Headache

Giant cell arteritis

Jaw claudication whilst eating

Tender, thickened, pulseless temporal arteriesESR > 40 mm/h

Prompt steroids (saves vision)

Exclude in any > 50y with persistent headache > 2/52

Migraine

SEE HEADACHES II

Cluster headache

Autosomal dominantM > F, smokersSuperficial tempral artery hypersensitivty to 5HT

Rapid onset of STRICTLY unilateral (and always same side)Pain around 1 eye, watery & bloodshotEpidsodes last 15-160 mins, 1-2 episodes/dayClusters last 4-12/52 then pain free for months

Acute: 100% Oxygen, sumatriptan; Prevention: verapamil, lithium, steroids

Glaucoma

Elderley and hypermetropic

Rapid onset of constant aching around 1 eyeRadiation to foreheadGreatly decreased visionNausea & vomiting

Red, congested eye, cloudy corneaDilated, fixed, oval pupil

EXPERT HELP!Acetazolamide

Trigeminal neuralgia

Trigeminal nerve distributionAnomalous intracranial vessels compressing trigeminal rootTypically male > 50y

Unilateral paroxysms of intense, stabbing pain, lasting secondsMost commonly in mandibular and maxillary divisionsMay recur frequently through day and nightMay be triggered by touching the area, shaving etc.

CarbamazepineLamotriginePhenytoinGabapentinSurgery: peripheral nerve, trigeminal ganglion, root

Meningitis

SEE HEADACHES II

Encephalitis

Inflammation of brain parenchyma > meningesViral (HSV, Japanese B, HIV, coxsackie, echo, rabies, West Nile)Measles: subacute sclerosing panecephalitisRubella: progressive rubella panencephalitisS. aureus and other pyogenic bacteria from e.g. sinus, SBE/IE

MeningismDecreased consciousnessConvulsions ± focal CNSΨ: temporal lobe fits, amnesia, odd behaviour

Wernicke's encephalopathy

CSF microscopy, serology, throat swabs, stool culture

EXPERT HELP! ITUAciclovir for HSVEmpirical Abx: ceftriaxone, benpen

Sub-arachnoid

SEE HEADACHES II

Sinusitis

Often 2° bacterial infection after viralSometimes 2° to tooth root infection

Dull, constant ache over affected frontal/maxillary sinusTender overlying skin ± post-nasal dripEthmoid/sphenoid pain is felt deep in midlinePain worse bending over, may have associated coryza

Usually self limitingAnalgesia and steam inhalationDiscourage smoking and alcohol excessAntiobiotics (e.g. amox/doxy) may work

Tropical infection

E.g. malaria, typhoid, Dengue feverSEE INFECTIOUS DISEASE NOTES

Head injury

Common following minor head trauma

Pain local to trauma or generalisedLasts ~2/52, may resist analgesia

Subdural haematomaExtradural haematoma

DrowsinessFocal neurology

Tension headache

Very common, any demographicEsp. middle-aged women

Tight band around headBilateral, non-pulsatileStress & depression

Chronic raised ICP

Occurs in 50% of RICPSOL (neoplasm, abscess, subdural)Benign intracranial hypertension

Present on waking/causes wakingWorse lying down

Don't lumbar puncture

VomitingPapilloedemaEpilepsyProgressive focal neurologyMental or behavioural change

Medication misuse

Chronic use of:- mixed analgesia (i.e. with codeine)- opiates- ergotamines- triptans

Episodic --> daily headache

Withdraw culpritPrescribe preventer (TCA, valproate, gabapentin)