- Headaches can have many causes, both ocular and systemic. A thorough medical history is important to determine the nature and cause of a patient's headache. - The history should explore symptoms like site, onset, characteristics, radiation, associated symptoms, timing, exacerbating/relieving factors, and severity. - A comprehensive examination of vision, ocular motility, the anterior segment, fundus, refraction and visual fields can help identify potential ocular causes, while neurological and other system examinations may reveal underlying systemic disorders. - Further investigations should be guided by the history and examination findings to arrive at a diagnosis and appropriate management.

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….