HEADACHE-HISTORY TAKING

1. HEADACHE OF THE HISTORY

2. തലവേദന ഒരു ചെറിയ
കളിയല്ല!!!

3. • How to take a medical history from
a patient that presented mainly
with headache?

4. • A headache or cephalagia is pain anywhere in
the region of head or neck
• Can be a symptom of a number of different
conditions of head and neck

5. • Headache in itself is not a disease but
merely a symptom of a disease.
• A symptom which may accompany
many different types of conditions. May
be sight threatening or life threatening

7. Ocular causes of Headache
Three categories
• a) headache due to refractory error and eye
muscle weakness
• b) headache due to secondary diseases of eye
• c) those due to systemic disorders having
prominent ocular symptom

8. A) Refractory error and muscle
weakness
• Mainly in afternoon or evening at the end of
work
• Hypermetropia and astigmatism
• Low grade refractory error is main cause
• Ocular muscle imbalance as latent
squint ,convergence insufficiency &
accommodative insufficiency also causes
headache

9. B) Secondary to eye diseases
• Acute angle closure glaucoma
• Acute iritis
• Keratitis
• Ocular ischemic syndrome

10. C) Systemic disorders with visual
symptoms
• Raised intra cranial pressure
• Migraine
• Temporal arteritis
• Psychogenic

11. Analysis of headache (History Taking)
• Site
• Onset?
• Characteristics?
• Radiation?
• Associated symptoms
• Timing?
• Exacerbating & relieving factors?
• Severity?
SOCRATES

12. 1. Site
• Unilateral ?
– Migraine
– Cluster
• Bilateral?
– Tension headache
• Ocular?
– Cluster
– Migraine
– Cluster

13. 1. Site
• Paranasal?
– Sinusitis
• Mass
– Localized then become diffuse (bifrontal,
bioccipital) due to elevated ICP
• Occipit?
– Meningeal
– Hemorrhagic
– Joints

14. 1. Site
• Post herpetic neuralgia along the 1st
division of Trigeminal V nerve.
• Trigeminal neuralgia along the 2nd and 3rd
divisions of Trigeminal V nerve.
• Unilateral (e.g. migraine) / frontal
Bilateral (e.g. tension headache)

15. 2. Onset
• Acute?
– Meningeal
– Hemorrhagic
•
• Subacute?
– Intracranial mass
•
• Chronic?
– Migraine

16. 3. Characteristics
• Pulsatile = tension headache or migraine
• Tightness = tension headache
• Dull + steady = mass
• Sharp = neuritic, neuralgia

17. 4. Radiation
• Tension headache may arise in the occipital
region and radiate to all head
• Neck (meningitis) / face (e.g. trigeminal
neuralgia) / eye (e.g. acute closed
angle glaucoma)

18. 5. Associated symptoms
In headache analysis,
• asking about the ASSOCIATED SYMPTOMS is
very very important in order to reach a
DIAGNOSIS

19. 5. Associated symptoms
• Weight loss Mass
• Fever + chills systemic infections OR
meningitis
• Vision Ocular, Migraine, Optic nerve
and visual pathway lesions.

20. 5. Associated symptoms
• Nausea + vomiting Migraine OR Mass
• Diarrhea Migraine
• Photophobia Migraine, Meningitis
• Myalgia + tension Viral infection
• Ipsilateral rhinorrhea and lacrimation cluster

21. 6. Timing
• Maximal on awaking sinus, mass
• Awake the patient, 30-90 minutes on same
time each day exacerbated by alcohol
cluster
• End of work (weekend, month end, day end)
tension
• Episodic, lasting 4-72 hours migraine

22. 7. Exacerbating and relieving factors
• Foods
• Position
• Sleep
• Cough Mass
• Sneezing Mass

23. 8. Severity
• Measured by interfering with
Eating
Talking
Sleeping
• A better approach to measure severity is to
ask the patient to give the pain point out of 1
to 10 (scale method)

24. Past medical history
• Previous episodes of headache/migraine?
• Previous intracranial bleeds? (e.g.
subarachnoid haemorrhage)
• Head trauma in last three months?
• History of malignancy?
• Other medical conditions?
• Previous surgery? – e.g. CSF shunting
(blocked/infected shunts present
with headache)

25. Drug history
• Regular prescribed medication?
• Anticoagulants or antiplatelets? – e.g.
Warfarin / Aspirin

26. Family history
• Neurological diagnoses in first degree
relatives? – e.g. migraine

27. Social history
• Smoking – How many cigarettes a day? How
long have they smoked for?
• Alcohol – How many units a week? – be
specific about type / volume / strength of
alcohol
• Recreational drug use – headache may be
withdrawal related

28. Systemic enquiry
• Cardiovascular
• Respiratory
• GI
• Urinary
• Musculoskeletal
• Dermatology

29. Examination
• Detailed OCULAR and SYSTEMIC examination
• A) Visual Acuity –decrease vision with
Headache
i) refractory errors
ii) acute angle closure glaucoma
iii) anterior uveitis
iv) ocular ischemic syndrome

30. • Transient loss of vision (Amaurosis Fugax)
i) migraine
ii) severe hypertension
iii) papilledema
B) Ocular motility
restricted in Ophthalmoplegic migraine
C) Cover test/uncover test – to rule out PHORIA
and TROPIA

31. • Conjunctiva –congestion( to R/O glaucoma,
uveitis
• Cornea - edema
• Anterior chamber- depth, cells and flares
Pupil - RAPD ( compressive neuropathy)
dilated ( cerebral aneurysm
• Intraocular pressure

32. • Fundus examination - look for the signs of
i) Papilledema
ii) Glaucoma
iii) ocular ischemic syndrome

33. • Refraction – both with and without cycloplegic
• Orthoptic - for evaluation of
convergence,accommodative and fusional
insufficiency and phorias
• Visual field
• Gonioscopy
• Detailed neurological, ENT, dental, and
psychiatric evaluation will be needed according
to associated symptoms

34. Opening the consultation
• Introduce yourself – name/role
• Confirm patient details – name/DOB
• Explain the need to take a history
• Gain consent
• Ensure the patient is comfortable

35. Presenting complaint
• open questioning
• “So what’s brought you in today?” or “Tell
me about your headache”
• Allow the patient time to answer
• “Ok, so tell me more about that” “Can you
explain what that pain was like?”

36. History of presenting complaint
• SOCRATES

37. Investigations
• Should be done according to suspected cause
and associated symptoms
• i) x ray PNS - to R/O sinusitis
• ii) ESR /temporal artery biopsy
• iii) CT or MRI - to R/O intra cranial pathology
• iv) Carotid flow study - ocular ischemia
• v) Lumbar puncture - meningitis

38. ഇനി ചെറിയ കളികൾ ഇല്ല.
േലിയ കളികൾ മാത്തം

39. ശുഭം

40. Thank You….