Medical Exchange & Discovery 2016: Clinical English Course

Lesson 3: Headache Activity 1: Primary & Secondary Headaches

Primary Headache Syndrome

• migraine

• tension headache

• cluster headache

Secondary Causes

• CNS infection: • meningitis

• encephalitis

• cerebral abscess/tumor

• Non-CNS infection: • sinusitis

• fever

• herpes zoster: “Ramsay Hunt syndrome”

• ear infections

• dental infections

• Vascular: • subarachnoid hemorrhage (SAH)

• subdural hematoma

• epidural hematoma

• intracerebral hemorrhage

• temporal arteritis (giant cell arteritis)

• carotid or vertebral artery dissection

• Ophthalmologic: • glaucoma

• iritis

• optic neuritis

• Miscellaneous: • hypoglycemia

• trigeminal neuralgia

• withdrawal from caffeine and chronic analgesics (rebound headache)

• preeclampsia

• pseudotumor cerebri

• mass lesion

• hypertension

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Medical Exchange & Discovery 2016: Clinical English Course

Lesson 3: Headache Activity 2: Headache Associated Symptoms

Constitutional Symptoms Visual Symptoms

Sensory Symptoms Motor Symptoms

Miscellaneous

Migraine Aura Related Symptoms

Medical Terms Lay Terms

emesis

pyrexia

lethargy

anorexia

somnolence

Medical Terms Lay Terms

dysesthesia

anesthesia/hypoesthesia

paresthesia

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Medical Terms Lay Terms

diplopia

scotoma

phosphene

ocular pain

epiphora

Medical Terms Lay Terms

paralysis

tremor

ataxia

nuchal rigidity

dysarthria

Medical Terms Lay Terms

tinnitus

vertigo

vesicular lesion

ptosis

miosis

rhinorrhea

lacrimation

Medical Terms Lay Terms

photophobia

phonophobia/sonophobia

osmophobia

Medical Exchange & Discovery 2016: Clinical English Course

Lesson 3: Headache Activity 3: Mini Cases: Headache

Adopted from First Aid for the USMLE Step 2 CS, Fourth Edition (First Aid USMLE)

Options

Headache

Case 1

21 yo F presents with several episodes of throbbing left temporal pain that lasts for 2-3 hours. Before onset, she sees flashes of light in her right visual field and feels weakness and numbness on the right side of her body for a few minutes. Headaches are often associated with nausea and vomiting. She has a family history of migraine.

Case 6

35 yo M presents with sudden severe “thunderclap” headache with vomiting, confusion, left hemiplegia, and nuchal rigidity.

Case 2

26 yo M presents with severe right temporal headaches associated with ipsilateral rhinorrhea, eye tearing, and redness. Episodes have occurred at the same time every night for the past week and last for 45 minutes.

Case 7

25 yo M presents with high fever, severe headache, confusion, photophobia, and nuchal rigidity. Kernig and Brudzinski signs are positive.

Case 3

65 yo F presents with severe, intermittent right temporal headache, fever, blurred vision in her right eye, and pain in her jaw when chewing.

Case 8

18 yo obese F presents with a pulsatile headache, vomiting, and blurred vision for the past 2-3 weeks. She is taking OCPs.

Case 4

30 yo F presents with frontal headache, fever, and nasal discharge. There is pain on palpation of the frontal and maxillary sinuses. She has a history of allergies.

Case 9

57 yo M c/o daily pain in the right cheek for the past month. The pain is electric and stabbing in characteristic and occurs while he is shaving. Each episode lasts 2-4 minutes.

Case 5

50 yo F presents with recurrent episodes of bilateral squeezing headaches that occur 3-4 times a week, typically toward the end of her work day. She is experiencing significant stress in her life.

Case 10

38 yo M believes he is having a cluster headache. He presents with drooling and right facial nerve paralysis. On exam, he has vesicular lesions on an erythematous base in the ear canal.

cluster headacheherpes zoster infection: “Ramsay Hunt syndrome”

meningitis migraine pseudotumor cerebri

sinusitissubarachnoid hemorrhage (SAH)

temporal arteritis (giant cell arteritis)

tension headache trigeminal neuralgia

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Medical Exchange & Discovery 2016: Clinical English Course

Lesson 3: Headache Activity 4: Primary Headache Syndromes

Migraine Tension Headache Cluster Headache

Onset

• onset in adolescence• slow onset• several episodes• prodrome symptoms (1 or 2

days prior to headache)

• gradual onset• may occur acutely under

emotional distress or intense worry

• often present upon rising or shortly thereafter

• appear in clusters• multiple attacks in same

time of day or month• often during sleep or early

morning

Provoking & Palliating Factors

• worsen with routine physical activities

• photophobia• phonophobia• osmophobia

• increased sensitivity to pressure in pericranial tissue

• not worsened with exertion

• aggravated by lying down• precipitated/exacerbated by

EtOH

Quality • pulsating (pounding/throbbing)

• non-pulsating

• dull

• distracting

• pressing or tightening

• stabbing

• excruciating

• sharp

• penetrating

• burning

Region & Radiation • unilateral

• bilateral• across the forehead or on

the sides and back of the head

• unilateral orbital, supraorbital, temporal

Severity • disabling intensitiy• 9-10 out of 10

• mild to moderate• distracting intensity• 3-5 out of 10

• severe• “suicidal headache”• 9-10 out of 10

Associated Symptoms

• aura (scintillating scotoma or flashing lights)

• paresthesias• nausea/vomiting• neurologic deficits• fluid retention

• muscular tightness or stiffness in neck, occipital, and frontal regions

• difficulty in concentrating

• restless/agitation• ipsilateral conjunctival

injection, lacrimation, nasal congestion, rhinorrhea, forehead/facial sweating, flushing, miosis, and ptosis

Timing• one-day duration (last 4-72

hours)

• followed by postdrome symptoms

• last 30 min to 7 days

• short lived

• lasting up to 3 hours

• typically 1-2 cluster periods per year last 2 weeks to to 3 months

Risk Factors• females• family history of migraine• Caucasian

• stress• middle-aged• lack of physical activities

• males• older than 20 years old• smoking• EtOH• family history of cluster

headache

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Medical Exchange & Discovery 2016: Clinical English Course

Lesson 3: Headache Activity 5: History Taking: History of Present Illness (OPQRST)

Clinical Questions

Opening Question“How can I help you today?”“Could you tell me more about your headache?”

Onset“How did the headache start?”“What where you doing when the headache started?” “Is this the first time you have this type of headache?”

Provoking & Palliating Factors“Does anything trigger your headaches?”“What makes your headache worse?”“What makes your headache better?”

Quality“Could you describe your headache?”“Is your headache (sharp/dull/throbbing/stabbing)?”

Region & Radiation

“Could you show me where the headache is?”“So your headache is located in (body part), right?”“Do you have headache anywhere else?”“Has the headache location changed since it started?”

Severity“On a scale of one to ten, ten being the worst pain you can imagine, how would you rate your headache now/when it started?”

Associated Symptoms

“Do any other symptoms accompany your headache?”“Do you have (symptom: noun)?” “Do you feel (symptom: adjective)?” “Have you noticed any changes in (habit)?” “Has anyone you know noticed any change in (appearance)?”“Have you been (verb)ing more than usual?”“Sometimes patients with headache have (symptom: noun). Has this happened to you?”

Timing

“How often have you been having headaches?”“When did the headaches first start?”“How long do the headaches last?”“Have you noticed any changes in your headache pattern?”

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