Headaches - Amazon S3€¦ · headaches •The best (and worst) questions to ask •Headaches are...
Transcript of Headaches - Amazon S3€¦ · headaches •The best (and worst) questions to ask •Headaches are...
Headaches
How to (not) take a history
Outline
• Common types of headache
• Patterns and associated features of common headaches
• The best (and worst) questions to ask
• Headaches are common
– 2% of ED attendances
– Most are benign
– Get good at taking a history
Pt 1
• 18 year old female, brought in by parents
• Sore throat for 1 day
• Complains of severe headache, worsening over the course of the day
• Fever
What additional questions should I ask?
• Neck stiffness
• Photophobia
• Confused/drowsy?
• Sinus symptoms
• Unwell contacts
Pt 2
• 55 year old male
• Sudden onset severe headache at 3am
What additional questions should I ask?
• Provoking factors
• Vomiting
• Neck stiffness
• Photophobia
• Had before?
• Drugs?
Pt 3
• 24 year old female
• Headache worsening over course of the day
• No fever
• In a dark room
What additional questions should I ask?
• Photophobia/phonophobia
• Visual symptoms
• Medication
• Had before?
• Relieving/exacerbating factors
Pt 4
• 35 year old male
• Headache for several weeks, not responding to analgesia
What additional questions should I ask?
• Medications
• Relationship to time of day?
• Sleeping?
• Relieving/exacerbating factors
Pt 5
• 24 year old female
• overweight
• Headache for several weeks, worsening, waking from sleep
What additional questions should I ask?
• Relationship with time of day
• Posture?
• Vomiting?
• Visual disturbance
How to take a headache history
How to take a headache history
How to diagnose headaches
Its all about timing
• Onset
• Pattern
• Associated features
Onset Seconds Minutes-hours Hours- days
SAH Meningitis Raised ICP
Stroke Venous sinus thrombosis Tension headache/chronic daily headache
Pituitary apoplexy Sinusitis Malignant hypertension/PRES
Glaucoma Giant cell arteritis
Migraine SDH
Cluster headache Brain abscess
Optic neuritis
Thunderclap headaches
• A true thunderclap headache has an onset within seconds and reaches maximal intensity within 5 minutes.
• Headaches due to a vascular event always last longer than 1 hour
Pattern Time of day Worse in morning
• Raised ICP Worse in evening • Tension
headache
Continuous • Venous sinus
thrombosis • Brain abscess
Location Unilateral • Cluster headache • Glaucoma
Bilateral • Tension
headache • meningitis
Frontal • Sinusitis
Frequency Recurrent • Cluster headache • Chronic daily
headache • Migraine
Singular • Vascular event • Meningitis • Venous sinus
thrombosis
Associated features Fever Meningitis
Neck stiffness Meningitis, SAH, dissection
Visual aura/disturbance Migraine, glaucoma, giant cell arteritis, optic neuritis
Photophobia Meningitis, migraine
Phonophobia Migraine
Drowsiness/confusion Meningoencephalitis, hypertensive encephalopathy
Focal neurology Stroke, abscess, tumour, dissection, venous sinus thrombosis
Trauma SDH, dissection, SAH
Very high BP Hypertensive encephalopathy, intraparenchymal bleed
Red flags
• Age >50 • Altered level of consciousness • Seizure • True thunderclap headache • Associated with exertion • Don’t usually get headaches • Focal neurology • Immunosuppression • Visual disturbance • Pregnancy/post-partum • Medications (anti coagulants, cocaine) • History of cancer
Taking a history
• What time did the headache start? • What were you doing at the time? • How quickly did the headache come on? • No, HOW quickly? • When was the headache at its worst? • Did the headache wake you up or did you wake up with
a headache? • Has it stopped you from doing things? • Have you had a headache like this before? • Is it the worst headache of your life? • Bending/coughing/sneezing
Learning points
• Be persistent in your history taking
• Make sure you fully understand the nature of the headache
• Learn headache patterns