The sinister causes can be remembered using the mnemonic VIVID: . . . Vascular: subarachnoid haemorrhage (SAH), haematoma (subdural or extradural), cerebral venous sinus thrombosis, cerebellar infarct Infection: meningitis, encephalitis Vision-threatening: temporal arteritis, acute glaucoma, cavernous sinus thrombosis, pituitary apoplexy, posterior leucoencephalopathy Intracranial pressure (raised): space-occupying lesion (SOL; e.g. tumour, abscess, cyst), cerebral oedema (e.g. trauma, altitude), hydrocephalus, malignant hypertension, idiopathic intracranial hypertension Dissection: carotid dissection . . . The approach to headache is the same as that to pain anywhere in the body: you need to start by characterizing the pain. One useful way of doing this is by following another mnemonic, SOCRATES: . . . Site of pain, and has it moved since it began? Onset of pain—was it sudden or gradual, and did something trigger it? Character of pain—throbbing, dull ache, sharp stabbing? Radiation of pain—has the pain spread? . . . Attenuating factors—does anything make the pain better (e.g. position, medications)? Timing of pain—how long has it gone on for, has it been constant or coming and going? Is it worse at a particular time of the day? Exacerbating factors—does anything make the pain worse (e.g. lying down, standing up, coughing, fatigue)? Severity—on a scale of 0 to 10, where 10 is the worst pain ever (e.g. childbirth). In addition, you should enquire about the presence or absence of the following ‘red flags’: • Decreased level of consciousness. This is a worrying feature of any medical presentation. Combined with headache, SAH needs exclusion. If there is a history of head injury, it could suggest a subdural haematoma (fluctuating consciousness) or extradural haematoma (altered consciousness following a lucid interval). Meningitis and encephalitis can also affect consciousness. • Sudden onset, worst headache ever. Suggests SAH, with blood in the cerebrospinal fluid (CSF) irritating the meninges. It can be informative to ask the patient whether they remember the exact moment when the headache started—a very severe headache of almost instantaneous onset is characteristic of SAH. Patients describe it like, for example, ‘being hit on the back of the head with a bat’.
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