1- If patient is complaining of acute headache (meningitis/ subarachnoid hg) (Management + quick hx

& examination)
2- If patient is complaining of chronic headache then psychosocial questions.
3- Don’t ever forget (pain killers)
4- When you give DDS try to exclude what will kill the patient first: SOL, SAH, meningitis.
5- DDs of headache (Take head from outside to inside)
 Skull: any chance you sustained trauma to your head
 Meninges: meningitis: fever, vomiting, neck stiffness, shy away from light, rash
 Subarachnoid hg: below meninges (meningitis - fever)
 Brain: space occupying lesion: early morning headache, early morning vomiting, gradual worsening/
weakness in limbs
 Sinusitis: headache increased by leaning forward, runny stuffy nose
 Eye: Acute angle glaucoma: (pain in eyes, redness in eyes, colored haloes around light),
vision problems: do you wear glasses, any problem in reading?
 Migraine: One sided headache +You must ask about aura just before headache what happened?
(advice about it in management) + blurred vision + nausea and vomiting + sensitive to light +
Family hx
 Cluster headache: comes in episodes+ Always has past hx of headache +Tearing + red eye + pain
around one eye + runny nose
 Tension headache: band like headache + Worse in evening, stress, anxiety, noise, anger, light +
relieved by sleep + Due to stress you must find cause of stress & try to manage it
 GCA: Pain while chewing + Pain while combing + Painful eye + joint pain (polymyalgia Rheumatica)
 Hangover: drinking last night

Questions of DD:
1. any recent trauma to your head?
2. Any shyness to light? Any rash? Any neck stiffness? Any vomiting? Any fever?
3. Do you have any pain on chewing, combing? Do you have any visual problems? Any pain in the eye?
4. Haloes around lights? Any red eye?
5. Weakness in the face? Weakness in the arm? Slurred speech?
6. Pain on leaning forwards? +
Mood + sleep + stress + contact + FLAWS

Cheat Sheet:
Headache with eye symptoms:
GCA(painful eye) , Acute angle Glaucoma(pain/redness/haloes around light), Cluster headache(tearing/red
eye/pain around the eye), Migraine(blurred vision), SAH, ICH
Headache With Fever:
Meningitis
Headache with Stress:
Tension headache
Headache with Nausea/vomiting:
Migraine(N/V), SOL (V), Meningitis(V), Hangover headache(N)
Migraine Aure
Strange Smell, Hearing Voice, Flashes of light, Blurry vision,Pins and needle sensation
 Steroid Side Effects Weight gain, BP, Stomach ulcer, Bone weakening, Mood(anxiety/dep), Infection
risk(Omeprazole/Bisphosphonates/Regular exercise/Steroid card)

Disease Subarachnoid Meningitis Hangover Intracranial Acute Sinusitis

hemorrhage (Alcohol overdose) hypertension (Cheeks spaces viral
(bleeding in brain) inf)
Presentation 60Y in ED Worst Headache 22Y/M 30+ female 31Y/F
occipital headache Confusion Headache Back/ BMI high Forehead/B/W the
9/10+ neck pain Fever all over +-vomit +blurry vision eyes /Cheeks for 4
+ meningeal signs +meningeal +nausea +nausea days +blocked nose
(light prob, neck signs Pulsatile (drum
stiffness,no rash/fever) beating on brain.
Pain Thunderclap Dull Dull continuous Throbbing Worse in Dull
Radiates to neck Gradual non- the morning Better
radiating 6/10 standing up
Time Acute Acute Acute Chronic Acute/Chronic (4D)
Rule our Meningitis(rash/fever) SAH -SAH SOL -Worse when
(confusion/slurring/ LOC)
Stroke -SOL Injury leaning forward
-Dehydration/ -With Greenish
hypoglycemia discharge from nose
+-loss of smell
Risk factors HTN Contact Living -Party last COCP -Meningitis
Kidney disease in a dorm night Obesity -Swelling/pain
Bleeding disorder Travel (Couple of around the eyes
Stress pints of beer -COVID 19
Family hx of sudden and whisky -Hx of cough,
death shots (50 flu/runny nose,
units) tummy pain for 1M.
Examinations Neurological of head OBS+GPE -OBS/GPE Fundoscopy -OBS+Neurological
and arm Neurological -Neurological (Papillary edema) of head and arm
Eye (Fundoscopy) (+ Kernig, Fundoscopy BMI -Eye (Fundoscopy)
Nose Brudzinski) -Nose(polyp/sinus)

Investigations 1.CT scan LP FBC RBS MRI Routine, XrayPNS,

2.LP in 12 hours CT scan CTPNS on if red
flags/in F/U
Management (Dim the light) Senior Treat ED referral Self-resolving in 2-
-ABCDE of Antibiotics dehydration: Neurologist 3 days
resuscitation Fluids 1.Fluids 1.Depending on the 1.Painkiller(Ibuprof
2.Immediate admission/ Steroids (rehydration with cause (obesity conc/ en)
referral water /IV fluids) Surgical tx )
Reportable 2.Decongestant
3.Senior/Neurosurgeon
Infection control 2. Pain killer 2.Consider Dexa nasal
4.Bloods/CT/LP(after 12
H to see Xanthchromia) Treat 3. Painkiller 3.Clean with salt
5.Morphine hypoglycemia: water
6.Nimodipine 1.Sugary foods 4.Anti-histamine
60mg/6H/3W 2.Bullion Soup 5.Rest
-Labetalol(Anti-HTN) 3.Meal before 6.Plenty of Fluids
-Anti-emetics drinking 7.If >10 days, high
-Anti-conversant Treat cause: dose nasal
7.Conservative/Surgery 1.Advice on corticosteroid for 14
(clipping/coiling) drinking within days+ Antibiotic for
limit 5 days
2.Don’t drink more 8.One
than your body can sided/recurrent
handle (ENT referral for
FESS)
Safety net -Weakness anywhere Prophylaxis for -Further drinking - -Meningitis
in the body contacts habits -Swelling/pain
-Speech Caution: around the
-Fits/vomiting Avoid driving eyes/visual problem
F/U in 1W
Chronic Migraine Menstrual Migraine Tension CO poisoning GCA
Headache (No cause/no cure) (due to periods) (stress at home/work) (Faulty (Inflam arteries around
the side of head)
(due to stress) equip/boiler)
Presentation 35Y/F 17Y/F 60Y/F 17y/m-GP 60Y/F
Headache-one Headache for 3 year Tight Band like Headache at Left sided-
Headache 3/52
sided +-Aura PCM/Ibuprofen not headache home + Getting R eye vision
for 1W helping Bank Manager out of building problem
+Flashes of light resolve problem
+Sleep disturb
Pain Throbbing /Dull Dull, Starts 3D Dull Throbbing Dull
before periods stops
after 2 days into
periods
Time Chronic (1W)’ Chronic Chronic (2M) Chronic (4W) Chronic(3W)
Details 8/10, non-radiating Blood disorder -Worse at particular -Started after -Not relieved by
Worse with light / Blood thinner time of the day shifting to new meds +Fhx
-New stress at building Jaw pain(chew/open
noise +Nausea Kidney disease -Flushing of face mouth)
Blurred vision work/Issues with
-Chest pain, muscle Left scalp tender
husband about son
No effect with pain, confusion, Shoulder and thigh
PCM/Ibuprofen dizzy, Neuro signs muscle pain
-(ask about pregnant
Library Attendant lady/child at home)
Rule out -SOL PMS(breast -SOL(Flaws) C: co-occupants -Vision loss
-GCA tenderness, loss of -Cluster headache with headache -Migraine
-Trigeminal appetite, mood O: if symptoms get -PMR(pain
neuralgia swings, trouble better Outdoors on raising hand
-Recent new stress sleeping, low sex M: maintenance above head )
-Occupation drive (paraffin heater,
-COCP use gas boiler, cooker)
A: Alarm CO
-kidney problem
H:Housing
Examination OBs-Neurological of -OBS/GPE -Neurological of head OBS+ GPE Obs+ Scalp+
head and arm -Neurological and arm Ear +Eye Shoulder+
-Eye (Fundoscopy) -Fundoscopy -Eye (Fundoscopy) Neurological Thigh+ Eye
-Nose and Ear -Nose exam
Investigation FBC, LFTSs FBC(anemia) Bloods(anemia) CO in
CRP, ECR blood(Carboxyhem
oglobin levels)
TEA>Triptan, anti-emetic,
1.Intranasal 1.Serious
Management Analgesic
1.Paracetamol/Ibupr 1.Medical ED
sumatriptan during the ofen (for a short 2.100% O2 (Vision-loss)
1.Paracetamol attack of migraine. time) 3.Blood test 2.Admit
Ibuprofen (during 2. Diary of headache 3.Inv(bloods,RB
aura/before attack) and periods 2.Manage Stress 4. PCM for pain
S,ESR,CRP)
During Attack: (start/end/type/severity) (1.Discuss with 5. Get housemates 4.High Dose
1. 1st line Aspirin 3.Start COCP once boss/HR checked
Prednisolone 40-
relationship b/w department. 6.Set an alarm.
900mg 7.Proper ventilation 60mg then
2.Sumatriptan (2nd headache and periods 2.Couple therapy) of house > open tapering in 3-4W
line) <18 nasal
confirm. 3.Life-style changes window 5.Pain
4.Exerise and healthy diet (Regular exercise, 8. Services checked Killer(PCM/Cod
>18 oral (DESA) are effective in
Yoga, Massage, by qualified eine)
3.Antiemetics Oral controlling such kind of engineer.
medicine) 6.Ophthalmalogi
(prochlorperazine) headaches.
4.Diary Report to Health st(Ix(temporal
4.Migraine Protection team biopsy),dx,Tx)
Diary(date, time, activity, 7.Aspirin 75mg
duration, treatment)
5.Prophylaxis- if
1.Headache more than 1 day
2.More than 2 attack/W.
3.activities of life effected >3
days.
Safety net -If has aura- COCP Vomiting, Rash Medication over-use 1.Don’t make Steroid side
-Prophylaxis by headache wooded/ coal effects
Neurologist(Beta- fire at home Vision loss
blocker) 2.Severe Clots(Aspirin)
S/N>Change in breathing PMR
pattern of headache/ problem
Worse in morning/ 2.1M f/u
Weight loss
Concerns Could it be a brain
tumor?