Curriculum standards

Knowledge guides

LG16: Pain, including headaches and facial pain

Key presentations and conditions

Advanced Trainees will have a comprehensive depth of knowledge of these presentations and conditions.

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Less common or more complex presentations and conditions

Advanced Trainees will understand these presentations and conditions.

Advanced Trainees will understand the resources that should be used to help manage patients with these presentations and conditions.

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Epidemiology, pathophysiology, and clinical sciences

Advanced Trainees will have a comprehensive depth of knowledge of the principles of the foundational sciences.

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Investigations, procedures, and clinical assessment tools

Advanced Trainees will know the scientific foundation of each investigation and procedure, including relevant anatomy and physiology. They will be able to interpret the reported results of each investigation or procedure.

Advanced Trainees will know how to explain the investigation or procedure to patients, families, and carers, and be able to explain procedural risk and obtain informed consent where applicable.

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Important specific issues

Advanced Trainees will identify important specialty-specific issues and the impact of these on diagnosis and management and integrate these into care.

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Presentations – emergency

Acute pain
Bladder / Bowel dysfunction
Sudden onset new severe headache
Sudden onset weakness / sensory disturbance

Presentations – headache

Asthenia / Fatigue
Dysesthesia / Numbness
Neuropathic pain
Pain / Stiffness, chronic
Weakness

Conditions – acute

Central causes, such as:
- demyelination
- stroke, including:
  - cerebral venous thrombosis
  - intracerebral haemorrhagic
  - ischaemic
Peripheral nerves, such as:
- Guillain–Barré syndrome
- inflammatory plexopathies
Primary headache disorders, such as:
- cluster headache
- glossopharyngeal neuralgia
- trigeminal autonomic cephalgias
- trigeminal neuralgia

Conditions – chronic

Conversion disorder / Functional neurological disorder
Peripheral nerves:
- entrapment neuropathies
- peripheral neuropathies:
  - acquired
  - inherited
- radiculopathies
Primary headache disorders, such as:
- migraine
- tension-type headache
- trigeminal autonomic cephalgias
Secondary headache disorders, such as:
- benign sex headache
- cervical arterial dissection
- cervicogenic headaches
- giant cell arteritis
- idiopathic intracranial hypertension
- low pressure headaches
- medication overuse headache
- myofascial pain syndrome
- reversible vasoconstriction syndrome
- space-occupying lesions
- temporomandibular joint disorders
- tumour

Conditions – emergency

Central / Peripheral:
- giant cell arteritis
- meningoencephalitis
- subarachnoid haemorrhage
- traumatic brain injury, including:
  - concussion
Spinal cord:
- demyelinating conditions, including:
  - multiple sclerosis
  - neuromyelitis optica spectrum disorder (NMOSD)
- extrinsic compression
- ischaemia, including:
  - stroke

For each presentation and condition, Advanced Trainees will know how to:

Synthesise

recognise the clinical presentation
identify relevant epidemiology, prevalence, pathophysiology, and clinical science
take a comprehensive clinical history
conduct an appropriate examination
establish a differential diagnosis
plan and arrange appropriate investigations
consider the impact of illness and disease on patients and their quality of life when developing a management plan

Manage

provide evidence-based management
prescribe therapies tailored to patients’ needs and conditions
recognise potential complications of disease and its management, and initiate preventative strategies
involve multidisciplinary teams

Consider other factors

identify individual and social factors and the impact of these on diagnosis and management

Conditions

Vasculitis / cerebrovascular inflammatory conditions

For each presentation and condition, Advanced Trainees will know how to:

Synthesise

recognise the clinical presentation
identify relevant epidemiology, prevalence, pathophysiology, and clinical science
take a comprehensive clinical history
conduct an appropriate examination
establish a differential diagnosis
plan and arrange appropriate investigations
consider the impact of illness and disease on patients and their quality of life when developing a management plan

Manage

provide evidence-based management
prescribe therapies tailored to patients’ needs and conditions
recognise potential complications of disease and its management, and initiate preventative strategies
involve multidisciplinary teams

Consider other factors

identify individual and social factors and the impact of these on diagnosis and management

Common, rare, primary, and secondary diseases that result in headache, pain, and sensory disturbance
Neuroanatomy, neuropharmacology, and neurophysiology involved in the generation of headache and facial pain
Neuroanatomy, neuropharmacology, and neurophysiology of the pain pathway, peripheral nerves, and sensory pathways

Cerebrospinal fluid (CSF) procedures and investigations

Lumbar puncture (LP) and interpretation of investigation results, such as:
- basic CSF analysis:
  - cell count
  - cytology
  - glucose level
  - immunological tests
  - microbiological tests
  - protein level
  - xanthochromia
- opening pressure
- special tests:
  - oligoclonal bands
  - spectrophotometry

Clinical neurophysiology investigations

Electromyography (EMG):
- evoked potentials:
  - brainstem
  - somatosensory
  - visual
- needle EMG
Nerve conduction studies (NCS):
- motor and sensory studies

Neurogenetic investigations

Genetic testing, including, but not limited to:
- chromosomal testing, such as:
  - karyotype
  - microarray
- genomic testing, including whole exome or genome sequencing
- mitochondrial genome sequencing
- targeted panel testing
Referral to a neurogeneticist

Neuroimaging investigations

CT, including:
- CT angiography
- perfusion
- venography
MRI, including:
- functional (fMRI)
- magnetic resonance:
  - angiography (MRA)
  - spectroscopy (MRS)
  - venogram (MRV)
- with contrast
Myelography
Vascular imaging:
- catheter angiography
- neuroimmunology investigations

Neuroimmunology investigations

Autoantibody measurement:
- anti-aquaporin 4 and myelin oligodendrocyte antibodies
- paraneoplastic antibodies
Referral to a neuroimmunologist

Neuropathology investigations

Biopsy:
- brain
- muscle
- nerve
- temporal artery

Neuropsychological investigations

Cognitive screening:
- Mini-Mental State Examination
- Montreal Cognitive Assessment
- Rowland Universal Dementia Assessment Scale
Referral to a neuropsychologist

Other investigations

Polysomnography
Serum investigations:
- autoimmune screen
- blood glucose
- electrolytes
- full blood count
- infective serology
- inflammatory markers
- thrombophilia screen
- toxic / metabolic screen, including heavy metals, and mineral or vitamin deficiency

Importance of early diagnosis and treatment of acute conditions, such as:
- giant cell arteritis
- meningitis
- subarachnoid haemorrhage
Knowledge and treatment strategies for psychosocial effects and drivers of pain
Management strategies for the common types of headaches, such as:
- acute
- non-pharmaceutical interventions
- preventative
- rational use of medications
Overlap with other allied health and medical specialties, such as pain services, physiotherapy, and rehabilitation medicine, and when it is appropriate to refer
Overlap with other medical conditions, such as depression / anxiety and sleep apnoea
Prognosis and economic and lifestyle implications of these disorders