A few headache cases

GA 1 Please see this 65 y.o. retired shoe designer with occipital headaches for 3 months not helped by physiotherapy. Woken at night by pain. Tender trapezius. ESR 8 (3 weeks ago). Rarely attends surgery but visited once per week for last 2 months. Extremely anxious.

GA? What is your diagnosis?

GA 2 Began after sore throat which has persisted Neck then jaw ache Worse in a.m., tenderness on top of head and temples Initially pain on eating and tiredness in jaw on chewing Episode of double vision lasting 4 days started while exercising neck and cleared 6 days earlier

GA?? What is your diagnosis now?

GA 4 ESR 64 CRP 50 Temp artery biopsy +ve Dramatic response to Prednisolone 60mg daily

Case 7.Mr C 49 y.o. History Emergency admission ref by GP 7 days earlier -while sitting watching TV, sudden hearing loss for 1-2-min followed by severe bitemporal headache, like an explosion in the head, spreading to back of neck and lower back and thighs, nausea and vomiting 9-10 times, and diarrhoea - settled. Examination - Looked well, mild photophobia and neck stiffness.

Case 7.Mr C 49 y.o. Investigations CT 2 days later “normal” CSF - clear and colourless, 22 lymphos, 44 rbcs, protein 0.87, glucose 2.8 (blood gluc 5.9)

Mr C CT

Mr C What is your diagnosis?

Mr C Carotid angiogram

Subarachnoid haemorrhage Clinical features and diagnosis Clinical features –Sudden severe headache –Loss of consciousness or vomiting in 90% –Neck stiffness Diagnosis –CT brain scan –LP for CSF xanthochromia

Subarachnoid haemorrhage Probability of recognising aneurysmal SAH on CT TimeProbability Day 095% Day 374% One week50% Two weeks30% Three weeksapprox 0%

AS case history 37 y o woman Headaches as a child recurred 4 years ago Attacks of impaired peripheral vision may have lights on right side for 30 mins Followed by occipital then left sided or generalised headache, nausea, vomiting, photophobia, lasting 1-2 hrs or all day, 1/month but may be more often Worse on exertion Recent rushing in ears and unclear vision

AS - R fundus

AS - MRI Flair to show aqueduct

AS VP shunt inserted CSF under very high pressure Immediate cessation of rushing noise and improved clarity of vision

Mrs IH - History June sudden onset thumping back of head radiating to front 1 hr later nausea & vomiting. Photophobia. Neck stiff Better lying down Admitted to hospital CT normal, CSF normal. Home after 10 days Seen 1 month later - Symptoms persisted OK lying down Pain R lower chest Examination normal Diagnosis?

IH - MRI

IH 2 History RTA Seat belt burn R side of neck Severe headache and vomiting on getting up Fine lying down Numbness L arm

IH Diagnosis?