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Headaches 3 Year OSCE practice Saade MohammedDisclaimer! These teaching sessions are made and run entirely by Senior Medical Students who volunteer to teach To our best knowledge what we are teaching is correct, be aware that we will not take responsibility for any inaccuracies present during these sessions This session is in no way associated or endorsed by the Medical School Primary vs Secondary Headache- Differentials Surgical Sieve Acute vs Chronic Primary Vs Secondary • Tension Headache • Meningitis • Cluster headache • Temporal Arthritis • Migraine • Subarachnoid Haemorrhage • Trigeminal Neuralgia • Raised ICP • Glaucoma • Sinusitis Vascular Infection Trauma Metabolic Surgical Sieve- Iatrogenic Neoplastic VIT AMINCDEF Congenital Degenerative Endocrine FunctionalSurgical Sieve Continued • Vascular- Haemorrhagic or ischaemic stroke • Infection- Meningitis, encephalitis, abscess • Trauma • Metabolic- anaemia, hyponatraemia • Iatrogenic- After lumbar puncture, PPI, analgesia overuse, hormones (e.g. OCP), nitrates • Neoplastic- Space occupying lesion- malignant or benign tumour • Congenital- arteriovenous malformation (AVM) • Degenerative- Multiple sclerosis • Endocrine- hyper/ hypothyroidism, Addison's, Cushing's (due to SOL) • Functional- TMJ pain, migraines and other non-pathological headaches Acute or Chronic • Subarachnoid Haemorrhage • Migraine • Tension type • Cerebral Sinus Venus Thrombosis • Acute Migraine • Occipital Neuralgia • Meningitis • Raised intracranial pressure (idiopathic intracranial HTN or SOL) • Encephalitis • Traumatic brain injury • Haemorrhagic Stroke • Traumatic Brain Injury • Trigeminal Neuralgia • Temporal Arthritis (Giant Cell Arthritis- GCA) • TMJ pain • Cerebral VasculitisOther differentials • Intracranial venous Thrombosis • Intracranial Haemorrhages: Subdural, extradural, intracerebral • Malignant hypertension • Hypoxia • Viraemia • Cervical spondylosis • PreeclampsiaSTRUCTURE! STRUCTURE! STRUCTURE! Headache HistoryHPC: Socrates • Site- unilateral, bilateral, band, around the eye, nerve distribution • Onset- sudden, gradual, aura/ warning • Character- stabbing, throbbing, pressure • Radiation- nerve distribution, jaw, neck • Associated Symptoms- runny nose, flushing, photophobia, neck stiffness, nausea and vomiting • Time- constant, worse at the end of the day, length of time per episode, worse in morning • Exacerbating/ Relieving factors- head position, strenuous activity, coughing/ pain killers, dark room. • Severity- Scale of 0-10. How long did it take to get max severity? Is it still severe? • Always ask how it affects their functionality/ day to day life • Meningitis • Non blanching rash Red Flags • Fever • Neck Stiffness • Photophobia • Temporal Arthritis • Vision changes • Jaw claudication • Scalp tenderness • Subarachnoid Haemorrhage • Thunder clap headache- sudden onset • Symptoms of malignancy • Signs of Raised intracranial pressure • Nocturnal, worse in the morning • Worse on lying flat • Worse onRelevant Past Medical History • Recent Head Trauma • Migraine • Past Neurosurgery • Subarachnoid aneurysm • PMH of cancer (could be brain mets) • Hypertension (risk of stroke) • Polymyalgia Rheumatica (associated with temporal arthritis)Relevant Drug History • Those associated with overuse headaches • Opiates • Triptans • NSAIDs • Paracetamol • Blood thinning medications- aspirin, warfarin, NOACs • Side effects • Over the counter medication • ALLERGIESRelevant Family History • Headaches • Cancer • Brain Bleeds • Clotting disorders • Bleeding disorders • Ask specifically about the AGE of development for these conditions- younger= more likely to be genetic associationsRelevant Social History • General Social context • Type of accommodation, are they coping, who they live with • Sleeping hygiene • Presence of gas fire or boiler (carbon monoxide→ headache) • Smoking, including pack years • Drinking- frequency, type and volume • Recreational Drug use- frequency and type (e.g. cannabis, cocaine, amphetamines cause headache) • OccupationHeadaches in the OSCE History, examination, investigation Migraine • Chronic, episodic, primary headache condition • Types: Migraine w/ or w/o aura, aura w/o headache • Risk factors- young, female • Triggers to ask about • Menstruation, sleep deprivation, chocolate, cheese, alcohol, oral contraceptives • Presentation: • Severe, unilateral pulsing pain (commonly behind the eye), disabling • Photophobia, N+V, phonophobia • Alleviated by being in a dark room and sleep • Worse on movement • Auras: visual, sensory, motor or speech disturbances Tension Type Headaches (TTH) • Chronic, non-disabling, primary headache (most common headache) • Types: Episodic (<15 days 1/12), Chronic (>15 days 1/12) • Presentation: • Generalised occipito-frontal pressure or tight band around the head • Pain in neck, upper back, ears and jaw • No GI or visual symptoms • No interference with sleep • Pt ma have underlying anxiety/ depression • Lasts 30mins- 7 days • Assessment by optometrist as eye straining can be a cause TTH Cluster Headache • Presentation: • Recurrent severe headache • Rapid onset • Unilateral, typically around the eye, temple or forehead • Lasts 15- 180 minutes, mostly at night • Occurs in clusters- once or twice a day for 4-8 weeks every year or 2 • Associated with: ipsilateral lacrimation, rhinorrhoea, nasal congestion, sweating, conjunctival injectionWhich is which? T emporal Arthritis • AKA Giant cell arthritis (GCA) • Vasculitis (inflammation) of branches of the external carotid and temporal arteries • Commonly associated with polymyalgia rheumatica • Occurs in >50 • Presentation: • Headache • Pain/ tenderness on temple • Scalp tenderness (ask about combing hair) • Jaw claudication • Proximal muscle stiffness/ pain • GCA can be complicated by blindness (preventable) so it is important to pick upSubarachnoid Haemorrhage • Risk Factors: Hypertension, smoking, Age >50 • Usually caused by a ruptured cerebral berry aneurysm- circle of Willis • Typical History: • Sudden onset occipital headache (thunderclap headache) • The headache reaches maximum intensity almost immediately • Occurs during strenuous activity e.g., heavy lifting • Associated symptoms: vomiting, reduced consciousness, seizuresSubarachnoid Haemorrhage • Risk Factors: Hypertension, smoking, Age >50 • Usually caused by a ruptured cerebral berry aneurysm- circle of Willis • Typical History: • Sudden onset occipital headache (thunderclap headache) • The headache reaches maximum intensity almost immediately • Occurs during strenuous activity e.g., heavy lifting • Associated symptoms: vomiting, reduced consciousness, seizures • Xanthochromia in LPIdiopathic Intracranial Hypertension (IIH) • Typical patient: Obese young females in 30s • Presentation: • Symptoms of high intracranial pressure (ICP) • Blurred vision and visual obscuration (papilleodema) • CNVI palsy • Hormonal precipitating factors- obesity, O, obesity, steroid therapies and Abx treatment • Bilateral papilloedemaT rigeminal Neuralgia • Chronic condition characterised by intense and extreme episodes of pain in the face • Risk factors: Males, >50 • Neuropathic disorder of CNV • Presentation: • Paroxysmal, unilateral, stabbing/ shooting pain in the distribution of branches of CNV (usually V2 or V3) • Sudden inset, episodic, short lived and sudden stop • Triggers: light touch to the face, washing, shaving, eating, cold wind or vibrations Subdural Haemorrhage: More likely in elderly patients, presents acutely or sub-acutely following head trauma, raised ICP symptoms, change in GCS Other Extradural Haemorrhage: More likely young Intracranial patient following traumatic head injury, symptoms of raised IC, associated with skull Haemorrhages fracture, can present with a lucid interval Intracerebral Haemorrhage: Haemorrhagic stroke, stroke symptoms, confusion, symptoms of raised ICP • Subdural-Banana • Extradural-Lemon Bleeds on a CT Scan (3) • Subarachnoid-followsthe subarachnoidspace,sulciandseen inthe cisterns- 90% sensitivity inthe first 24hours • Intracerebral-inthe parenchyma or the ventricles or bothHeadache Assessment- Examination • Examination • Full neuro if relevant with history • Assess GCS • Always want to do: • Fundoscopy/ Ophthalmoscopy • Blood pressure • Head and neck- neck stiffness, temporal arteries • Findings • Tension Headache: Tension and tenderness in neck and scalp muscles • Cluster Headache: lacrimation, swollen eye-lid, Horner’s syndrome, conjunctival injection • Trigeminal Neuralgia: Normal • Raised ICP: Papilledema on fundoscopy, visual field defects, Cushing's triadHeadache Assessment- Investigations • Depend on history and likely differentials • Migraine, Tension and cluster headaches= clinical diagnosis • Bloods: • electrolyte imbalancefection and liver/ kidney failure→ encephalopathy or • Blood cultures • Serology- enterovirus (viral meningitis), HSV, HIV, Syphilis • Other microbiology- urine dip, CSF • Imaging: • Non-contrast CT→ intracranial bleed • MRI- MRA (aneurysm), MRV (venous sinus thrombosis) • Indication to do a Lumbar Puncture? • Suspicion of: • Bacterial Meningitis Special T ests- • Viral (aseptic) Meningitis • Fungal Meningitis CSF (Lumbar • Tuberculosis Meningitis Puncture) • Subarachnoid Haemorrhage • Guillain Barre Syndrome • Multiple Sclerosis CSF Analysis Normal Bacterial M Viral M Fungal M TB M SAH GBS MS Appearance Clear & Cloudy & Clear Clear or Opaque→ Blood Clear or Clear Colourless Turbid Cloudy Fibrin Web stained→ xanthochro Yellowish mia >12hrs WBC 0-5 High >1000 High High High High Normal 0-20 cells/uL RBC 0-10/mm3 Normal Normal Normal Normal High Normal Normal Protein 0.15- High >50 High High High High High Mildly High 0.45g/L Glucose 2.8- Low Normal Low Low Normal Normal Normal 4.2mmol/L Opening 10-20cm High Normal or High High High Normal or Normal Pressure H2O High HighThank you Any questions? 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