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
- Bilateral tight band sensation
- Recurrent
- Occurs late in day
- Association with stress
- 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
- 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)
- 2 second paroxysms of stabbing pain in unilateral trigeminal nerve distribution
- Face screws up with pain
Secondary – intracranial
- Photophobia
- Neck stiffness
- Systemic symptoms, e.g. fever, non-blanching rash
- Very sudden onset severe headache
- ‘Like someone hit me with a brick over the head’
- Meningism
Many causes, e.g. tumour, idiopathic intracranial hypertension
- Worse in morning and with coughing and bending
- Vomiting and reduced GCSÂ
- May have neurological symptoms/seizures
- History of malignancy/immunocompromise
- Venous sinus thrombosis
- Intracranial haemorrhages (intracerebral, subarachnoid, subdural)
- Infections (abscess, encephalitis, meningitis, viraemia)
- Spontaneous intracranial hypotensionÂ
- Pituitary apoplexy
Secondary – extracranial
- Unilateral throbbing pain
- Scalp tenderness and jaw claudication
- >55 years
- May have visual involvement
- Pain around one eye
- Swollen red eye
- Visual blurring and halos
- Facial pain exacerbated by leaning head forward
- Rhinorrhoea
- 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
- 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
- Attacks of sudden rotational vertigo
- Evoked by head turning
- Lasts ~30 seconds
- Often preceded by URTI
- Sudden rotational vertigo and vomiting
- Lasts several days but imbalance may persist
- May re-occur several times per year
- Often preceded by URTIÂ
- Severe vertigo and hearing disturbance
- May have tinnitus, otalgia, nausea, fever
- TRIAD: vertigo + tinnitus + hearing loss
- Attacks last minutes-hours
- Acoustic neuroma (vestibular schwannoma)
- Chronic otitis media
- Eustachian tube dysfunction
- Ramsay-Hunt syndrome (vertigo, facial palsy, otalgia, zoster rash)
- Cholesteatoma
- Sudden onset
- Other neurological symptoms
- Sudden onset
- Other cerebellar symptoms
- Momentary vertigo attacks precipitated by neck extension
- Elderly with cervical osteoarthritis
- 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
- 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
- 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
- Collapse on exertion
- SOB worse on exertion
- Structural, e.g. hypertrophic obstructive cardiomyopathy, arrhythmogenic right ventricular dysplasia
- PEÂ
- Vertebrobasilar insufficiency (elderly with cervical osteoarthritis)
- Partial
- Simple partial:Â focal motor seizure, no LOC
- Complex partial (e.g. temporal lobe epilepsy):Â strange actions with impaired awareness
- Generalised
- Tonic-clonic (grand mal):Â 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:Â all muscles relax and drop to floor
- Tonic:Â all muscles become rigid
- Myoclonic:Â involuntary flexion
- TETRAD = rigidity + tremor + bradykinesia + postural instability
- Neurological symptoms, e.g. limb/face weakness, slurred speech, hemianopia
- LOC/syncope very uncommon
- Neuropathy e.g. MS
- Intracranial haemorrhage (extradural, subarachnoid, subdural)
- Drop attack (sudden leg weakness without warning/LOC/confusion)
- Occurs in response to stimuli, e.g. emotion/pain/fear/prolonged standing
- Preceding nausea, pallor, sweat, closing visual fields
- Then LOC for ~2 minutes
- Dizziness ± LOC on standing from lying
- Recently medication changes (e.g. antihypertensives)
- Situation syncope (e.g. cough syncope, effort syncope, micturition syncope)
- Carotid sinus hypersensitivity (precipitated by head turning/shaving)
- Mechanical fall/postural instability
- Alcohol/drugs useÂ
- Alcohol excess
- Polypharmacy
- Recreational drugs
- AbdominalÂ
- Ectopic pregnancy
- Ruptured AAA
- MiscellaneousÂ
- Delirium (secondary to infection)
- Any cause of vertigo aboveÂ
- 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?
Oops! This section is restricted to members.
Oops! This section is restricted to members.
Oops! This section is restricted to members.
Time to test yourself! Try some stations.
- Headache history
- Stroke
- SAH
- TIA
- There’s lots more to do…
