Approach - headache

Question 1

(8) Things to ask in a neurological Hx

Answer 1

–Weakness
–Numbness
–Dizziness
–Clumsiness
–Pain
–Speech problems
–Disturbance of hearing or vision
–Altered mentation or consciousness

Question 2

How can you classify neurological patterns (5)?

Answer 2

• Peripheral nerve (e.g. femoral, median)
• Spinal nerve
• Peripheral neuropathy
• Hemisyndrome
• Spinal cord (e.g. paraplegia)

Question 3

How do you classify timeline of a headache?

Answer 3

•Onset
–Acute: Instantaneous (ictal), Seconds, Minutes, Hours
–Sub-acute
–Chronic
•Sequence of symptoms
•Constant vs. episodic
•Progressive vs. stable
•Gradual vs. step-wise

Question 4

What (3) interacting illnesses & risk factors should you ask in a headache?

Answer 4

–Diabetes
–Rheumatological conditions
–Vascular risk

Question 5

5 types of important headaches

Answer 5

• Migraine: Headache+Aura
• Tension-type headache
• Chronic daily headache
• Sub-arachnoid haemorrhage
• Raised intracranial pressure

Question 6

Describe migraine

• epidemiology
• risk factors
• Px
• associated features

Answer 6

•Common: 20% women, 5-10% of men
•Idiopathic headache syndrome: Genetic
•May be preceded by aura but
Over 2/3 have migraine without aura

Px:
• a few hours to 3 days
•Recurrent, episodic headache
•Really bad pain
–Moderate to severe
–Building over minutes
•UNILATERAL
•Pulsating
•Aggravated by exercise

Associated with:
–Nausea and vomiting
–Photo- or phonophobia
- paraesthesia, weakness, dysphasia, basilar migraine 
- visual phenomena

Question 7

Describe tension-type headache

• Px
• associated features

Answer 7

•Mild to moderate
•Band-like
–BILATERAL
–Pressing

•NOT associated with
–Exercise induction
–Nausea
–Photo/phonophobia

Question 8

Describe chronic daily headache

• Px
• associated features

Answer 8

•Most days, most of the day

•Chronic migraine
–Evolves from migraine without aura
–Just as miserable as it sounds

•Chronic tension-type headache
–Individually mild headaches
–Persistence distressing

Question 9

Describe subarachnoid haemorrhage

• timeline
• Px
• associated features
• Ix

Answer 9

•Thunderclap headache: SUDDEN ONSET IS THE KEY

•May have neurological symptoms/signs
–Weakness/sensory loss
–Impairment of consciousness often occurs. Depth of coma marks prognosis

Headache is meningeal
•Moderate to severe
•Photo/phonophobia
•Nausea
•May be unilateral

Ix: plain CT. If negative, do lumbar puncture

Question 10

Other (3) thunderclap headaches than SAH

Answer 10

• Sexual and exertional headaches
• Vasospastic headache
• Primary thunderclap headache

Question 11

Describe raised ICP headache

• Px
• associated features

Answer 11

• Diffuse headache
• Variable severity: Often progressive
• Nausea prominent

•Worse with increases in ICP
–Valsalva (cough, straining)
–Morning headache
–Better standing

•Papiloedema
–Peripheral visual loss
–Transient blindness

•Diplopia
–Sixth nerve palsy

Question 12

26yo woman with transient, objective left sided weakness and sensory disturbance.

Acute presentation to ED.
Sensory and motor symptoms fully resolved.

DDx?

Answer 12

• Migraine aura: High prior probability
• Transient ischaemic attack
• Focal seizure
• Hypoglycaemia
• Vasospastic headache
• Functional neurological disorder

Question 13

Compare Px of migraine, TIA & focal seizures

Answer 13

All have cortical involvement, acute onset

Migraine:

• gradual offset & often stepwise
• nausea, headache
• photo/phonophobia
• more likely in young

TIA:

• gradual offset
• CV history. MI/Stroke/PVD
• common in >65yo

Focal seizure:

• distinct offset; Todd’s paresis
• clonus/dystonia prior to weakness
• dyscognitive phase
• previous, stereotyped events

Question 14

Does EEG diagnose seizure?

Answer 14

NO.

But it predicts recurrence sometimes