RED FLAGS IN HEADACHE;
A HEADACHE FOR THE MAU
DOCTOR
FAYYAZ AHMED
CONSULTANT NEUROLOGIST
HULL & EAST YORKSHIRE HOSPITALS
NHS TRUST
Objectives

Recognising red flags in Headache

Clinical Features of Serious Headache
Disorders

Investigation plan and further referral
HEADACHES
One of the commonest symptom
 Account for 30% GP and 50% Neurology
Referrals
 95% of the population at some stage
experience headaches
 15-19% of Acute Medical Admissions ,
55% of Neurology in A & E

(1)
(2)
1. Weatherall M., J RCP Edinb 2006; 36: 196-200
2. Craig J., Patterson V., Roche L., JamisonJ., Accident and Emergency Neurology: time for a
reappraisal? Health Trends, 1997, 29, 89-91
DILEMMA IN MAU/A&E
DILEMMA IN MAU/AE
AM I DEALING WITH A SERIOUS
HEADACHE ?
 DO I URGENTLY INVESTIGATE OR ASK
FOR HELP NOW OR AS AN OP ?
 WHO DO I ASK FOR HELP; NEUROLOGIST
OR NEUROSURGEON?
 AM I OK TO SEND THIS PATIENT HOME?

SERIOUS HEADACHES
Subarachnoid Haemorrhage
Brain Tumours or Space Occupying Lesion
(SOL)
Infections like Meningitis, Encephalitis
Temporal arteritis
RECOGNISE SERIOUS HEADACHES
RED FLAG HEADACHES
Hyperacute onset no previous history
Gradually progressive no previous history
Presence of any neurological signs
Headaches above the age of 60
Change in characteristics or pattern
NON URGENT HEADACHES
Round the Clock for > 3 months
 No Neurological Signs
 Acute Exacerbations of Known Migraines
 Episodic Headaches > 6 months with clear
headache free intervals

Thunderclap Headache (TCH)


Peaks within a minute
Primary and Secondary (Clinically cannot differentiate)1






Primary TCH – Diagnosis of exclusion
SAH – CT/LP earlier or CTA later
Arterial Dissection – Focal Neurological signs
Pituitary Apoplexy – CT/MRI abnormal
Venous Sinus Thrombosis – Raised CSF, CTV
Spontaneous Intracranial Hypotension –Typical history
1. Linn et al JNNP 1998:65; 791-3
SAH







11 per 100,000
85% Saccular Aneurysm, 10% perimensephalic 5% AVM
Peaks within a minute and last at least an hour
Worst Ever
May be associated with LOC
NV Photo/phonophobia
Neck Rigidity, Kernig’s sign
SAH

CT scan Sensitivity1





97%
85%
76%
58%
within 12 hours
after 24 hours
after 48 hours
after 5 days
LP Xanthocromia
100% 12 hrs – 2 weeks
 70% week 3
 40% week 4

1. Van der Wee et al JNNP 1995
SAH – MISDIAGNOSIS


1.
2.
Reasons1
 The diagnosis was not considered
 Failure to understand limitations of CT
 Failure to properly perform / analyse CSF
 Wrong investigation – MRI/MRA
1 in 20 SAH patients are missed in A & E2
NEGM 2000, 342; 29-36
Stroke 2007, 38; 1216
SAH - MISDIAGNOSIS
Instantaneous headaches only in 50%
 1 in 6 SAH may present with a fit
 1-2% present with acute confusion
 LP is traumatic
 Focusing on hypertension and arrhythmia

RECENT AND PROGRESSIVE HEADACHES
weeks to < 3/12

EXCLUDE
 SOL
 Cerebral
Venous Sinus Thrombosis
 Idiopathic Intracranial Hypertension
 > 55 Consider Temporal Arteritis

NEW DAILY PERSISTENT HEADACHES
 Diagnosis
of exclusion
 Daily unremitting from onset
 Migrainous or TTH
SYMPTOMS of Raised ICP





Headaches worse on straining and Early Morning
Nausea and Vomiting
Drowsiness
Visual Symptoms
Seizures
SIGNS of Raised ICP






Impairment in Conscious Level (GCS<15)
Papilloedema
Hypertension
Bradycardia
False localising signs such as VI N palsy
Focal Neurological Signs
CT
Meningioma
G.B.M
Cerebral
Metastasis
Cerebral Venous Thrombosis

Female, Smoker, OCP, Postpartum

Dehydration, Hyperviscosity

Drowsy, Seizures, Focal Signs
Cerebral Venous Thrombosis

Clinical Suspicion

CT Venogram/MRA

Anticoagulation
Benign Intracranial Hypertension

Female, Overweight, Smoker, OCP

Visual Symptoms

Papilloedema
Benign Intracranial Hypertension

Clinical Suspicion

CT/MRI MRA

Lumbar Puncture

Acetazolamide/Topiramate/Diuretic
TEMPORAL ARTERITIS; Features
Uncommon below the age of 55
 Women twice as much as Men

Common in British / Scandinavian
 Fairly Uncommon in Asian/Africans

Bengtsson B-A, Malmvall BE. Giant Cell Arteritis, Acta Med Scand, 1982;658:1-102
TEMPORAL ARTERITIS; Symptoms
Recent onset on uni or bilateral temporal
Headaches
 Cutaneous Allodynia
 Jaw Claudication

Systemic Symptoms
 Pain and aching in Shoulder/Pelvic girdle
muscles

TEMPORAL ARTERITIS; Diagnosis

Clinical Suspicion

ESR/PV and CRP Normal < 1%

Temporal Artery Biopsy – Controversial

Steroids
Hayreh SS, Podhajsky PA, Raman RI. Giant Cell Arteritis; Validity and Reliability of various diagnostic criteria.
Am j Ophthalmol 1997;123:285-296.
FEBRILE HEADACHES; DAYS

Meningitis – Viral, Bacterial

Encephalitis
ENCEPHALITIS: Symptoms/Signs
Headaches and altered conscious level
 Seizures
 Focal Signs

ENCEPHALITIS: Diagnosis

CT/MRI (Diffuse or Focal Oedema)

EEG (Slow waves over affected area)
CSF (Lymphocytes)
PCR positive for HSV-1,VZV
 Acyclovir

Headache that Needs Urgent Imaging
BASH guidelines





Clinical signs present
Pronounced signs of raised intracranial pressure
Change in cognitive functional personality
Relevant systemic disease
Worst headache ever particularly if crescendo is
reached in minutes or rapidly deteriorating
SUMMARY

Serious Causes are Uncommon

SAH, Meningitis, Encephalitis SOL and TA are the
main serious headaches

Refer to Neurosurgeon (SAH) or Neurologists
when in doubt
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Contact Debbie.Buttle@hey.nhs.uk