Headache
GP Letter
Neurology clinic
Dear Dr
Re: J. Potter, (DOB: 12/12/1975)
I would be grateful if you kindly review this 41 years
old gentleman with on
and off headache for the last 3 months. I tried some
pain killers but
unfortunately it is not touching it. I am a bit concerned
as he gave a family
history of a brain tumor (his brother) and I wonder if
that could be of
significance. His hemoglobin is 134 g/l and his U&Es
are all with in normal
range.
Kind Regards,
Dr. GP
Differential Diagnosis
SERIOUS CAUSES
Subarachnoid
Hemorrhage
Meningitis
Carotid Or
Vertebral
Artery
Dissection
Cerebral
Venous
Thrombosis
Pituitary
Apoplexy
GCA
Intracerebral
Hemorrhage
Brain
tumors:1ry or
2ry
COMMON CAUSES OTHER CAUSES
Migraine
Tension
Headache
Autonomic Brain
Cephalgias Abscess,
(Cluster HIV
Headache) Smoking
Exertional Cessation
Medication Carbon
Overuse Monoxide
Headache Poisoning
Trigeminal Alcohol
neuralgia withdrawal
Benign
Intracranial
HTN
Headache
GP Letter
Neurology clinic
Dear Dr
Re: J. Potter, (DOB: 12/12/1975)
I would be grateful if you kindly review this 41 years
old gentleman with on
and off headache for the last 3 months. I tried some
pain killers but
unfortunately it is not touching it. I am a bit concerned
as he gave a family
history of a brain tumor (his brother) and I wonder if
that could be of
significance. His hemoglobin is 134 g/l and his U&Es
are all with in normal
range.
Kind Regards,
Dr. GP
Differential Diagnosis
Analysis Of Complaint
Initially double check What Is Meant By Headache?
Headache is pain of the head vault.
It is different than facial pain or neck pain, but
patients may name all
(headache).
Headache is pain, so Follow SOCRATES.
Where Exactly In Your Head?
How Did It Start; Suddenly Or Gradually?
How Long?
Is It Getting Better Or Worse?
Could You Describe The Pain?? Is It Throbbing, Band
Like, Boring
Pain??
Is It Radiating Any Where Else?
Do You Have It All The Time/Attacks? When Mostly?
(Tension At
Night, Increased ICP In Morning)
What Makes It Better? What Makes It Worse?
How Would You Give It On A Scale From 0-10? Is It The
Worst
Headache In Your Life?
Questions To R/O Differential Diagnosis
Encephalitis / Meningitis
Have You Noticed Any Fevers? Skin Rash? Stiffness Of
Your Neck?
Any Contact With Sick Children?
Change In Behavior? Consciousness?
PMR/GCA
Is It On The Temporal Side Of the Head?
Any Pain & Stiffness in Your Shoulders?
Head Pain, Jaw Cramps/Claudication While Eating?
Any Visual Problems?
Sub/Extra Dural Hematomas
Did You Hit Your Head?
Are you on Any Blood Thinners?
Change In Behavior? Consciousness?
Any Associated weakness?
Do You Drink Alcohol? (Chronic Subdural)
Sub-Arachnoid Hemorrhage
The Worst headache Ever?
Neck Stiffness?
Are you Taking Any Blood Thinners?
PMH of Kidney problems?
FH: Of Bleed In the Brain?
Increased ICP
Does It Occur In The Early Morning?
Do You Through Up?
Any Blurring Of Vision?
Any Weakness in Arms or Legs?
Any Fits?
Pituitary Tumors
Signs of Increased ICP: See Before
Acromegaly:
What About Your Shoe And Ring Size, Do They Fit?
Can You See The Sides Of The Road?
Prolactinoma:
Any Breast Discharge?
Decreased sexual desire?
Pituitary Apoplexy
Any Sudden Severe Bleeding?
Associated Endocrine Symptoms?
Cerebral Sinus Thrombosis
Any PMH of Having Clots in Your Legs or Lungs?
Double Vision?
Any Medication Causing your Blood to be Thicker, e.g.
HRT, OCPs.
Are You Pregnant? (For female patients)
Acute Onset, Thunder Clap Headache.
Benign Intracranial Hypertension
Have You Gained Weight Recently?
Do You Have Double Vision?
Are You Taking Steroids, Vit. A, Tetracyclines, OCPs?
All tests Done are Normal?
Tension Headache
Is It Band Like Over Your Head, Occurs At The End Of
The Day?
Have You Been Stressed Recently?
What About Your Mood?
Migraine
Is It Unilateral?
Is It Preceded By Any Unusual Sensations, Taste In
Your Mouth?
Any Weakness?
Any Blurry Vision? (Aura)
Eased by sitting in Dark Quiet Room?
Cluster Headache
Is It Around the Eyes?
Occurring in Clusters?
Any Watering Of Your Eyes? Redness?
Runny Nose, Nose Blockage?
Does It Occur Several Times In The Day?
Does It Occur At The Same Time Each Year?
Trigeminal Neuralgia
Any Pain In Your Face, Triggered By Chewing, Washing
Face?
Carbon Monoxide Poisoning
Does It Get Better When You Are Away From Home?
Other Family Members having The Same Symptoms?
Do You Have Any Fuel Burning Devices (Furnaces, Gas
Heaters, Gas
Boilers, Gas Working Stoves, Gas Generators, and
Power Tools?
Medications Induced headache
Nitrates?
Sildenafil?
Long standing Analgesics (Opioids & Non-Opioids)
Use?
Hypertension
PMH of HTN or New Diagnosis?
Quick Discussion
How Would You Investigate This Case?
CT Head With or Without Contrast / MRI Brain for:
Brain Tumors
Bleeds
SAH
Meningitis/Encephalitis
Lumbar Puncture
SAH= Xanthochromia
Meningitis= raised proteins, Raised WBCs, Glucose
abnormality
according to the cause
Idiopathic Intracranial HTN = Raised opening pressure
& therapeutic
Temporal Artery Biopsy = GCA
Pituitary Function tests = Pituitary Tumors/Apoplexy
VBG = CO Poisoning
How Would You Treat This Case With Headache?
Analgesia
Admit to hospital If Alarming Symptoms
Treat The Cause
Migraine = Analgesia Sumatriptan, Prevention with
Betablocker &
TCA
Cluster Headache = high Flow Oxygn , Analgesia ,
prophylaxis with
CCBs
Brain Tumor = Neurosurgical R/V
Pituitary Apolpexy = Endocrine/Neuro-surgical R/V
Meningitis = Antibiotics + Admission to hospital
Blood Pressure Control
Trigeminal Neuralgia = Carbamazepine
