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
- 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 GCS
- May have neurological symptoms/seizures
- History of malignancy/immunocompromise
- Venous sinus thrombosis
- Intracranial haemorrhages (intracerebral, subarachnoid, subdural)
- Infections (abscess, encephalitis, meningitis, viraemia)
- Spontaneous intracranial hypotension
- 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
- 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
- Vestibular neuritis
- Viral labyrinthitis
- Ménière’s disease
- Other peripheral causes
- 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 URTI
- 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
Central
- 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
- 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
- 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
- PE
- Vertebrobasilar insufficiency (elderly with cervical osteoarthritis)
Neurological
- 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
- 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)
Reflex
- 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)
Others
- 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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