Easy reference
Common conditions
- Head injury
- Spinal cord injury
- Disc prolapse
- Peripheral nerve trauma Conditions affecting the peripheral nerves
- herpes zoster
- Cauda equina syndrome
- peripheral neuropathy
- carpal tunnel syndrome
- cubital tunnel syndrome
- Guillian-Barre syndrome Condition effecting cranial nerves
- bells palsy
- trigeminal neuralgia
- herpes zoster Condition causing seizure
- Epilepsy condition due to vascular disease
- cerebrovascular disease
- stroke
- subarachnoid haemorrhage
- TIA
- Amaurosis fugax Conditions causing vertigo
- Benign paroxysmal positional vertigo
- Menieres syndrome Conditions causing a primary headache
- Migraine
- tension headache
- medication overuse headache Conditions causing a secondary headache
- intracranial tumour
- meningitis
- encephalitis Non-neurological symptoms which can also cause headache
- sinusitis
- temporal arteritis Conditions causing hearing loss
- sensorineural hearing loss
- Conductive hearing loss Conditions causing visual loss
- optic neuritis Other significant neurological conditions
- Multiple sclerosis
- benign essential tremor
- Parkinsons disease
- Motor neurone disease
- Alzheimers disease
Associated symptoms
-
Headache
-
Facial pain
-
Neck pain
-
Back pain
-
Change in level of consciousness
-
Syncope
-
Seizure / Fit
-
Weakness
-
Gait
-
Dizziness
-
Vertigo
-
Nausea and vomiting
-
Balance
-
Disturbed perception
- Sensory changes (Sensory loss and paraesthesiae)
- Vision
- Hearing Loss/impairment/disturbance
- Altered sense of smell and taste
-
Speech disorder
-
Language disorder
-
Voice disorders
-
Dysphagia
-
Involuntary movements
-
Disturbance of sphincter control (bladder, bowel)
- Disturbance of bladder control
- Disturbance of bowel control
-
Altered cognition
Even deeper
Headache
Headaches are common and affect up to 80% of the population at some time. They can be acute, subacute, and chronic. Acute headaches are usually severe and result in emergency department attendance. Sub-acute and chronic headaches are more commonly seen in primary care.
The table below is a useful summary. It includes significant and common causes of headache and is not exhaustive.
| Type of headache | Length of time present | Example |
|---|---|---|
| Acute headache | Seconds to minutes | - Subarachnoid haemorrhage - Migraine |
| Sub-acute headache | Hours to days | - Meningitis - Tension headache |
| Sub-acute headache | Days to weeks | - Increased intracranial pressure - Intracranial mass lesion - Temporal arteritis - Sinusitis |
| Chronic headache | Episodic over months to years (more than 15 headaches a month) | - Medication overuse headache - Chronic tension headache - Recurrent migraine |
Headache can be divided into two types, either a primary headache disorder or a secondary headache disorder. A primary headache is when the pain in the patient’s head is the condition and a secondary headache is a when the pain in the patient’s head is a symptom caused by an underlying disease process.
Primary headache disorders include:
- Migraine
- Tension headache
Secondary headache disorders due to underlying pathology include:
- Raised intracranial pressure
- Space occupying lesion
- Tumour
- Intracranial bleed
- Space occupying lesion
- Infection
- Meningitis
- Encephalitis
- Sinusitis
Headache due to raised intracranial pressure or bacterial meningitis must not be misdiagnosed.
Headache due to raised intracranial pressure is typically:
- present on waking
- worse with:
- straining
- coughing
- sneezing
- bending over
- associated with vomiting
Headache caused by bacterial meningitis is associated with:
- generalised headache
- fever
- neck stiffness
- photophobia/light sensitivity
- vomiting
- intense malaise/unwellness
Facial
This symptom is often linked with headache in medical textbooks. This may be because the face is seen as part of the “head”. Facial pain can be caused by conditions such as trigeminal neuralgia, temporal arteritis, or sinusitis.
Back pain
Back pain, especially low back pain, is a common symptom. In any year one third of adults will have low back pain.
If the back pain radiates to the leg and the leg pain is greater than the back pain it is likely to be due to lumbar radicular pain. This may be caused by:
- Disc prolapse
- Cauda equina syndrome (a neurosurgical emergency presenting with sphincter disturbance causing urinary retention and faecal overflow incontinence, gait disturbance, and reduced sensation in the “saddle” area – perineum and buttocks)
Change in level of consciousness
It will be especially important to get a detailed description of what happened to help you determine the cause.
You will need to find out:
- What exactly happened (in the patient’s words or in the words of a witness)
- Precipitant - What preceded the loss of consciousness
- Duration - How long it lasted
- Recovery - the nature of the recovery
- Associated symptoms - what other symptoms were associated with what happened
Common causes are:
- Syncope
- Seizure
Syncope
Syncope is the medical term for “fainting”. It can be described by the patient as a collapse or a blackout. It is the transient loss of consciousness resulting from cerebral anoxia.
A subarachnoid haemorrhage may cause syncope.
If the patient was aware of palpitations preceding the event it may have been due to a cardiac arrhythmia.
If the patient had a trigger such as pain, illness, or emotion it may have been due to vasovagal syncope.
If the patient had recently changed position from sitting to standing it could be due to postural hypotension.
Seizure / Fit
A seizure (or fit) is sudden transient neurological event due to paroxysmal discharge of cerebral neurons. It can cause convulsions (quick repetitive contraction and relaxation of muscles that causes uncontrolled shaking), sensory disturbances, or loss of consciousness.
There are two main types of seizure:
- Generalised
- Focal (also known as partial)
Generalised seizures If the whole brain is affected the seizure will be generalised. Tonic-clonic seizures are the most common type of generalised seizure.
A tonic-clonic seizure:
- may be preceded by an aura (a type of focal seizure – see below)
- starts with tonic phase - abrupt loss of consciousness with body stiffening
- is followed by the clonic phase - rhythmical jerking
- may be associated with urinary and/or faecal incontinence
- may be associated with tongue biting
Focal seizures If only part of the brain is affected the seizure will be focal. Focal seizures may or may not cause loss of consciousness.
Focal seizures are characterized by whether there is:
- Aura
- Patient may notice a particular taste or smell
- Patient may have déjà vu – the sense that something has happened before
- Patient may hear music
- Patient may feel very fearful
- Patient may have nausea or abdominal pain.
- Motor features such as one limb jerking
- Transient loss of awareness or responsiveness
Weakness
Weakness or loss of muscle strength is an important symptom of neurological disease.
There are two types of weakness defined by where in the nervous system the lesion occurs.
These are:
- upper motor neurone (UMN) lesions
- lower motor neurone (LMN) lesions
Upper motor neurone weakness
Upper motor neurone (UMN) weakness occurs when the lesion is in the brain or spinal cord above the level of the anterior horn cell (motor pathways in the cerebral cortex, internal capsule, cerebral peduncles, brainstem, or spinal cord).
The part of the body with weakness is determined by where the lesion is.
Lower motor neurone weakness
Lower motor neurone weakness occurs when the lesion interrupts the spinal reflex arc.
Conditions associated with weakness due to lower motor neurone lesions include:
- Motor neurone disease
- Peripheral nerve laceration
- Guillain Barre Syndrome
| Type of weakness | Site of weakness | Possible cause |
| Hemiparesis/hemiplegia | One side of the body (may involve both arm and leg) | Contralateral motor cortex pathway lesion |
| Paraparesis/paraplegia | Both legs | Lower spinal cord lesion (L1 or below) |
| Quadriparesis/quadriplegia | All four limbs | High cervical spinal cord lesion (C3 or above) Brainstem lesion |
| Monoparesis/monoplegia | Only one limb | Motor cortex or partial internal capsule lesion |
Gait
Gait disorder can be due to:
- weakness of the legs
- ataxia –where there is a tendency to fall to one or other side, with or without incoordination in the limbs - usually due to disease of the cerebellum and includes the effect of large amounts of alcohol
- loss of proprioception (position sense), in which case there may be a positive
- Romberg’s sign: worsening of balance when the eyes are closed.
- Parkinson’s disease with typical features that may include:
- moving more slowly than expected for age
- festinating (from the Latin verb festinare “to hurry”), when strides become
- icker and shorter than normal, making it appear that the patient is hurrying
- taking jerky steps
- moving arms less when walking
- falling frequently
- freezing of gait
Dizziness
This is a vague term that is often used by patients. You will need to ask what the patient means by dizziness and explore this symptom.
Do they mean that they feel:
- weak? (weakness)
- about to faint? (pre-syncope)
- light-headed? (pre-syncope)
- unsteady? (poor balance)
- they are moving when they are still? (vertigo)
- the world is moving around them? (vertigo)
Vertigo
Vertigo is a perceived sense of motion when there is no movement made by the patient or movement in their surroundings. The patient may say they feel they are “moving when they are still” or they may say that “the world is moving around them”.
Vertigo is commonly due to a problem with the vestibular apparatus in the inner ear (peripheral cause), and less commonly due to a problem in the brain (central cause).
It may be associated with an inability to stand and walk, nausea, vomiting, pallor, sweating, headache, or alteration of hearing depending on the cause.
Nausea and vomiting
Any condition that causes raised intracranial pressure such as a space occupying lesion, infarct, or infection can result in vomiting with or without nausea.
Patients with central nervous system pathology who have nausea and vomiting usually present with additional neurologic signs such as cranial nerve dysfunction or long-tract signs.
Conditions that affect the inner ear may cause nausea and vomiting and are often associated with vertigo.
Migraine headaches classically cause nausea and vomiting.
Patients may also experience symptoms of nausea and vomiting in response to emotional or physical stressors.
Balance
Balance is the state of being steady without falling. Balance disturbance may be due to:
- Weakness
- Vertigo You will need to take a careful history to determine the cause. If loss of balance is associated with vertigo, then the vestibular system and its connections are probably involved