Headache

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Headache

Di erential Diagnosis

Serious Causes
Subarachnoid Hemorrhage
Meningitis
Carotid Or Vertebral Artery Dissection
Cerebral Venous Thrombosis
Pituitary Apoplexy
GCA
Intracerebral Hemorrhage Brain
Tumors:1ry or 2ry

Common causes:
Migraine
Tension Headache
Autonomic Cephalgias (Cluster Headache)
Exertional Medication
Overuse Headache
Trigeminal neuralgia
Benign Intracranial HTN
Metabolic Causes (Dehydration,
Hyponatraemia)
Uncontrolled HTN
Errors of Refraction
Referred Pain: Tooth, Ear, Sinuses, Eyes, Face,
Neck
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Other causes:
Brain Abscess,
HIV
Smoking Cessation
Carbon Monoxide Poisoning
Alcohol withdrawal

Analysis Of Complaint
Initially double check What Is Meant By
Headache?
Headache is pain of the head vault.
It is di erent than facial pain or neck pain, but
patients may name all (headache).

Headache is pain, so Follow SOCRATES. Where


Exactly In Your Head?

How Did It Start; Suddenly Or Gradually?


How Long?

Is It Getting Better Or Worse?

Could You Describe The Pain?? Is It


Throbbing, Band Like, Boring Pain??

Is It Radiating Any Where Else?


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Do You Have It All The Time/Attacks?

When Mostly? (Tension At Night,


Increased ICP In Morning)

What Makes It Better?

What Makes It Worse?

How Would You Give It On A Scale From


0-10? Is It The Worst Headache In Your
Life?

Questions To R/O Di erential


Diagnosis

Encephalitis / Meningitis
Have You Noticed Any Fevers?

Skin Rash?

Sti ness Of Your Neck?

Any Contact With Sick Children?


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Change In Behavior? Consciousness?

PMR/GCA
Is It On The Temporal Side Of the Head?

Any Pain & Sti ness in Your Shoulders?

Head Pain, Jaw Cramps/Claudication


While Eating?

Any Visual Problems?

Sub/Extra Dural Hematomas


Did You Hit Your Head?

Are you on Any Blood Thinners?

Change In Behavior? Consciousness?

Any Associated weakness?

Do You Drink Alcohol? (Chronic


Subdural)
ff
Sub-Arachnoid Hemorrhage
The Worst headache Ever?

Neck Sti ness?

Are you Taking Any Blood Thinners?

PMH of Kidney problems?

FH: Of Bleed In the Brain?

Increased ICP
Does It Occur In The Early Morning?

Do You Through Up?

Any Blurring Of Vision?

Any Weakness in Arms or Legs?

Any Fits?
ff
Pituitary Tumors
Signs of Increased ICP: See Before

Acromegaly:
What About Your Shoe And Ring Size,
Do They Fit?

Can You See The Sides Of The Road?

Prolactinoma:
Any Breast Discharge?

Decreased sexual desire?

Pituitary Apoplexy
Any Sudden Severe Bleeding?

Associated Endocrine Symptoms?


Cerebral Sinus Thrombosis
Any PMH of Having Clots in Your Legs
or Lungs?

Double Vision?

Any Medication Causing your Blood to


be Thicker, e.g. HRT, OCPs. Are You
Pregnant? (For female patients)

Acute Onset, Thunder Clap Headache.

Benign Intracranial Hypertension


Have You Gained Weight Recently?

Do You Have Double Vision?

Are You Taking Steroids, Vit. A,


Tetracyclines, OCPs?

All tests Done are Normal?


Tension Headache
Is It Band Like Over Your Head,
Occurs At The End Of The Day?

Have You Been Stressed Recently?

What About Your Mood?

Migraine
Is It Unilateral?
Is It Preceded By Any Unusual
Sensations, Taste In Your Mouth? Any
Weakness?
Any Blurry Vision? (Aura)
Eased by sitting in Dark Quiet Room?

Cluster Headache
Is It Around the Eyes?
Occurring in Clusters?
Any Watering Of Your Eyes? Redness?
Runny Nose, Nose Blockage?
Does It Occur Several Times In The
Day? Does It Occur At The Same Time
Each Year?

Trigeminal Neuralgia
Any Pain In Your Face, Triggered By
Chewing, Washing Face?

Carbon Monoxide Poisoning


Does It Get Better When You Are Away
From Home?
Other Family Members having The
Same Symptoms?
Do You Have Any Fuel Burning
Devices (Furnaces, Gas Heaters, Gas
Boilers, Gas Working Stoves, Gas
Generators, and Power Tools?

Medications Induced headache


Nitrates?
Sildena l?

Long standing Analgesics


(Opioids & Non-Opioids) Use?

Hypertension
PMH of HTN or New Diagnosis?

Quick Discussion
How Would You Investigate This
Case?

CT Head With or Without Contrast /

MRI Brain for:

Brain Tumors
fi
Bleeds

SAH Meningitis/Encephalitis
Lumbar Puncture
SAH= Xanthochromia
Meningitis= raised proteins, Raised
WBCs, Glucose abnormality according
to the cause
Idiopathic Intracranial HTN = Raised
opening pressure & therapeutic
Temporal Artery Biopsy = GCA
Pituitary Function tests = Pituitary
Tumors/Apoplexy VBG = CO Poisoning
How Would You Treat This Case
With Headache?

Analgesia

Admit to hospital If Alarming


Symptoms Treat The Cause
Migraine = Analgesia Sumatriptan,
Prevention with Betablocker & TCA

Cluster Headache = high Flow Oxygn ,


Analgesia , prophylaxis with CCBs

Brain Tumor = Neurosurgical R/V

Pituitary Apolpexy = Endocrine/Neuro-


surgical R/V Meningitis = Antibiotics +
Admission to hospital Blood Pressure
Control

Trigeminal Neuralgia = Carbamazepine

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