Semantically, the term headache encompasses all aches and pains located in the head, but in practice, its application is restricted to discomfort in the region of the cranial vault. Facial, lingual, and pharyngeal pains are put aside as something different and usually not considered as headaches
Red flag symptom means that a headache warrants further investigation.
Mononeuritis multiplex (multiple mononeuropathy and/or multifocal neuropathy) affects several or multiple nerves. Polyneuropathy describes diffuse, symmetrical disease, usually commencing peripherally.
Common problems in neurology
• Vertigo and dizziness
• Dementia and Parkinson disease
I would like to stress on how to simplify this problems and to discuss certain
points which would help for prompt and early referrals:
• Approximately 30% people - experience moderate to severe
dizziness at some point in their life (Neuhauser et al. 2005).
• “Dizziness” refers to various abnormal sensations relating to
perception of the body’s relationship to space.
• Dizziness - may represent variety of symptoms including :
1. Spinning or movement of the environment (True vertigo)
2. Light-headedness or Presyncope, or
3. Imbalance while walking
• A brief general medical examination is important.
• Postural Hypotension measurement.
• Orthostatic hypotension - probably the most common
general medical cause of dizziness among patients referred to
• Identifying an irregular cardiac rhythm may help.
• Other general examination measures to consider in individual
patients include a Visual assessment (adequate vision is
important for balance) and a musculoskeletal inspection
(significant arthritis can impair gait).
• In CNS examination look for nystagmus.
Common causes of vertigo
• Rapid onset of severe
vertigo, nausea, vomiting,
• Symptoms gradually
resolve over several days
• Etiology - probably viral.
• Benign and self-limited
• Head thrust test
• Patients typically experience
brief episodes of vertigo
when getting in and out of
bed, turning in bed, bending
down and straightening up,
or extending the head back
to look up.
• taught to perform a
• Dix–Hallpike test.
MENIERE DISEASE: Vertigo+ Hearing Loss+ Tinnitus+ Aural fullness
• Symptom based
•No organic causes •Etiology based
• It is the second most common cause of headaches (m/c is
tension type headache)1
• Often can be recognized by its activators= TRIGGERS
-light, sound, stress, hunger, menstruation, stormy weather, lack or excess
of sleep, barometric pressure change, alcohol
basis of life style adjustments
• A headache diary is often useful in making diagnosis,
assessing disability and frequency of treatment for acute
1 Harrison’s Principles of Internal Medicine 18thed
Potential phases of migraine attack
1. Prodrome – occurs hours to days before headache, change in
mood, behaviour, appetite, cognition
2. Aura- occurs within 1 hour of headache, most commonly visual
• Visual aura
– Most common
– Consists of photopsias, bright flashing lights, scintilating
scotomas, field cuts and fortification spectra(zig zag
Negative scotoma. Loss of local
awareness of local structure
Positive Scotoma. Additional structures One side loss of perception.
• Sensory aura
– Numbness and paresthesiae in a limb
Motor weakness and aphasia are less common
Symptoms similar to classical migraine but without aura
• Foods rich in tyramine ( cheese, redwine)
• Foods containing monosodium glutamate (Chinese and
• Foods containing nitrates ( salami, smoked meat)
• Caffeinated beverages (soft drinks, tea and coffee)
Simplified Diagnostic Criteria for Migraine
Repeated attacks of headache lasting 4–72 h in patients with a normal
physical examination, no other reasonable cause for the headache, and:
At Least 2 of the Following
Plus at Least 1 of the Following
Unilateral pain Nausea/vomiting
Throbbing pain Photophobia and phonophobia
Aggravation by movement
Moderate or severe intensity
Treatment: Tension-Type Headache
• The pain of TTH can generally be managed with simple
analgesics such as acetaminophen, aspirin, or NSAIDs.
• Behavioral approaches including relaxation can also be
• TRIPTANS in pure TTH are NOT HELPFUL, although triptans are
effective in TTH when the patient also has migraine.
• For chronic TTH , AMITRIPTYLINE is the only proven
treatment Other TCA, SSRI and the benzodiazepines have not
been shown to be effective.