Clinical approach to head ache

History & clinical examination

History……………………………?????

I. WHERE IS THE PAIN???????

SITES

FRONTAL

TEMPORALVERTEX

OCCIPITAL/NECK PAIN

FACIAL

GENERALISED

1.FRONTAL…………..

i. FRONTAL SINUSITIS……………….(more in morning during awakening , less intense at noon)

draining out of collection due to gravity in upright posture… Sneezing,stooping,blowing

ii. Tension head ache……………..(bilateral,in frontal temporal and vertex….felt as fullness,pressure or tightness)

3.INCREASED INTRACRANIAL TENSION……………………bi frontal / bi occipital

4.Cough and exertional head ache……………………...front of head

5.migraine variants…………..

6.LP HEAD ACHE (usually occipitonuchal)

……sudden upright posture after procedure

2.TEMPORAL………………………….

i. COMMON MIGRAINE………………………….in

temporo frontal area

ii. TEMPORAL ARTERITIS……………

ThrobbingU/L,B/L

iii. Cluster head ache……………

iv. Costens syndrome……..TMJ ARTHRITIS

v. Drugs like sorbitrate

3.VERTEX……………………..

i. ETHMOID & SPHENOID SINUSITIS………

Localised deep in midlineBehind the root of nosesphenoid less on walking

ii. Head ache associated with psychiatric illness

4.OCCIPITAL & NECK PAIN…………………

i. Cervical spondylosisii. sub arachnoid heamorrhageiii. Meningitisiv. POST. FOSSA TUMOURSv. Cough & exertional headachevi. Occipital neuralgiavii. d/s of ligaments & joints in upper part of spine

viii.WHIPLASH INJURY OF NECK

5.FACIAL PAIN………………..

i. OCULAR

ii. Ear

iii. DENTAL

iv. maxillary sinustis

v. TRIGEMINAL NEURALGIA , carotidynia , glossopharyngial neuralgia ………

6.GENERALISED HEAD ACHE…………..

i. BRAIN TUMOUR HEADACHE

iii. TENSION HEAD ACHE

iv. Post traumatic headache

ii. Related to SYSTEMIC D/S (fever , hypercapnia , hypoglycemia , drugs , anemia)

---Head ache well localised on the skull with the finger is never associated with any significant d/s………..

---ANT. 2/3rd OF HEAD Supra tentorial structures

---VERTEX & BACK Infra tentorial structures

Points to remember…………………

II. WHAT IS THE MODE OF ONSET????????????

ACUTETraumaticDrugsAv anuerysm ruptureCluster head acheSAHTemporal arteritsACUTE GLAUCOMAACUTE MENINGITIS

CHRONICMIGRAINETemporal arteritisTension head acheBRAIN TUMOUR PAINc/c menigitis

Points to remember…………………..

Many years duration with little or no progression BENIGN

FIRST SEVERE HEAD ACHESUB ACUTE WORSENING OVER DAYS

Rule out serious problem……….

III. WHEN DOES IT OCCUR???

i. Worse in the morning…………….

Organic d/s of brain Consumption of alcoholCERVICAL SPONDYLOSISFRONTAL SINUSITISSevere anemiaHYPERTENSION

ii.Nocturnal head ache…………….

CLUSTER HEADACHETEMPORAL ARTERITISorganic d/s may get worsened

iv.Meal time head ache…..

TRIGEMINAL NEURALGIATemporal arteritis

chewing

Glossopharyngeal neuralgiaCAROTIDYNIA

swallowing

iii.Worse in evening………..

EYE STRAINTension head acheFatigue and mental exhautionETHMOIDAL &SPHENOIDAL SINUSITIS

iv.Orthostatic headache…………….

POST LUMBAR PUNCTURE PAINSubdural hematomaBenign intra cranial hypertension

IV. WHAT IS THE CHARACTER & SEVERITY???

Throbbing headache

Excruciating, nonpulsatile

Dull &episodic icepicking pain

Deep,dull aching or bursting quality

MIGRAINE

CLUSTER HEADACHE

TEMPORAL ARTERITIS

BRAIN TUMOUR

Intense stabbing pain

TRIGEMINAL NEURALGIA

TO ASSESS SEVERITY …..ASK ……………

If pain affects day to day lifeIf pain interferes with sleep……indicate whether it prevents sleep or awakens the pat. From sleep…………….

V. WHAT BRINGS THE PAIN & WHAT AGGRAVATES IT???

Anger, exitement worry,&lack of sleep& CHINESE FOOD…&…ALCOHOL

MIGRAINE

Prolonged use of eyes OCULAR HEAD ACHE

Cold,hot,or sweet DENTAL PAIN

STOOPING SINUSITIS

Chewing,smiling,talking,

TRIGEMINAL

NEURALGIA

Pain after period of inactivity OCCIPITAL &NECK PAINEg : pain after sleep occurs in cervical arthritis

Sudden movement ,coughing or straining

ICT

Lying down aggravation

SUB DURAL HEMATOMA,POST. FOSSA TRS.

VI. WHAT MAKES IT BETTER????

MIGRAINE relieved by SLEEPING/DARK SURROUNDINGS…………..

Temporal arteritis can be relieved by STEROIDS

VII. WHERE DOES IT MOVE??????

Throat , neck muscles ,spine/post. fossa structures

EAR

Raised ICT,thrombosis of basilar artery

FRONTAL AREA

VIII.Accompanying symptoms???

i. MIGRAINE

Aura like photophobia &visual symptoms HemiplegiaBrain stem symptoms

ii. CLUSTER HEADACHE

Red eye with lacrimationStuffy nose with rhinorrhea

iii. TEMPORAL ARTERITIS

FeverWt. lossPalpable tender artery

iv. MENINGITIS

FeverVomitingNeck stiffness

iv. BRAIN TUMOUR HEAD ACHE

Projectile vomiting

v. GLAUCOMA

Red & painfull eyeAbnormality in vision

vi.GLOSSOPHARYNGEAL NEURALGIA

bradycardia/syncope

vii. PROLACTIN SECRETING TR. OF PITUITORY

AMENORRHEAGALACTORRHEA

EXAMINATION……..

1.GENERAL EXAMINATION

2.VITALS

TemperaturePulseBPResp.rate

FEVER (meningitis)

3.ON FACE……….

a)sinusesMAXILLARY SINUS

Press over CANINE FOSSA on the cheek……with FORE FINGER & MIDDLE FINGER on the other----------note the FACIAL EXPRESSION of the patient

FRONTAL SINUS

Press over floor of sinuses,MEDIAL PART OF SUPRA ORBITAL margin….FORE FINGER & MIDDLE FINGER--------look the facial expression…

ETHMOID SINUSES

Press on sides of nose MIDWAY B/W INNER CANTHUS & NASION

b)Tooth

CariesPyorrhoea

c)Temporo mandibular joint

Ask the pat………………open & close mouth…move jaw side way& back forth….note PAIN , TENDERNESS& CREPITUS

TMJ arthritis

d)Ear……Pinna Auditory canal----pus,congestion…..Tympanic membrane----perforation(CSOM)Rinne’s,weber’s tests……………..

e)Eye…..PallorGlaucoma----- IOTCluster head ache--------myosis,ptosis,conjunctival congestion,lacrimationFUNDUS-----PAPPLIOEDEMA

f)Temporal artery………Tender……cord like

4.NECK………..

Neck stiffness……….

KERNIG’S SIGNBRUDZINSKI SIGN

KERNIG’S SIGN…………

i. Patient supineii. Flex the hip & knee to 90degreeiii. Extent the knee,with hip still flexed

PAIN IN POSTERIOR THIGH MUSCLE & DIFFICULTY IN KNEE EXTENSION

Spasm of hamstrings

BRUDZINSKI NECK SIGN

Flexion of both knees Pain & rigidity of neck

4.CNS EXAMINATION……

Focal neurological deficit (BRAIN TUMOUR HEAD ACHE)

4.CNS EXAMINATION……

Focal neurological deficit (BRAIN TUMOUR HEAD ACHE)

Summary…..

history

i. Whereii. Onsetiii. Wheniv. Character & severityv. Aggravating & relieving

factorsvi. Radiationvii. Accompanying symp

examination vitalsFace-sinuses,tooth,TMJ,ear,eyeNeck-kernig’s ,brudzinskiCNS-focal defecit