Table of Contents
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 thrombosisIntracranial haemorrhages (intracerebral, subarachnoid, subdural) Infections (abscess, encephalitis, meningitis, viraemia) Malignant hypertension Spontaneous intracranial hypotension Hypoxia/hypercapniaPituitary apoplexy Cervical spondylosisPre-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:
| Postural hypotension | -Dizziness ± LOC on standing from lying -Recently medication changes (e.g. antihypertensives) |
| 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 |
| 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 |
Others:
| Mechanical | -Mechanical fall/postural instability |
| Cardiovascular | -Structural e.g. hypertrophic obstructive cardiomyopathy, arrhythmogenic right ventricular dysplasia -Situation syncope (e.g. cough syncope, effort syncope, micturition syncope) -Carotid sinus hypersensitivity (precipitated by head turning/shaving) -Vertebrobasilar insufficiency (elderly with cervical osteoarthritis) -PE |
| Neurological | -Neuropathy e.g. MS-Intracranial haemorrhage (extradural, subarachnoid, subdural) -Drop attack (sudden leg weakness without warning/LOC/confusion) |
| 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 |
