 Ddx:

o Acute: VICIOUS
Vascular Haemorrhage: EH, SDH, SAH, ICH
Infarction: esp posterior circulation
Venous: sinus/cortical thrombosis
Infection/ Meningitis
inflammation Encephalitis
Abscess
Compression Obstructive hydrocephalus: tumour
Pituitary enlargement: apoplexy, tumour
ICP Spontaneous IC hypotension
Brain herniation
Ophthalmic Acute glaucoma
Unknown Situational: cough, exertion, coitus
Systemic HTN: phaeo
Infection: sinusitis, tonsillitis, atypical
pneumonia
Toxins: CO
o Chronic: MAD TINGS
Migraine  
Actual cluster  
headaches
Drugs Analgesics
Caffeine
Vasodilators
 Tension  
headaches
ICP ↑: tumour, aneurysm, AVM, benign
intracranial HTN (blurred vision,
papilloedema, ↑ blind spot)
↓: spontaneous intracranial hypotension
Neuralgia Trigeminal
GCA  
Systemic HTN
Organ failure
 
 Ix:
o Bloods
o Urine
o LP → CSF 12 hours after CT brain
 Opening pressure
 ↑ = SAH, meningitis
 ↓ = spontaneous intracranial hypotension
 ?xanthochromia = meningitis, SAH

Findings Bacteri TB Viral SAH
al
Appearan Turbid Fibrin web Clear Bloo
ce Viscous d
Cells PMN Lympho/mono Lympho/mono N
nuc nuc
Count 100 - 10 - 1000 50 - 1000  
1000
Glucose ↓ (< ↓ (< 1/2 N  
1/2 plasma)
plasma
)
Protein ↑↑ (> ↑↑↑ (1 - 5) N ↑
1.5)
 Require serum protein and glucose
 PCR for bacteria and viruses
 Gram stain and culture
 Gram +ve diplococci → strep pneumonia
 Gram +ve bacilli → listeria
 Gram -ve diplococci → neisseria
o CT head
 ?SAH - blood in cystern
o MRI head
 ?MRA - aneurysm
 ?MRV - sinus thrombosis
 CF:
o Red flags:
  Fever, photophobia, neck stiffness →
meningitis/encephalitis
 New neuro symptoms → haemorrhage, malignancy,
stroke
 Dizziness → stroke
 Visual disturbance → GCA, glaucoma
 Sudden onset occipital headache → SAH
 Worse on coughing/straining → ↑ ICP
 Postural, worse on standing, lying, bending over → ICP
 Wake up from sleep
 Vomiting → ↑ ICP, CO poisoning
 Trauma → ICH
 Pregnancy → pre-eclampsia
SAH Sudden onset, worse ever, occipital
Meningism: focal signs, ↓ LOC, photophobia
Venous sinus Sagittal: headache, vomiting, seizures, ↓ vision,
thrombosis papilledema
Transverse: headaches +/- mastoid pain, focal CNS
signs, seizures, papilledema
Cortical vein Thunderclap
thrombosis Stroke-like focal symptoms
Focal seizures
Meningitis Fever, photophobia, neck stiffness, Kernig's +ve
Purpuric rash
↓ consciousness
Encephalitis Fever, odd behaviour, fits, focal neuro
↓ consciousness
Acute glaucoma Constant unilateral eye pain radiating to forehead
↓ acuity, halo, N&V
Red eye, cloudy cornea
Dilated, nonresponsive pupil
Migraine Prodrome → aura → headache
Unilateral, throbbing
N&V
Photo/phonophobia
Rx:
 Acute - triptan + NSAID or triptan +
paracetamol
 Prophylaxis - topiramate or propanolol
Cluster Rapid onset, very severe around/behind eye
Red, watery eye, nasal congestion
Miosis, ptosis
15min - 3 hours, 1 - 2 X/day, mostly nocturnal
Clusters: 4 - 12 wks, remission for 3mo - 3yrs
Chronic vs episodic
Rx: 100% O2, non-rebreathe mask, Sumitriptan
Prev: verapamil, topiramate, lithium
Trigeminal Paroxysms of unilateral intense stabbing pain in
neuralgia trigeminal distribution
Triggers: washing area, shaving, eating, talking
Male > 50
1ary
2dary: compression CNV, MS, zoster, Chiari
malformation
Rx: CBZ, lamotrigine, gabapentin →microvascular
decompression
Analgesia Episodic headache → daily chronic headache
overuse OTC analgesia max 6 days/month
ICP ↑: worse in AM/cough/bending forwards,visual prob
(papilloedema), obese women, improve standing
↓: worse sitting or standing
Rx:
 ÏCH: Lose weight
TMJ dysfunction Preauricular pain on chewing
Assoc with crepitus
Earache, headache
GCA Unilateral temple/scalp pain and tenderness
Thickened, pulseless temporal artery
Jaw claudication, amaurosis fugax, sudden blindness
Assoc with PMR in 50%
Ix: ↑ ESR, ↑ plt, ↑ ALP, ↓ Hb, temporal artery
biopsy
Rx: high dose pred 5 - 7d, PPI and bisphosphonate
Guide by symptoms and ESR