Head ache history &examination

1. Clinical approach to head ache History & clinical examination

2. History……………………………????? WHERE IS THE PAIN??????? SITES FRONTAL TEMPORAL VERTEX OCCIPITAL/ NECK PAIN FACIAL GENERALISED

3. 1.FRONTAL………….. FRONTAL SINUSITIS ……………….(more in morning during awakening , less intense at noon ) draining out of collection due to gravity in upright posture… Sneezing,stooping,blowing Tension head ache……………..( bilateral,in frontal temporal and vertex….felt as fullness,pressure or tightness)

4. 3.INCREASED INTRACRANIAL TENSION …………………… bi frontal / bi occipital 4.Cough and exertional head ache……………………... front of head 5.migraine variants………….. 6.LP HEAD ACHE ( usually occipitonuchal ) …… sudden upright posture after procedure

5. 2.TEMPORAL…………………………. COMMON MIGRAINE ………………………….in temporo frontal area TEMPORAL ARTERITIS …………… Throbbing U/L,B/L Cluster head ache…………… Costens syndrome…….. TMJ ARTHRITIS Drugs like sorbitrate

6. 3.VERTEX…………………….. ETHMOID & SPHENOID SINUSITIS……… Localised deep in midline Behind the root of nose sphenoid less on walking Head ache associated with psychiatric illness

7. 4.OCCIPITAL & NECK PAIN………………… Cervical spondylosis sub arachnoid heamorrhage Meningitis POST. FOSSA TUMOURS Cough & exertional headache Occipital neuralgia d/s of ligaments & joints in upper part of spine WHIPLASH INJURY OF NECK

8. 5.FACIAL PAIN……………….. OCULAR Ear DENTAL maxillary sinustis TRIGEMINAL NEURALGIA , carotidynia , glossopharyngial neuralgia ………

9. 6.GENERALISED HEAD ACHE………….. BRAIN TUMOUR HEADACHE TENSION HEAD ACHE Post traumatic headache Related to SYSTEMIC D/S (fever , hypercapnia , hypoglycemia , drugs , anemia)

10. ---Head ache well localised on the skull with the finger is never associated with any significant d/s……….. ---ANT. 2/3 rd OF HEAD Supra tentorial structures ---VERTEX & BACK Infra tentorial structures Points to remember…………………

11. WHAT IS THE MODE OF ONSET???????????? ACUTE Traumatic Drugs Av anuerysm rupture Cluster head ache SAH Temporal arterits ACUTE GLAUCOMA ACUTE MENINGITIS CHRONIC MIGRAINE Temporal arteritis Tension head ache BRAIN TUMOUR PAIN c/c menigitis

12. Points to remember………………….. Many years duration with little or no progression BENIGN FIRST SEVERE HEAD ACHE SUB ACUTE WORSENING OVER DAYS Rule out serious problem……….

13. WHEN DOES IT OCCUR??? Worse in the morning ……………. Organic d/s of brain Consumption of alcohol CERVICAL SPONDYLOSIS FRONTAL SINUSITIS Severe anemia HYPERTENSION

14. Nocturnal head ache ……………. CLUSTER HEADACHE TEMPORAL ARTERITIS organic d/s may get worsened

15. Meal time head ache ….. TRIGEMINAL NEURALGIA Temporal arteritis chewing Glossopharyngeal neuralgia CAROTIDYNIA swallowing

16. Worse in evening……….. EYE STRAIN Tension head ache Fatigue and mental exhaution ETHMOIDAL &SPHENOIDAL SINUSITIS

17. Orthostatic headache ……………. POST LUMBAR PUNCTURE PAIN Subdural hematoma Benign intra cranial hypertension

18. WHAT IS THE CHARACTER & SEVERITY??? Throbbing headache Excruciating, nonpulsatile Dull &episodic icepicking pain Deep,dull aching or bursting quality MIGRAINE CLUSTER HEADACHE TEMPORAL ARTERITIS BRAIN TUMOUR

19. Intense stabbing pain TRIGEMINAL NEURALGIA TO ASSESS SEVERITY …..ASK …………… If pain affects day to day life If pain interferes with sleep…… indicate whether it prevents sleep or awakens the pat. From sleep…………….

20. WHAT BRINGS THE PAIN & WHAT AGGRAVATES IT??? Anger, exitement worry,&lack of sleep& CHINESE FOOD…&…ALCOHOL MIGRAINE Prolonged use of eyes OCULAR HEAD ACHE Cold,hot,or sweet DENTAL PAIN

21. STOOPING SINUSITIS Chewing,smiling,talking , TRIGEMINAL NEURALGIA Pain after period of inactivity OCCIPITAL &NECK PAIN Eg : pain after sleep occurs in cervical arthritis

22. Sudden movement , coughing or straining ICT Lying down aggravation SUB DURAL HEMATOMA, POST. FOSSA TRS .

23. WHAT MAKES IT BETTER???? MIGRAINE relieved by SLEEPING/DARK SURROUNDINGS ………….. Temporal arteritis can be relieved by STEROIDS

24. WHERE DOES IT MOVE?????? Throat , neck muscles ,spine/post. fossa structures EAR Raised ICT,thrombosis of basilar artery FRONTAL AREA

25. Accompanying symptoms??? MIGRAINE Aura like photophobia &visual symptoms Hemiplegia Brain stem symptoms

26. CLUSTER HEADACHE Red eye with lacrimation Stuffy nose with rhinorrhea

27. TEMPORAL ARTERITIS Fever Wt. loss Palpable tender artery MENINGITIS Fever Vomiting Neck stiffness

28. BRAIN TUMOUR HEAD ACHE Projectile vomiting GLAUCOMA Red & painfull eye Abnormality in vision

29. GLOSSOPHARYNGEAL NEURALGIA bradycardia /syncope PROLACTIN SECRETING TR. OF PITUITORY AMENORRHEA GALACTORRHEA

30. EXAMINATION …….. 1.GENERAL EXAMINATION 2.VITALS Temperature Pulse BP Resp.rate FEVER (meningitis)

31. 3.ON FACE………. sinuses MAXILLARY SINUS Press over CANINE FOSSA on the cheek……with FORE FINGER & MIDDLE FINGER on the other----------note the FACIAL EXPRESSION of the patient

32. FRONTAL SINUS Press over floor of sinuses,MEDIAL PART OF SUPRA ORBITAL margin….FORE FINGER & MIDDLE FINGER--------look the facial expression… ETHMOID SINUSES Press on sides of nose MIDWAY B/W INNER CANTHUS & NASION

33. Tooth Caries Pyorrhoea Temporo mandibular joint Ask the pat……………… open & close mouth…move jaw side way& back forth ….note PAIN , TENDERNESS& CREPITUS TMJ arthritis

34. Ear…… Pinna Auditory canal---- pus,congestion ….. Tympanic membrane----perforation(CSOM) Rinne’s,weber’s tests…………….. Eye….. Pallor Glaucoma----- IOT Cluster head ache-------- myosis,ptosis,conjunctival congestion,lacrimation FUNDUS-----PAPPLIOEDEMA

35. Temporal artery……… Tender……cord like 4.NECK ……….. Neck stiffness………. KERNIG’S SIGN BRUDZINSKI SIGN

36. KERNIG’S SIGN………… Patient supine Flex the hip & knee to 90degree Extent the knee,with hip still flexed PAIN IN POSTERIOR THIGH MUSCLE & DIFFICULTY IN KNEE EXTENSION Spasm of hamstrings

37. BRUDZINSKI NECK SIGN Flexion of both knees Pain & rigidity of neck 4.CNS EXAMINATION…… Focal neurological deficit ( BRAIN TUMOUR HEAD ACHE)

38. 4.CNS EXAMINATION…… Focal neurological deficit ( BRAIN TUMOUR HEAD ACHE)

39. Summary….. history Where Onset When Character & severity Aggravating & relieving factors Radiation Accompanying symp examination vitals Face- sinuses,tooth,TMJ,ear,eye Neck- kernig’s , brudzinski CNS-focal defecit