HEADACHE
4th year module
Introduction
• Headaches are very common – who hasn’t had one?
• We see a lot of patients with headache in the ED and the trick
is to work out those that have a benign cause for their
headache vs those who have a potentially devastating
diagnosis.
• An excellent history and thorough examination will greatly
help in differentiating these two group of patients
Headache – a framework
• Primary headache
• Recurrent and (generally)benign
• Secondary headache
• Due to an underlying disease process
• Potentially very serious/fatal
Primary headache
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Migraine
Tension headache
Cluster headache
Rebound or analgesia associated headache
Secondary headache
• Vascular
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Subarachnoid haemorrhage
AVM
Stroke
Cavernous sinus thrombosis
Carotid or vertebral artery
dissection
• Temporal arteritis
• Tumour
• Trauma
• Epidural/subdural/subarachnoid
haemorrhage
• Infection
• Meningitis
• Encephalitis
• Brain abscess
• Benign intracranial hypertension
• Ophthalmological
• Glaucoma
• Optic neuritis
• Iritis
• Toxins
• Carbon monoxide poisoning
• Metabolic
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Hypoxia
Hypercapnoea
Hypoglycaemia
Preeclampsia
• Other
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Sinusitis
Dental
TMJ dysfunction
Trigeminal neuralgia
Post LP headache
History
• A good history is essential in the diagnosis of the cause of the patient’s headache
• Onset
• Sudden vs gradual
• What were they doing when they headache started?
• Intensity/severity
• ? Worst ever
• Location
• Uni or bilateral, frontal/occipital
• Pattern
• Recurrent/previous similar headaches vs new onset
• Improving/worsening
• Worse at particular time of the day?
• Associated features
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Fever
Nausea/vomiting
Visual changes
Photophobia
Neck pain
Loss of consciousness/syncope
Focal neurological deficit
Examination
• Vital signs
• Temperature, BP
• Full and thorough neurological examination
• Cranial nerves including fundoscopy
• Limb neurology
• Gait
• Skin
• ? Rash
• Look for signs of meningism
• Neck suppleness/movement
• Kernigs: with patient flat bend thigh/knee to 90 degrees, positive if painful to
straighten knee
• Brudenskis: involuntary lifting of the legs when lifting a patient's head off the
examining couch, with the patient lying supine.
• Also should include…..
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Eye examination
ENT examination
Dental/TMJ examination
Temporal artery palpation if indicated
Investigations
• Most patients with a benign cause for their headache require
no investigations
• Further workup might include…..
• Blood tests
• Particularly looking at inflammatory markers (WCC, CRP, ESR)
• Lumbar puncture
• Neuroimaging
• CT (with or without contrast)
• MRI/MRA
Notes on a few of the
big players…..
Migraine
• May be preceded by an aura (10-20%)
• Typically visual symptoms: eg - scintillating scotoma
• More common in females, often have family hx
• Typically
• Recurrent in nature
• Same or similar onset/severity/triggers/associated symptoms
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Gradual onset
Moderate to severe intensity
Frontal, unilateral, pulsating in nature
Accompanied by photo/phonophobia, nausea/vomiting
Lasts up to 72 hours
• Sometimes may be preceded or accompanied with focal
neurological deficits
• But this is a diagnosis of exclusion!
Cluster headache
• Typically affects young men
• Intense unilateral periocular headaches that come in clusters
with complete recovery between attacks
• Eg: 30-90 mins 1-6x/day for 2 weeks
• Often associated with unilateral autonomic symptoms
• Ptosis/miosis
• Lacrimation/rhinorrhoea/nasal congestion
• Conjunctival injection
• High flow oxygen therapy is a very effective treatment
• Also sumitriptan
Subarachnoid haemorrhage
• Typically sudden onset, worst ever headache
• “thunderclap”
• Most commonly occiptonucal in location
• Can just present with sudden onset neck pain
• Can be associated with syncope, vomiting, decreased LOC, focal
neurological deficit
• ½ will present to ED with a completely normal neurological
examination
• A “sentinel bleed” (ie: leak) can completely resolve with no or very
little analgesia
• The next bleed is generally catastrophic
• Standard of diagnostic care at present is a CT head followed by a LP
at least 12h after onset of headache if this is normal (looking for
blood in the CSF/xanthochromia)
• *watch this space: there is some evidence that if the CT is performed
within 6h of onset of headache, that a normal CT may be enough to
rule out SAH
Tumours
• Around 50% of people with brain tumours will have no
headache
• May present with signs of increased ICP
• Worse in the morning
• Associated vomiting
• Can present with seizure
• May have associated neurological deficits
• Focal deficits, visual symptoms, ataxia
• Can be uni or bilateral, continuous or intermittant
• Think of this if a patient has presented with a subacute onset
of worsening headaches unlike those experienced before
Temporal arteritis
• Usually occurs in women >50 years
• Typically unilateral piercing temporal pain with tenderness
over the (often non-pulsitile) temporal artery
• May have associated claudication symptoms
• TMJ pain with chewing
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Strongly associated with polymyalgia rheumatica
Inflammatory markers (ESR/CRP) typically raised
Diagnosis is by temporal artery biopsy
Failure to diagnose and treat (with high dose steroids) can
lead to blindness (ischaemic optic neuritis)