1. Headaches Continued

2. Examination 3 minute neurological test

3. Examination- 3 minute neurological  This was designed by neurologists to ensure that sinister causes of headaches were not missed  This is suitable for those patients whose history suggsts migraine or tension-type headache

4. ExaminationNotes Romberg’s test Patient falling with eyes closed Tandem gait test Heel-to-toe walking Walking on heels Tests pyramidal tract Drift of outstretched arms Tests pyramidal tract Finger-nose test Tests coordination Fine finger movements Tests pyramidal and extrapyramidal tracts Hand Tapping Cerebellar and brainstem disease Visual Fields to confrontation Eye movements Face and tongue movements Fundoscopy Reflexes

5. How do we rate headaches? MIDAS Score

6. Midas Score  MIDAS QUESTIONNAIRE  INSTRUCTIONS: Please answer the following questions about ALL your headaches you have had over the last three months. Write your answer in the box next to each question. Write zero if you did not do the activity in the last 3 months. Please 'tab' through all five boxes to calculate your MIDAS score.   1  On how many days in the last 3 months did you miss work or school because of your headaches?   2  How many days in the last 3 months was your productivity at work or school reduced by half or more because of your headaches? (Do not include days you counted in question 1 where you missed work or school)   3  On how many days in the last 3 months did you not do household work because of your headaches?   4  How many days in the last 3 months was your productivity in household work reduced by half or more because of your headaches? (Do not include days you counted in question 3 where you did not do household work)   5  On how many days in the last three months did you miss family, social or leisure activities because of your headaches?   Your rating: TOTAL:  Your rating: TOTAL: 

7.  A  On how many days in the last 3 months did you have a headache? (If a headache lasted more than 1 day, count each day)  days   B  On a scale of 0-10, on average how painful were these headaches? (Where 0 = no pain at all, and 10 = pain as bad as it can be)    Grade  Definition  Score  I Minimal or infrequent disability0-5  II Mild or infrequent disability6-10  IIlModerate disability11-20  IVSevere disability21+   © Innovative Medical Research 1997  The MIDAS programme is sponsored by AstraZeneca   

8. Other Causes of Headache

9. Sinister Headaches  Causes of sinister headache that must not be missed include  1. Meningitis  2. Intracranial tumours (brain tumours)  3. Subarachnoid haemorrhage  4. Temporal arteritis  5. Primary angle closure glaucoma  6. Idiopathic intracranial hypertension. 7. Subacute carbon monoxide poisoning

10. Meningitis Usually accompanied by fever and neck stiffness in an obviously ill patient.

11. Intracranial Tumours produce headache when they are large enough to cause raised intracranial pressure, which is usually apparent from the history. Papilloedema or focal neurological signs, or both, will usually be present. Fortunately these are very rare.

12. Subarachnoid haemorrhage headache is often described as the worst ever, and is usually (but not always) of sudden or ictal onset. Neck stiffness may take hours to develop. In elderly patients particularly, classic symptoms and signs may be absent.

13. Temporal arteritis headache is persistent but often worse at night and sometimes severe, in a patient over 50 who does not feel entirely well. It may be accompanied by marked scalp tenderness

14. Primary angle closure glaucoma rare before middle age, may present dramatically with acute ocular hypertension, a painful red eye with the pupil midodilated and fixed and, essentially, impaired vision, and nausea and vomiting. In other cases, headache or eye pain is episodic and mild. The diagnosis is suggested if patient reports coloured halos around lights.

15. Idiopathic intracranial hypertension rare cause of headache; occurs especially with obese young women. May not be evident on history alone; papilloedema indicates the diagnosis.

16. Subacute carbon monoxide poisoning uncommon but potentially fatal. Symptoms include headaches, nausea, vomiting, giddiness, muscular weakness, dimness of vision, and double vision.

17. Scenarios  I need 8 volunteers- 4 girls and 4 boys  4 doctors and 4 patients

18. Brendan  Brendan 19 year old music student and amateur rock musician recently moved to area so no records received as yet

19. Jennifer  Jennifer is a 67 year old- retired shop assistant, She seldom visits the doctor although has a life long history of migraine, her medical records include very few consultations for headaches

20. Duncan  Duncan is a 38 year old. He is a freelance editor and is married with one child. His medical records contain no other previous consultation for migraine.

21. Mandy  Mandy is 29 years old. She is an air hostess. She does have a previous history of migraine, possibly linked to menstruation. She is in a stable relationship and has no children