{"id":64,"date":"2010-06-09T10:22:22","date_gmt":"2010-06-09T09:22:22","guid":{"rendered":"https:\/\/cloverock.info\/mockosce23\/new\/patients-suffering-from-headache\/"},"modified":"2023-01-11T23:57:12","modified_gmt":"2023-01-11T23:57:12","slug":"patients-suffering-from-headache","status":"publish","type":"post","link":"https:\/\/www.qpercom.com\/sim\/index.php\/the-neurological-examination\/patients-suffering-from-headache\/patients-suffering-from-headache\/","title":{"rendered":"Patients suffering from headache"},"content":{"rendered":"<p><strong>Introduction<\/strong><br \/>\nHeadache is a very common complaint. Many people who (now and again) suffer from headache do not consult a doctor. The patient is often aware of the cause of the headache (tension, bad night\u2019s sleep, alcohol) and treats themself with rest and\/or analgesics. If a patient consults a doctor it usually means they are concerned and think that their complaints are caused by a serious condition. The patient wants the doctor to find a cause for their complaint, if possible, and at the very least they hope the doctor can rule out serious (somatic) conditions.<\/p>\n<p><strong>History-taking<\/strong><br \/>\nAll headache patients should be asked the following important questions:<\/p>\n<p><em>Duration and course<\/em><\/p>\n<ul>\n<li>When and how did the pain begin?<\/li>\n<li>Is the pain constantly present or does it come in attacks?<\/li>\n<li>Is the pain present upon wakening or does it develop during the course of the day?<\/li>\n<li>Has the pain become worse recently?<\/li>\n<li>If the pain comes in attacks, how long does such an attack last?<\/li>\n<li>Do you feel one of these headache attacks coming on in one way or another?<\/li>\n<li>Do the attacks occur mainly during weekends and holidays?<\/li>\n<li>Did something happen before you first starting suffering from headaches which could be the cause?<\/li>\n<\/ul>\n<p><em>Location<\/em><br \/>\nWhere in your head is the pain worst?<\/p>\n<p><em>Nature<\/em><br \/>\nIs the headache<\/p>\n<ul>\n<li>stabbing?<\/li>\n<li>throbbing or hammering?<\/li>\n<li>pressing?<\/li>\n<\/ul>\n<p><em>Influencing factors<\/em><br \/>\nDoes the pain get worse:<\/p>\n<ul>\n<li>upon exertion?<\/li>\n<li>with emotions?<\/li>\n<li>when bending down?<\/li>\n<li>with bright light?<\/li>\n<li>when reading?<\/li>\n<li>when watching television?<\/li>\n<li>during menstruation?<\/li>\n<\/ul>\n<p>Does the pain get better?<\/p>\n<ul>\n<li>when you take painkillers?<\/li>\n<li>or other medication?<\/li>\n<li>after a good night\u2019s sleep?<\/li>\n<li>when the neck muscles are massaged?<\/li>\n<\/ul>\n<p><em>Additional signs and symptoms<\/em><br \/>\nPrior to the pain have you experienced any of the following symptoms:<\/p>\n<ul>\n<li>do you see flashing lights?<\/li>\n<li>does your vision suddenly get much worse?<\/li>\n<li>do you suffer from tingling in your face, arms or legs?<\/li>\n<li>do you suffer from paralysis or loss of strength in your arms or legs?<\/li>\n<li>is your sense of smell altered?<\/li>\n<\/ul>\n<p>Do you suffer from one of the following complaints during the headache (attack):<\/p>\n<ul>\n<li>do you shy away from light?<\/li>\n<li>does your vision get worse?<\/li>\n<li>do you vomit?<\/li>\n<li>do you have a red, watery eye?<\/li>\n<li>do you suffer from a runny nose?<\/li>\n<li>do you suffer from loss of strength in your arms or legs?<\/li>\n<li>do you suffer from dizziness?<\/li>\n<li>do you suffer from ringing in your ears?<\/li>\n<li>do you suffer from double vision?<\/li>\n<li>do you have a temperature?<\/li>\n<li>do you feel pain anywhere other than your head?<\/li>\n<\/ul>\n<p>It is also important to inquire about the familial history of head-ache, the patient\u2019s medication use, alcohol intake and use of other drugs, as well as previous illnesses, any periods of hospitalisation and operations.<br \/>\nIf the history-taking does not reveal a somatic condition to be the cause of the headache, it is important to ask the patient whether the headache could be related to any problems the patient may have. Such a question must be asked in way that the patient retains the sense of being respected.<\/p>\n<h2>The examination<\/h2>\n<p>Generally you will have formed one or more hypotheses about the cause of the headache after this history-taking. The physical examination should be used to test these hypotheses.<\/p>\n<p><strong><em>Increased intracranial pressure<\/em><\/strong><br \/>\n<strong>1.<\/strong>&nbsp; If you suspect increased intracranial pressure because:<\/p>\n<ul>\n<li>The pain is primarily present in the morning.<\/li>\n<li>The pain gets worse upon coughing, sneezing or bearing down.<\/li>\n<li>The pain is accompanied by vomiting, you should carry out the following examination:\n<ul>\n<li>Assess whether the patient\u2019s state of consciousness is impaired (EMV score, see &#8216;The unconcious patient&#8217;).<\/li>\n<li>Measure the pulse rate and blood pressure (increased intracranial pressure can lead to a slow pulse rate and rising blood pressure).<\/li>\n<li>Examine the abducent nerve function and the oculomotor nerve function (refer to &#8216;The cranial nerves&#8217;).<\/li>\n<li>Carry out funduscopy to determine the presence of optic disc oedema.<\/li>\n<li>In children you should measure the circumference of the head and compare it with previous measurements.<em>\ufeff<\/em><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><em><strong>Meningeal irritation<\/strong><\/em><br \/>\n<strong>2.<\/strong>&nbsp; If you suspect meningeal irritation because<\/p>\n<ul>\n<li>the onset of the pain was acute (like a \u2018bang\u2019 inside their head)<\/li>\n<li>the pain is accompanied by fever<\/li>\n<li>the pain was preceded by a middle ear infection, for example,<\/li>\n<\/ul>\n<p>You should carry out the following examination:<\/p>\n<ul>\n<li>Assess whether there is any sign of impaired consciousness.<\/li>\n<li>Carry out the tests for meningeal irritation (refer to &#8216;Signs of meningeal irritation&#8217;).<br \/>\n<em>Note 1: During the first hours following an arachnoidal haemorrhage, the meningeal irritation tests are often negative. <\/em><br \/>\n<em>Note 2: In infants and small children with meningitis, the meningeal irritation tests (pain when putting on a diaper, pain when lifting out of bed) are often negative. The child will be apathetic and drowsy.<\/em><\/li>\n<li>If you suspect an arachnoidal haemorrhage, you should carry out funduscopy to see whether there is any pre-retinal bleeding.<br \/>\n<em>Note: pre-retinal bleeding only occurs in a small percentage of cases.<\/em><\/li>\n<p><em><\/em><\/ul>\n<p><em><strong>Migraine<\/strong><\/em><br \/>\n<strong>3.<\/strong>&nbsp; If you suspect migraine because:<\/p>\n<ul>\n<li>the pain occurs in attacks<\/li>\n<li>the pain attacks occur primarily in the weekend or holidays or during menstruation<\/li>\n<li>the patient is aware that the pain attacks are coming due to prodromal symptoms (flashing lights, poor vision, tingling, paralysis)<\/li>\n<li>the pain is accompanied by nausea and vomiting<\/li>\n<li>the pain is accompanied by photophobia<\/li>\n<li>there is a family history of migraine,<\/li>\n<\/ul>\n<p>There is unfortunately no physical diagnostic examination available to test your hypothesis.<\/p>\n<p><em><strong>Cluster headaches (Horton\u2019s neuralgia)<\/strong><\/em><br \/>\n<strong>4.&nbsp; <\/strong>If you suspect cluster headaches because<\/p>\n<ul>\n<li>the pain occurs in attacks that last less than about 1.5 hours<\/li>\n<li>the pain attacks often occur at night<\/li>\n<li>the pain attacks occur in clusters (daily for a few weeks long and then symptome-free for months or years)<\/li>\n<li>the pain is localised in or around one eye,<\/li>\n<\/ul>\n<p>You should carry out the following examination:<\/p>\n<ul>\n<li>During a pain attack assess whether it involves a cluster headache (miosis, ptosis, anhydrosis, enophthalmia).<\/li>\n<\/ul>\n<p><em><strong>Trigeminal neuralgia<\/strong><\/em><br \/>\n<strong>5.<\/strong>&nbsp;If you suspect trigeminal neuralgia because<\/p>\n<ul>\n<li>the pain occurs in short attacks of about 5-10 jabs of pain each time<\/li>\n<li>the pain is localised in the 2nd or 3rd branch of the trigeminal nerve<\/li>\n<li>the pain can be evoked by eating or lightly touching certain points around the nose or mouth, for example, the diagnosis will have to be based on the history-taking because examination will always show the trigeminal nerve to be intact.<\/li>\n<p><strong><\/strong><\/ul>\n<p><strong><em>Temporal arteritis (giant cell arteritis)<\/em><\/strong><br \/>\n<strong>6.<\/strong>&nbsp; If you suspect temporal arteritis because<\/p>\n<ul>\n<li>the pain is continuous<\/li>\n<li>the nature of the pain is throbbing<\/li>\n<li>the pain is located around the temple area<\/li>\n<li>the pain occurs in the jaw muscles after chewing for some time (jaw claudication)<\/li>\n<li>the pain becomes worse if the patient lies down<\/li>\n<li>the pain also becomes worse if the patient bends down<\/li>\n<li>the patient also suffers from muscle pain elsewhere<\/li>\n<li>the pain is accompanied by a visual disturbance<\/li>\n<li>the patient is older than 50,<\/li>\n<\/ul>\n<p>You should&nbsp; carry out the following examination:<\/p>\n<ul>\n<li>Palpate the temporal arteries and assess whether the temporal artery on the painful side is tender to palpation, thickened, hard and bumpy.<\/li>\n<li>Assess whether the pulsations on this side are not palpable or palpable to a lesser extent.<\/li>\n<li>Measure the patient\u2019s vision, as other arteries (in particular the retinal arteries) are often also affected, which can lead to visual disturbances.<\/li>\n<li>Determine the erythrocyte sedimentation rate (ESR). The ESR is almost always highly elevated with temporal arteritis (&gt; 40 mm).<\/li>\n<\/ul>\n<p><em><strong>Tension headache<\/strong><\/em><br \/>\n<strong>7. <\/strong>&nbsp;If you suspect tension headache because<\/p>\n<ul>\n<li>the pain is constantly present<\/li>\n<li>the pain radiates from the neck to the forehead<\/li>\n<li>the pain seems to sit around the head like a tight band<\/li>\n<li>the pain occurs after or during tension or emotions<\/li>\n<li>the pain occurs after reading or watching television for a long time<\/li>\n<li>the pain depends on the patient\u2019s position (lying down in a relaxed manner can, for example, ease the pain)<\/li>\n<\/ul>\n<p>You should carry out the following examination:<\/p>\n<ul>\n<li>Press your thumb and index finger firmly on the occiput at the point where the trapezius muscle attaches [Figure 117].<\/li>\n<li>Enquire whether this hurts.<\/li>\n<li>Next apply equal pressure with the thumb and index finger to the mastoid process, left and right [Figure 118].<\/li>\n<li>Enquire whether this hurts more. With headaches caused by muscle tension, this should not be the case. Pressure at the trapezius muscle point of attachment is more painful.<\/li>\n<li>Determine the visual acuity. A non-corrected refractive error can cause a tension headache.<\/li>\n<\/ul>\n<p><span class=\"jce_caption\" style=\"display: inline-block;\"><img loading=\"lazy\" decoding=\"async\" class=\" size-full wp-image-62\" src=\"https:\/\/cloverock.info\/mockosce23\/new\/wp-content\/uploads\/2010\/06\/NeuroExam_n-fig-117.jpg\" width=\"400\" height=\"294\" srcset=\"https:\/\/www.qpercom.com\/sim\/wp-content\/uploads\/2010\/06\/NeuroExam_n-fig-117.jpg 400w, https:\/\/www.qpercom.com\/sim\/wp-content\/uploads\/2010\/06\/NeuroExam_n-fig-117-300x221.jpg 300w\" sizes=\"auto, (max-width: 400px) 100vw, 400px\" \/><span style=\"width: 400px; display: block;\">Figure 117<\/span><\/span><\/p>\n<p><span class=\"jce_caption\" style=\"display: inline-block;\"><img loading=\"lazy\" decoding=\"async\" class=\" size-full wp-image-63\" src=\"https:\/\/cloverock.info\/mockosce23\/new\/wp-content\/uploads\/2010\/06\/NeuroExam_n-fig-118.jpg\" width=\"400\" height=\"294\" srcset=\"https:\/\/www.qpercom.com\/sim\/wp-content\/uploads\/2010\/06\/NeuroExam_n-fig-118.jpg 400w, https:\/\/www.qpercom.com\/sim\/wp-content\/uploads\/2010\/06\/NeuroExam_n-fig-118-300x221.jpg 300w\" sizes=\"auto, (max-width: 400px) 100vw, 400px\" \/><span style=\"width: 400px; display: block;\">Figure 118<\/span><\/span><\/p>\n<p><strong>Malignant hypertension<\/strong><br \/>\n<strong>8.<\/strong>&nbsp; If you suspect malignant hypertension because<\/p>\n<ul>\n<li>the pain is continually present&nbsp;<\/li>\n<li>the pain is felt in the entire head<\/li>\n<li>the nature of the pain is pounding&nbsp;<\/li>\n<li>the pain is accompanied by nausea and vomiting<\/li>\n<li>the patient is known to have high blood pressure,<\/li>\n<\/ul>\n<p>You should carry out the following examination:<\/p>\n<ul>\n<li>Measure the blood pressure.<\/li>\n<\/ul>\n<p>If you find a diastolic pressure below 100 mmHg during the headache episode, you should search for a different cause.<\/p>\n<p><em><strong>Glaucoma<\/strong><\/em><br \/>\n<strong>9.<\/strong>&nbsp; If you suspect glaucoma because<\/p>\n<ul>\n<li>the pain is localised in or around the eye<\/li>\n<li>the pain is accompanied by visual disorders (blurry vision)<\/li>\n<li>the pain is associated with vomiting,<\/li>\n<\/ul>\n<p>You should carry out the following examination:<\/p>\n<ul>\n<li>measure the visual acuity<\/li>\n<li>examine the anterior eye segment (depth of anterior chamber, pupillary width)<\/li>\n<li>examine the intraocular pressure. For the correct technique you are referred to the book entitled \u2018The Examination of the Eye and Vision\u2019 from this series.<\/li>\n<p><em><\/em><\/ul>\n<p><em><strong>Sinusitis<\/strong><\/em><br \/>\n<strong>10.&nbsp; <\/strong>If you suspect sinusitis because<\/p>\n<ul>\n<li>the pain is located around one of the sinuses<\/li>\n<li>the pain worsens upon bending over<\/li>\n<li>the pain is accompanied by fever<\/li>\n<li>the pain is accompanied by rhinitis,<\/li>\n<\/ul>\n<p>You should carry out the following examination:<\/p>\n<ul>\n<li>percuss and palpate the sinus.<\/li>\n<li>assess whether this aggravates the patient\u2019s pain.<\/li>\n<p><em><\/em><\/ul>\n<p><em><strong>Temporomandibular syndrome (Costen\u2019s syndrome)<\/strong><\/em><br \/>\n<strong>11.<\/strong>&nbsp; If you suspect temporomandibular syndrome because<\/p>\n<ul>\n<li>the pain is located in or just in front of the ear<\/li>\n<li>the pain becomes worse upon chewing,<\/li>\n<\/ul>\n<p>You should carry out the following examination:<\/p>\n<ul>\n<li>palpate the patient\u2019s temporomandibular joint while the patient opens and closes their mouth.<\/li>\n<li>inquire whether this is painful.<em><br \/>\nNB: do not palpate too firmly as this will always be painful.<\/em><\/li>\n<li>assess whether there is poor teeth occlusion.<\/li>\n<\/ul>\n<p>It is not always as easy to establish a diagnosis as may be suggested by the preceding text.<br \/>\nAlthough it is not difficult to recognise arachnoidal haemorrhage in a patient whose headache started with a sudden bang and in whom the meningeal irritation tests are all positive, or to identify glaucoma in a patient with sky-high intraocular pressure, the signs are not always this clear. A thorough understanding of the above-mentioned diseases and syndromes is therefore essential.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Introduction Headache is a very common complaint. Many people who (now and again) suffer from headache do not consult a doctor. The patient is often aware of the cause of the headache (tension, bad night\u2019s sleep, alcohol) and treats themself with rest and\/or analgesics. If a patient consults a doctor it usually means they are [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[16],"tags":[113],"class_list":["post-64","post","type-post","status-publish","format-standard","hentry","category-patients-suffering-from-headache","tag-the-neurological-examination"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.3 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Patients suffering from headache - Qpercom | Skills in Medicine<\/title>\n<meta name=\"description\" content=\"Online Mock OSCEs with examiners, patient actors, instant results and personalised feedback. 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