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288 Chapter 7: Nervous system

Table 7.1 Important causes of headache
Diagnosis Symptoms
Subarachnoid haemorrhage This is classically a sudden onset, very severe headache ‘as if kicked by a horse.’ There may
be signs of meningeal irritation (vomiting, photophobia and neck stiffness) and loss of
consciousness. The headache may subside or persist, but is typically at its worst at the
dramatic onset.
Meningitis A generalised headache classically associated with fever and neck stiffness. Vomiting and
photophobia are common. The speed of onset may be over minutes, hours or even days.
Tension type headache This is a common cause of chronic, constant headaches. Usually a throbbing, tight band or
pressure sensation around the head. Care is required to exclude temporal arteritis in
patients over the age of 50 years if a short history.
Headaches due to raised A headache that is worst on waking (due to the increased cerebral oedema from lying flat)
intracranial pressure or exacerbated by coughing, straining or sneezing (as these increase CSF pressure).
Vomiting may be present. When due to an underlying tumour, the time course may be
short, or over months to years depending on the site and any associated complications
such as haemorrhage or hydrocephalus.
Migraine Classical migraine has an aura (a prodrome of symptoms such as flashing lights) lasting up
to an hour preceding the onset of pain, frequently accompanied by nausea and
vomiting. The headache is often localised, becoming generalised and persists for several
hours.
Cervical spondylosis Pain in the suboccipital region associated with head posture and local tenderness relieved
by neck support.
Temporal arteritis Severe headache and scalp tenderness over the inflamed, palpably thickened superficial
temporal arteries with progressive loss of the pulse. They may complain of pain in the
jaw on eating or talking (jaw claudication). Patients are over 50 years and may have a
history of polymyalgia rheumatica.

Hypocalcaemia may cause a tonic-clonic seizure as- nerve), or central lesions (brain stem). In both types

sociated with paraesthesia, numbness, cramps and motion, particularly of the head, can exacerbate the sen-
tetany. sation. With a chronic lesion such as a tumour, adaptive
Hysteria may lead to non-epileptic attacks (pseudo- mechanisms reduce the sensation of dizziness over a pe-
seizures) with or without feigned loss of consciousness. riod of weeks.
The patient will drop to the ground in front of witnesses,
withoutsustaininganyinjuryandhaveafluctuatinglevel Labyrinth disorders (peripheral lesions)
of consciousness for some time with unusual seizure- Peripherallesionstendtocauseaunidirectionalhorizon-
like movements such as pelvic thrusting and forced eye tal nystagmus enhanced by asking the patient to look in
closure. There may be a history of previous psychiatric the direction of the fast phase. When the patient walks,
illness or other functional symptoms. This is a diagnosis they tend to veer to one side, but walking is generally
of exclusion and should be made with caution. preserved except in the acute stages (see Table 7.2).
Vestibular neuronitis (acute labrynthopathy) – The

most common cause of acute vertigo with nystag-
Dizziness and vertigo
mus but without tinnitus or hearing loss. The cause is
Vertigo is defined as a hallucination of movement. It not known. Symptoms last days to weeks and can be
is the sensation experienced when getting off a round- reduced with vestibular sedatives (useful only in the
about and as part of alcohol intoxication. Patients may short term), but may recur.
complain of dizziness, giddiness, nausea, vomiting and Positional vertigo – vertigo and nystagmus lasting
finding standing and walking impossible. afew seconds which is prompted by head move-
Vertigo may result from peripheral lesions (disease of ment. One type is benign paroxysmal positional ver-
the labyrinth or the vestibular component of the VIIIth tigo (BPPV) which may follow vestibular neuronitis