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Probability diagnosis

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Acute:

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  • respiratory infection

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Chronic:

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  • tension-type headache

  • combination headache

  • migraine

  • transformed migraine

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Serious disorders not to be missed

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Cardiovascular:

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  • subarachnoid haemorrhage

  • intracranial haemorrhage

  • carotid or vertebral artery dissection

  • temporal arteritis

  • cerebral venous thrombosis

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Neoplasia:

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  • cerebral tumour

  • pituitary tumour

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Infection:

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  • meningitis (esp. fungal)

  • encephalitis

  • intracranial abscess

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Haematoma: extradural/subdural

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Glaucoma

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Benign intracranial hypertension

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Pitfalls (often missed)

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Cervical spondylosis/dysfunction

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Dental disorders

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Refractive errors of eye

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Sinusitis

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Ophthalmic herpes zoster (pre-eruption)

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Exertional headache

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Hypoglycaemia

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Post-traumatic headache (e.g. post-concussion)

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Post-spinal procedure (e.g. epidural, lumbar puncture)

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Sleep apnoea

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Rarities:

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  • Paget disease

  • post-sexual intercourse

  • cluster headache

  • Cushing syndrome

  • Conn syndrome

  • Addison disease

  • dysautonomic cephalgia

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Masquerades checklist

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Depression

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Diabetes

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Drugs (see list)

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Anaemia

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Thyroid disorder and other endocrine (as above)

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Spinal dysfunction (cerviogenic)

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UTI

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Is the patient trying to tell me something?

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Quite likely if there is an underlying psychogenic disorder.

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Key history

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A full description of the pain including a pain analysis should be obtained, especially associated symptoms. It is useful to get the patient to prepare a diary with a grid plotting the relative pain intensity with time of day. Family history, psychosocial history and drug history.

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Key examination

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  • Use the basic tools of trade: thermometer, sphygmomanometer, pen torch, diagnostic set with ophthalmoscope and stethoscope

  • Inspect the head, temporal arteries and eyes

  • Areas to palpate include the temporal arteries, the facial and neck muscles, the cervical spine and sinusitis, teeth and TMJs

  • Look for signs of meningeal irritation and papilloedema

  • A mental state examination is advisable

  • Perform a basic neurological examination

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Key investigations

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Consider:

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  • FBE

  • ESR/CRP

  • selective radiography (e.g. skull X-ray, sinus X-ray, CT scan or MRI scan).

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Diagnostic tips

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  • Hypertension is an uncommon cause of headache.

  • ‘Combination headaches’, which can last for days, have a mix of components such as tension, depression, vascular headache and drug dependence.

  • A patient >55 years presenting with unaccustomed headache probably has an organic cause.

  • Drugs that may cause headache: alcohol, analgesics (rebound), caffeine, antihypertensives (several), COCP, corticosteroids, NSAIDs (esp. indomethacin), vasodilators esp. nitrates, sildenafil.

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