Headache Clinical Case and Intro to Cranial Nerve Exam

Give 3 eye symptoms associated with headaches:

1) visual aura/ disturbance (migraine)

2) lacrimation (cluster headaches)

3) red eyes and pain (glaucoma)

What is lacrimation?

flow of tears

Give 2 ear symptoms associated with headaches:

1) discharge

2) otalgia

What is otalgia?

ear pain

What headache red flag is associated with jaw and temporal tenderness?

arteritis

What is arteritis?

inflammation of the arteries

What 2 nose symptoms are associated with headaches?

1) congestion

2) rhinorrhoea

Give 11 red flags for headaches (need to be investigated rapidly!):

1) seizures

2) eye pain or redness (glaucoma)

3) wakes patient up from sleep

4) personality change

5) worsens with postural changes

6) history of trauma

7) temporal artery tenderness (arteritis)

8) fever/ neck stiffness (meningitis)

9) triggered by cough or exercise

10) reduced cognitive ability

11) it the first/ worse thunderclap headache they've experienced (haemorrhage)

What is glaucoma?

A condition characterized by increased intraocular pressure and progressive vision loss due to optic nerve damage

What is a sub-arachnoid headache?

bleeding into the sub-arachnoid space

In which demographic is cerebral venous thrombosis most common?

young women who smoke or take the oral contraceptive pill

Give the 3 key presentations of meningitis:

1) fever

2) neck stiffness

3) photophobia

Are tension headaches typically bilateral or unilateral?

bilateral

Are migraines typically bilateral or unilateral?

unilateral

Describe the typical character of a tension headache:

pressing and tightening

Describe the typical character of a migraine:

pulsating pain

True or false: tension headaches are aggrevated by routine activity and associated with nausea and vomiting

false

True or false: migraines are aggravated by routine activity and associated with nausea and vomiting

true

Does a tension headache present with a normal or abnormal neurological examniantion?

normal

What abnormal findings may be seen in neuro exam for a migraine?

hemiplegia and photophobia

What is hemiplegia?

paralysis of one side of the body

Name the 12 cranial nerves:

1) olfactory

2) optic

3) oculomotor

4) trochlea

5) trigeminal

6) abducens

7) facial

8) vestibulocochlear

9) glossopharyngeal

10) vagus

11) spinal accessory

12) hypoglossal

What is monocular blindness?

loss of vision in one eye

What is the name given to a loss of vision in the outer half fields of each eye?

bitemporal heminanopia

What is the name given to a loss of vision in the right half of each eye?

right sided homonymous hemianopia

What is the name given to a loss of vision in the upper right quadrant of each eye?

upper right sided quadrantanopia

What is the name of the central semi circular loss of vision in both eyes?

central hemianoptic scotoma

How do you test the olfactory nerve?

as the patient if they have noticed any changes to their sense of smell

What are the four tests used to check the optic nerve?

1) pupillary reflexes

2) visual acuity

3) visual fields test

4) fundoscopy

What is the direct pupillary reflex test?

shining a light in one eye and checking for pupil constriction in the same eye

What is the consensual pupillary reflex test?

shining a light in one eye and checking for pupil constriction in the opposite eye

What is the visual acuity test?

using a Snellen chart to test one eye at a time

What is the visual fields test?

asking the patient to cover one eye and watch as the doctor moves their fingers into different visual quadrants - the patient is told to say 'yes' when the doctor wiggles their fingers

How is the optic disc identified in fundoscopy?

finding a large vessel and following it inwards

How are the oculomotor, trochlear and abducens nerves tested?

by completing the finger following test to check that eye movement is normal

How do you test the sensory division of the trigeminal nerve?

gently place cotton wool on different parts of the patient's skin whilst their eyes are closed and ask them to say 'ye' when they feel it

How do you test the motor division of the trigeminal nerve? (3)

1) ask the patients to clench teeth and palpate the jaw and temples

2) ask patient to move their jaw side to side

3) ask patient to open their mouth and resist the closing force inflicted by the doctor

How do you test the facial nerve?

have patient raise their eyebrows, scrunch their eyes, smile and puff out their cheeks and check their resistance when inflicting opposing forces

How do you test the vestibulocochlear nerve?

complete the hearing test by whispering a number in one ear at a time, asking the patient to repeat what they hear

How do you test the glossopharyngeal and vagus nerves?

1) ask patient to cough

2) ask patient to open their mouth and say 'ahh' checking that both sides of the palate rise equally

What two muscles does the accessory nerve innervate?

1) trapezius

2) sternocleidomastoid

How do you test the accessory nerve? (2)

1) have patient shrug their shoulders and resist downward force from the doctor

2) have patient turn their head from side to side and resist inward force from the doctor

What does the hypoglossal nerve do?

innervates the tongue

How do you test the hypoglossal nerve? (3)

1) ask patient to stick out their tongue and check for any muscle or fasciculation

2) have them move tongue from side to side

3) have them push their tongue on each side of their cheek