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4MB Clinical Problem-Solving

4MB Clinical Problem-Solving. Dr. Gerard Flaherty Dept. of Medicine. Presenting Complaint: 40-yr-old ♀ with headache. How recent in onset? Abrupt onset? How frequent? Episodic or constant? How long lasting? Intensity of pain? Quality of pain? Site of pain? Radiation? Eye pain? Aura?

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4MB Clinical Problem-Solving

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  1. 4MB Clinical Problem-Solving Dr. Gerard Flaherty Dept. of Medicine

  2. Presenting Complaint: 40-yr-old ♀ with headache

  3. How recent in onset? Abrupt onset? How frequent? Episodic or constant? How long lasting? Intensity of pain? Quality of pain? Site of pain? Radiation? Eye pain? Aura? Photophobia? Phonophobia? Associated vomiting? Diurnal variation? Snoring? Neck stiffness? Trigger factors? Aggravating factors? Relieving factors? Family history? What does the patient do during headache? What medication used? History of Presenting Complaint

  4. Fever? Pulse/BP Neck stiffness? Purpuric rash? Pupils? Neurologic exam GCS score Scalp tenderness? Examine eardrum Thickened temporal arteries? Fundoscopy – papilloedema? Sinus tenderness? Cervical tenderness/ROM? Obese? Facial plethora? Physical Examination

  5. 38-yr-old ♀ with headache, facial pain and dry cough.Give the diagnosis.

  6. 20-yr-old ♀ with headache, fever and neck stiffness.Give the diagnosis.

  7. 70-yr-old ♀ with a painful red eye and headache.Give the diagnosis.

  8. Investigations • FBC • ESR • Capillary blood glucose • Plasma Alkaline phosphatase • Arterial blood gas • Skull radiograph • Cervical spine radiographs • CT Brain • Lumbar puncture • CSF manometry • MR angiogram • Temporal artery biopsy • Sinus radiographs • Sleep studies

  9. 65-yr-old ♂ with headache, deafness and bone pain.Give the diagnosis.

  10. Tension headache Cluster headache Trauma Vascular Migraine Subarachnoid haemorrhage Arteriovenous malformation Subdural haematoma Hypertensive encephalopathy Temporal arteritis Skull disease Sinusitis Skull fracture Mastoiditis Paget’s disease of bone Acute mountain sickness Medications Nitrates Sildenafil OCP Metabolic Sepsis CO2 retention Hypoxia Obstructive sleep apnoea Hypoglycaemia Alcohol withdrawal Raised intracranial pressure Cerebral tumour Meningitis Otitis media Acute angle-closure glaucoma Hyperviscosity Differential Diagnosis

  11. 32-yr-old obese ♀ with headache. Normal CT Brain.Give the diagnosis.

  12. 68-yr-old alcoholic with headache, confusion and memory loss.Give the diagnosis.

  13. Classification of Migraine • Classic migraine • Common migraine • Hemiplegic migraine • Basilar migraine • Ophthalmoplegic migraine

  14. Factors Provoking Migraine • Stress • Sleep deprivation • Alcohol • Combined oral contraceptive pill • Exercise • Bright lights • Hunger • Menses • Food (chocolate, wine, cheese)

  15. Acute drug therapy Aspirin 900mg Paracetamol 1gm Ibuprofen 400mg Diclofenac 100mg PR Domperidone 30mg PR Sumatriptan 50mg Prophylaxis Propanolol 80-320mg OD Pizotifen 1.5mg OD Amitriptyline 50mg OD Methysergide 1-2mg TDS (under hospital supervision) Mefenamic acid 500mg TDS Drug Management of Migraine

  16. Causes of Headache that must NOT be missed! • Intracranial tumours • Meningitis • Subarachnoid haemorrhage • Temporal arteritis • Acute angle-closure glaucoma • Benign intracranial hypertension • Subacute CO poisoning

  17. Reference • Steiner TJ, Fontebasso M (2002) Clinical review: Headache. BMJ325:881-6.

  18. Next week…. Syncope

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