3. Intra cerebellar haemorrhage :
Typically present with abrupt onset
Ass. è nausea , vomiting, dizziness and ataxia
Ass. With GCS
Intra ventricular / intracerebral haemorrhage :
The onset is usu. Over minutes to hours
Ass. è focal neurological signs
Ass. è GCS
3 Intra cranial haemorrhage
4. Subarachnoid haemorrhage
Potentially, devastating bleed( typically aneurysm ) into subarachnoid
space.
Rapid onset (<2 min) , severe, continuous ( > 2h)
Occipital ( hit around the back of the head)
Ass. è Vomiting, dizziness, seizures
Neck stiffness, drowsy, photophobia, focal neurological signs, GCS
Urgent CT ; but CT mey be normal in small bleeds (20%)
If CT is normal, LP( >12 h after onset ) for xanthochromia
4
7. Meningitis
Fever (>38°C ), meningism
Headache develop over hours rather than sudden
Viral meningitis is self-limiting
Bacterial meningitis; life-threatening, GCS, shock, purpuric
rash, focal neurological signs
LP & blood culture & throat swab is diagnostic
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8. Encephalitis
Brain inflammation, usually viral
Rare and easily missed in the early stages
Drowsy, confusion, vomiting, seizures, preceding flu-like illness,
non-specific symptoms
Pyrexia, GCS, confusion, focal neurological signs, neck
stiffness, photophobia
Do an urgent CT head and LP to look for signs of infection.
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9. Migraine
Recurrent, severe
Lasting several hours to a few days
Ass. è photophobia, nausea, vomiting , focal neurological features (
aura e.g. flashing light, zigzags, visual loss )
Typically; intense, throbbing, unilateral, causing pt. to cease normal
activities in favour of bed- rest in quiet, darkened room
Triggers; cheese, chocolate, alcohol , oral contraceptives pill
First attack Aged > 40 is uncommon
Consider MRI head if new and > 55 year.
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10. Tension headache
Bilateral ( generalised or frontal)
Duration 30 min. to 7 days.
Dull, tight, pressing, in nature
Worse when stressed
Nausea and photophobia are usu. Absent
± scalp muscle tenderness
Pt continue with normal activities
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12. Cluster headache
Rapid-onset of excruciating pain around one eye that may become watery
and bloodshot with lid swelling, lacrimation
facial flushing, rhinorrhoea, miosis ± ptosis (20% of attacks).
Restlessness, agitation
Pain is strictly unilateral and almost always affects the same side.
It lasts 15–180min, occurs once or twice a day, and is often nocturnal.
Clusters last 4–12wks and are followed by pain-free periods of months or
even 1–2yrs before the next cluster. Sometimes it is chronic, not episodic.
Occur in clusters lasting days to weeks , separated by months without
symptoms
Male : female = 5:1, commoner in smokers.
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13. Temporal arteritis ( giant cell arteritis)
Large vessel vasculitis
Ass. é polymyalgia Rheumatica( proximal pain, stiffness)
More common in women
Unusual in pt. < 50 years
Localized headache ( temporal / occipital)
Scalp tenderness, jaw claudication , visual loss
Constitutional upset ( malaise, sweating, pyrexia, wt. loss)
Abnormal temporal artery ( inflamed, tender, non pulsatile, nodular )
Raised ESR, CRP, plts, ALP with anaemia
The potential for rapid onset irreversible visual loss necessitates urgent treatment
with steroids.
Temporal artery biopsy may confirm the diagnosis in < 1 wk. of starting therapy.
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14. Acute glaucoma
Ophthalmological emergency
Dt sudden increase in intraocular pressure
Pt is long-sighted, middle-aged or elderly, often occurs at night
conjunctival injection
clouding of the cornea
irregular/non-reactive pupil
↓visual acuity or blurred vision
sees coloured ‘halos’ around lights.
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15. Raised intracranial pressure
Caused by CVA, tumours, trauma, infection( abscess), cerebral oedema, ( post-
hypoxia ), electrolyte imbalance, coagulopathy, idiopathic.
Suspected è GCS, focal neurological signs, new onset seizures
Cushing’s reflex ( HR, BP )
Tend to be worse in the morning and on lying flat, coughing, straining
Ass. è Vomiting without nausea +/- papilloedema
CT brain is diagnostic
consider HIV
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16. Sinusitis
Inflammation of the mucosa of the paranasal sinuses due to bacteria, virus, fungi;
mey become chronic.
Dull, throbbing
Focal pain over the sinuses
Tend to be worse on bending forward
Ethmoid or sphenoid sinus pain is felt deep in the midline at the root of the nose.
Temp mey be normal
Invariable ass. è Nasal symptoms, Look for at least two of:
• nasal blockage/congestion
• rhinorrhoea/discharge
• loss of smell
• facial pressure or tenderness.
Sinusitis lasting > 8 wks requires CT to confirm dx
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17. Analgesics headache
Ass. è chronic analgesic use esp. Opioids
Bilateral
Occur prior to the next dose of analgesia
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18. Hypertensive crisis
Hypertension usually represents to a response to pain of the
headache and respond to the treatment of the headache
But, BP more than 200/120 is the cause of the headache
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19. Intracranial hypotension
CSF leakage, e.g. Iatrogenic after LP or epidural anaesthesia.
Suspect if headaches worse on standing
usu. Present within 4-5 days of the procedure
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20. Trauma
Extradural haemorrhage, Subdural haemorrhage, Concussion.
Commonly causes localized pain but can be more generalized.
It lasts ~2wks; often resistant to analgesia.
Do CT to exclude subdural or extradural haemorrhage if
drowsiness ± lucid interval, or focal signs
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21. Trigeminal neuralgia
Brief, repetitive episodes of intense shooting, stabbing, electric shock - like
pain in 2nd and 3rd divisions of trigeminal nerve
Paroxysms of intense, stabbing pain, lasting seconds.
The face screws up with pain (hence tic douloureux).
Triggers: Washing affected area, shaving, eating, talking, dental prostheses.
Typical patient: >50yrs old; in Asians F:M ≈ 2:1.
Secondary causes: Compression of the trigeminal root by anomalous or
aneurysmal intracranial vessels or a tumour, chronic meningeal
inflammation, MS, zoster, skull base malformation (e.g. Chiari).
MRI: Is necessary to exclude secondary causes (~14% of cases).
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23. Exertional headache
Sudden, bilateral, explosive pain
Typical on exercise or orgasm
May mimic migraine or SAH, but meningism is absent
Consider CT / LP to rule out SAH
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24. Drugs induced headache
Nitrate
Ca channel blocker
Metronidazole with alcohol
Recreational drugs e.g. Solvents
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26. Nice to know
All sudden onset, severe headaches should, ideally, be discussed
with a neurologist.
Headaches that recur tend to be benign: migraine, tension headache,
trigeminal neuralgia.
Chronic, progressive headaches can indicate increased ICP .
Consider benign intracranial hypertension in patients with features
of ↑intracranial pressure but no mass on neuroimaging.
Ask about stress or recent life events; may not explain the pathology,
but will help you appreciate the context in which symptoms are.
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27. Red flags
New-onset headache/change in headache in patients over 50 years
Persistent visual disturbance Focal CNS signs, ataxia or new cognitive or
behavioural disturbance
Headache that changes with posture or wakes the patient up
Headache brought on by physical exertion
Papilloedema
New-onset headache in a patient with known HIV or active malignancy
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👉 Arrange CT brain ± MRI and, if normal, seek input from a neurologist.
28. Sources
MacLeod's clinical diagnosis, 2013
Oxford Handbook of Clinical Medicine,10th edition
Oxford Handbook for the Foundation Programme, 5th edition
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