HEADACHE

DIFFERENTIAL DIAGNOSIS
Vacular Infection Vision-threatening Increase ICP Dissection
1. SAH 1. Meninigits 1. temporal arteritis 1. SOL: tumor, abscess, Carotid
2. Haematoma 2. encephalitis 2. acute glaucoma cyst dissection
3. Cerebral venous 3. pituitary apoplexy 2. Cerebral oedema:
sinus thrombosis 4. post. Leucoencephalopathy trauma, altitude
4. Cerebellar infarct 5. cavernous sinus thrombosis 3. Hydrocephalus
4. Malignant hypertension
Red flags: Causes of Non-sinister headache
1. Decreased level of conscioussness (LOC) 1. Tension-type headache
SAH: headache +decreased LOC Bifrontal pain,episodic, occuring with variable
Subdural haematoma: head injury+ fluctuating frequency, describe as P or tightness around
consciousness head like tighterning band, duration: few hours
Extradural haematoma: head injury+ altered Pt still can continue normal activity with the
consiousness following lucid interval headache (not severely disabling)
2. Sudden onset worse headache ever Trigger: stress, fatigue
SAH: blood in CSF iritating the meningitis 2. Migraine
3. Seizure Recurrent & unilateral headache
4. Focal neurological deficit: Throbbing/pulsatile headache
Intracranial pathology: Migraine with aura
limb weakness, speech problem Duration: 4-72hr
e.g: tumour sensitive to light, sound, smell
3rd nerve palsy: They are vulnerable to mediction overuse
presentation: ptosis, mydriasis (dilated pupil), eye headache from tx for their migraine
deviated down & out Trigger: stress, food (cheese, caffeine)
e.g: SAH due to ruptured aneurysm of post Ddx for migraine without aura: TIA
commnunicating artery (PCOM) 3. Sinusitis
6th nerve palsy: Facial pain coming on over hours to days a/w
presentation: convergent squint/failure to abduct coryzal symptoms
eye laterally Pain is tight as tension headache
e.g: 6th CN get compressed by mass as this Exacerbated by movement
nerve has longest intracranial course Duration: several days with time course
12th nerve palsy: consistent with infection
presentation: tongue deviation 4. Medication overuse headache
e.g: carotid artery dissection Headache resemble either migraine or tension-
Horners syndrome: type headache
triad of partial ptosis, miosis (constricted pupil) & Tx: withdrawal from analgesic use
anhydrosis (dry skin around orbit) 5. TMJ syndrome (headache +pain w jaw fx)
due to interuption of ipsilateral sympathetic 20-40y/o, F>M
pathway dull ache in masseter muscle/preauricular pain
e.g: carotid artery dissection (ask neck pain) & that may radiate to jaw or ear
cavernous sinus lesion. provoked by use of masseter muscle (eating)
5. Absence of previous episodes pt c/o hearing a click, grinding noise when they
New onset of headache in >50y/o: think of temporal move their jaw, decrease mandibular range of
arteritis motion
6. Reduced visual acuity ear pain: trigeminal nerve also supply middle ear
Temporal arteritis: in elderly muscles
TIA: Amourasis fugax +but rarely cause headache 6. Trigeminal neuralgia (intense, sharp stabbing pain)
Carotid artery dissection: cause loss of vision due to 60-70y/o, F>M
reduce blood flow to retina unilateral facial pain involving division of
7. Persistent headache, worse when lying down, early trigeminal nerve (V2/V3)
morning nausea Duration: pain last only seconds, 100x/day
High ICP: Worse when lying flat for prolonged times Trigger: eating, laughing, talking, touching
(overnight) due to effect of gravity but can occur affected area
when pt is bending over Pt avoid known trigger like shaving
Reduced ICP: common after LP + Headache worse 7. Cluster headache
when standing up suggested reduced ICP M>F
8. Progressive, persistent headache Occur at exatcly the same time every day or night
Expanding SOL: tumour, abscess, cyst, haematoma Duration:clusters for 6-12 weeks every 1-2years
9. Constitutional symptoms: Pain focused over one eye
Malignancy/TB/chronic inflammation (temporal Red watery eye, rhinorrhea, Horner syndrome
arteritis): Weight loss, night sweats, or fever Severely painful & disabling but often occur at
night, allowing daytime duties to continoue
Trigger: Alcohol