What is key to ask during the history?
• SOCRATES o Site o Onset -> time, is it sudden or gradual? o Character of pain o Associations -> symptoms o Time course -> does the pain follow any pattern? o Exacerbating/relieving factors o Severity
What are the red flags of a headache?
- Meningitis
- Temporal arteritis
- Glaucoma symptoms
- Raised ICP
- Subarachnoid haemorrhage
What are the relevant system reviews?
General
- Fever, skin rashes/bruising
Neurological
- General: fits/falls/loss of consciousness, dizziness, vision/hearing, neck stiffness/photophobia
- Motor: weakness/wasting, incontinence
- Sensory: pain, numbness, tingling
What are the signs of a tension headache?
- Bilateral tightening/pressing sensation
- Recurrent
- Lasts for 30 mins continuously
- Occurs late in the day
- Association with stress
What are the signs of a cluster headache?
- Unilateral, short painful attacks around one eye
- Can be sharp, boring, burning, throbbing or tightening
- May be lacrimation and flushing
- Constricted pupil (miosis) and/or dropping eyelid (ptosis)
- Lasts between 30 mins - 3 hours
- May occur once/twice a day for 1-3 months
What are the signs of a migraine?
- Unilateral or bilateral pulsating headache in trigeminal nerve distribution
- Aggravated by, or causes avoidance of routine activities
- May have aura (visual)
- Need to lie down in a dark room (photophobia)
- Last between few hours - days
What are the signs of trigeminal neuralgia?
- 2 seconds paroxysms of stabbing pain in unilateral trigeminal nerve distribution
- Face screws up with pain
What is a subarachnoid haemorrhage and what is it most commonly caused by?
Bleeding into the subarachnoid space. Most commonly caused by: - Aneurysm - Head injury - Arteriovenous malformations
What are the red-flag features of a subarachnoid haemorrhage?
- Thunderclap headache
- Loss of consciousness
- Nausea/vomiting
- Meningism (neck stiffness and muscle aches)
How would you diagnose a subarachnoid haemorrhage?
CT
- Blood distributed throughout basal cisterns, sulci and in severe cases the ventricular system
- CT is normal in 7% cases
Lumbar puncture -> wait 12 hours from symptom onset
- Xanthochromia
- Raised opening pressure
What is a subdural hematoma?
A collection of blood between the dural and arachnoid coverings of the brain.
As the volume of the haematoma increases, brain parenchyma is compressed and displaced, and the intracranial pressure may rise and cause herniation.
What are the red-flag features of a subdural hematoma?
- Evidence of trauma, coagulopathy or anticoagulant use
- Headache
- Nausea and vomiting
- Fluctuating level of consciousness
- Reduced GCS
How would a subdural hematoma show up on a CT?
- Significant mass effect and midline shift
- Crescent shaped
What is an extra-dural/epidural haematoma?
A collection of blood that forms between the inner surface of the skull and outer layer of the dura (endosteal layer).
What are the red-flag features of an extra-dural/epidural haematoma?
- Clearly defined head trauma
- Loss of consciousness followed by a period of improved neurological symptoms and consciousness
- Followed by a rapid decline
Haematoma compresses structures
How would a extra-dural /epidural haematoma show up on a CT?
- Brain shows compression and displacement of the midline and compression of the ventricle
- Outside the skull there is soft tissue swelling = trauma
- Bi-convex shape
What are the red-flag features of meningitis?
- Photophobia
- Neck stiffness (meningism)
- Headache
- Systemic features: non-blanching rash, fever
What is giant cell /temporal arteritis?
Cell-mediated immune response due to endothelial cell injury
What are the red-flag features of giant cell /temporal arteritis?
- Unilateral throbbing pain
- Scalp tenderness
- Jaw caludication
- May be visual problems (abducens palsy)
RISK FACTORS
- > 55 yrs
- Females
What are the investigations you would order for giant cell /temporal arteritis?
ESR >40mm/h
• Indirect measure of degree of inflammation in the body
CRP
Temporal artery biopsy -> shows giant cells
What is the management for giant cell /temporal arteritis?
- Prednisolone
- Aspirin
- PPI
What are the red-flag features of raised ICP?
- Worse in morning and with coughing and bending
- Vomiting
- Reduced GCS
- May be neurological symptoms and seizures
What are the red-flag features of glaucoma?
- Unilateral headache
- Eye pain
- Swollen red eye
- Visual blurring and halos
What could cause decreased consciousness level or localising signs?
- Stroke
- Encephalitis
- Meningitis
- Cerebral abscess
- Subarachnoid haemorrhage
- Venous sinus occlusion
- Subdural hematoma
- TB meningitis
