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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

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 differentialsVenous 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
Drugse.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:

SeizurePartial
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 diseaseTETRAD = 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?

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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