many causes, 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

Other intracranial causes

  • Venous sinus thrombosis
  • Intracranial haemorrhages (intracerebral, subarachnoid, subdural)
  • Infections (abscess, encephalitis, meningitis, viraemia)
  • Spontaneous intracranial hypotension
  • Pituitary apoplexy

Secondary – extracranial

Giant cell arteritis

  • Unilateral throbbing pain
  • Scalp tenderness and jaw claudication
  • >55 years
  • May have visual involvement

Glaucoma

  • Pain around one eye
  • Swollen red eye
  • Visual blurring and halos

Sinusitis

  • Facial pain exacerbated by leaning head forward
  • Rhinorrhoea

Other extracranial causes

  • Hypertensive headache
  • Hypoxia/hypercapnia
  • 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

Peripheral (vestibular)

Benign positional vertigo

  • Attacks of sudden rotational vertigo
  • Evoked by head turning
  • Lasts ~30 seconds

Vestibular neuritis

  • 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

Other peripheral causes

  • Acoustic neuroma (vestibular schwannoma)
  • Chronic otitis media
  • Eustachian tube dysfunction
  • Ramsay-Hunt syndrome (vertigo, facial palsy, otalgia, zoster rash)
  • Cholesteatoma

Central

Vertebrobasilar stroke

  • Sudden onset
  • Other neurological symptoms

Cerebellar stroke

  • Sudden onset
  • Other cerebellar symptoms

Vertebrobasilar insufficiency

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

Other central causes

  • 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

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

Other cardiac causes

  • Structural, e.g. hypertrophic obstructive cardiomyopathy, arrhythmogenic right ventricular dysplasia
  • PE 
  • Vertebrobasilar insufficiency (elderly with cervical osteoarthritis)

Neurological

Seizure

  • Partial

    • Simple partial: focal motor seizure, no LOC
    • Complex partial (e.g. temporal lobe epilepsy): strange actions with impaired awareness

    • 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

Other neurological causes

  • Neuropathy e.g. MS
  • Intracranial haemorrhage (extradural, subarachnoid, subdural)
  • Drop attack (sudden leg weakness without warning/LOC/confusion)

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?

Headache features

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Associated features

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Patient features

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Time to test yourself! Try some stations.

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

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