EMQ: 3
Headache
a)
Meningitis
b)
Subarachnoid haemorrhage
c)
Subdural haematoma
d)
Migraine
e)
Cluster headache
f)
Temporal arteritis
g)
Cerebral metastases
h)
Trigeminal neuralgia
i)
Benign intracranial hypertension
j)
Acute glaucoma
Select the most likely condition from the list above that
would account for the following scenario:
1) A 50-year-old female who has had a mastectomy followed
by radiotherapy and chemotherapy for breast cancer presents with a severe
headache associated with nausea and vomiting. On examination of the fundus
there is bilateral papilloedema.
Answer: g) cerebral metastases
The history of cancer should immediately alert one to the
possibility that this is the cause of the problem. Headache associated with
nausea and vomiting is suggestive of raised intracranial pressure and this is
confirmed by the presence of papilloedema. The most likely diagnosis would be
metastatic disease as a consequence of the breast cancer.
2) A 63-year-old female presents with headache. She gives
a history of pain in her jaw when she eats. On examination the scalp is
tender.
Answer: f) temporal arteritis
In an elderly patient presenting with headache one should
always consider temporal arteritis. The history of jaw claudication is very
suggestive of temporal arteritis and the scalp tenderness is also in favour of
this diagnosis.
3) A 45-year-old female presents with sudden onset
headache. She is drowsy and has neck stiffness
Answer: b) subarachnoid haemorrhage
Sudden onset headache should make one suspect an
intracranial haemorrhage. Associated drowsiness should make one think of
raised intracranial pressure. Neck stiffness would suggest meningeal
irritation and hence blood in contact with the leptomeninges (i.e.)
subarachnoid haemorrhage
4) A 35-year-old female presents with recurrent
unilateral throbbing headaches that are accompanied by nausea and vomiting.
The headache is preceded by an aura where she experiences the sensation of
seeing flashing lights.
Answer: d) migraine
The history of recurrent unilateral headache should make
one suspect migraine. The throbbing nature of the headache is in favour of
this. The fact that the headache is preceded by an aura lends weight to this
diagnosis.
5) A 75-year-old male presents with headache. He is
unsteady on his feet and has periods of drowsiness. His relatives say that he
has had several falls in the last few weeks.
Answer: c) subdural haematoma
In an elderly patient who has had several falls one
should think of subdural haematoma. The history of periods of drowsiness would
be in favour of this.
Revision Tip
For a classification of the causes of headache that will
help recall see ACES for PACES page 458
