Approach to headache

Primary headache syndromes most common

o Tension type headache
o Migraine
o Trigeminal autonomic cephalalgias
o Other
Secondary headache syndromes
o Head & neck trauma there is usually history of trauma, but not in most cases of
subdural haemorrhage
o Cranial or cervical vascular disorder (arterial dissection, venous sinus thrombosis)
o Mass lesion tumour, abscess
o Substance use or withdrawal (medication over-use headache)
o Disorder of homeostasis (CO2 retention, idiopathic intracranial hypertension)
o Disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or
cranial structures
o Psychiatric disorder (depression)

History taking

Site & radiation

o Where do you feel it front or back, one side or both sides?
o Band-like, occipital, bifrontal, temporal
o Is the pain on one side over the temple & have you had any blurred vision?
(temporal arteritis)
o Is the pain worse over your cheekbones? (sinusitis)
o Pain in the face can result from trigeminal neuralgia, temporomandibular arthritis,
glaucoma, cluster headache, temporal arteritis, psychiatric disease, aneurysm of the
internal carotid or posterior communication artery, or superior orbital fissure
syndrome
Onset & offset
o Thunderclap (instant & severe always consider subarachnoid haemorrhage)
o Sudden (secs-mins e.g. migraine, cluster)
o Gradual/insidious (hrs-days e.g. tension headache, cericogenic)
Character & tempo
o Dull, sharp, stabbing, throbbing, ache, squeezing, tight
o continuous, waxing & waning, escalating
Radiation (see above)
Associated factors
Do you get a warning that it is about to start e.g. flashing lights or zigzag
lines in your vision? (migraine)
Is it associated with sensitivity to light (photophobia)? (migraine)
Do you feel drowsy or nauseated? (raised ICP)
Are the attacks likely to occur in clusters & a/w watering of one eye? (cluster
headache)

Is there a prolonged feeling of tightness over the head but no other

symptoms? (tension headache)
Head: pain in the back of your head or neck? Face pain? Had a recent head
trauma?
Eyes: photophobia, blurred vision, watering or redness
Nose: runny nose, recent cold/flu
o Aura, photophobia, phonophobia, nausea
o Autonomic features (tearing, ptosis, rhinorrhoea)
o Focal neurology
o Behaviour during headache: still & quiet, agitates
o Systemic symptoms: fever, drowsiness, rash, PMR
o Meningism: neck stiffness, photophobia, agitation
Timing duration, pattern, periodicity
o Short-lasting headache (secs-mins e.g. cluster, SUNCT, paroxysmal hemicrania)
o Persistent headache (mins, hours, days, e.g. migraine, tension type headache)
o Chronic headache (days, weeks, months e.g. hemicranias continua, chronic migraine,
chronic tension-type headache)
o Periodicity: daily, weekly, monthly, years in between
o Time/s of day
Exacerbating & relieving factors
o Lying down in dark room
o Posture (better or worse lying down?)
Severity
o Disabling, interfering with functioning, days off work
Previous headaches similar or different to current headache?
Family history migraine, SAH
Current medications & medications tried consider medication-overuse headache
Social history depression, stress, smoking history, alcohol (esp recent hangover)
What the patient thinks or is worried about

Red flags

Unless part of typical migraine aura or autonomic features other neurological symptoms &
signs should suggest a secondary cause
Systemic features weight loss, fever, etc.
Reduced conscious state
Clear, reproducible, postural symptoms
Any headache with thunderclap onset needs to rule out SAH with CT +/- LP
Giant cell arteritis needs to be considered in any older patient with new onset headache
Severe & debilitating pain
Fever, vomiting
Worse with bending or coughing, morning
Young obese female on meds (IIH)

Physical examination (mainly looking for secondary causes)

Observe behaviour if having headache mental state exam to look for altered
consciousness, cognition, mood
Focal neurology
o Limb & cranial exams
o Autonomic features
o Conscious state
Always fundoscopy for papilloedema
Systemic exams depend on history basic observations, rash, fever, etc.
Vitals esp blood pressure

Investigations

FBC + CRP for infection

Lumbar puncture meningitis
Imaging if suspicious CT more effective for tumour & may help for stroke & SAH; MRI very
effective for intracerebral pathology but expensive & not as sensitive for bleeding; X-ray for
some indications

Migraine

Is common & in 10-20% population

headache plus syndrome
o Prodrome in 10% of migraine patients usually 1-2 hours before the headache there
is mood/behavioural change, yawning, hunger, cravings, fatigue
o Aura affects 30%; typically precedes the headache but may occur with headache or
following the headache & usually subsides in <60 mins
Typically visual but almost any neurological symptom can occur but are fully
reversible
+ve symptoms: flickering lights, flashes, tingling in limbs
-ve symptoms: hemianopia, numbness
The nature of aura may change over time
Visual: scintillating scotoma, pallanopsia, metamorphopsia
o Nausea & vomiting
o Phonophobia (sensitivity to sound)
o Photophobia (sensitivity to light)
Patient typically describes as severe, throbbing & UNILATERAL
Classical migraine with an aura: unilateral headache preceded by flashing lights or zigzag
lines a/w light hurting the eyes (photophobia)
Classical migraine with aura dx: headache + vomiting + visual aura
Typically lasts <24 hours but can continue for days
Often improves with vomiting &/or sleep & medication
Common migraine has no aura

Aura can occur without headache must then be differentiated from seizure &
cerebral ischaemia; focal seizures last secs-mins; TIAs/strokes do not evolve &
typically cause ve symptoms rather than +ve symptoms
Median frequency is 1.5 attacks per month but can be more frequent
Some people have clear triggers: hunger, sleep deprivation, stress (most common) come
down
Hormonal triggers in women, menstruation, exogenous oestrogen most improves with
pregnancy but can paradoxically worsen; character of migraine can change after menopause

Trigeminal autonomic cephalalgias (TAC)

Involve activation of the trigeminal parasympathetic system

Characterized by short lasting headaches with variable autonomic involvement
Cluster headache is the most common TAC others are rare
o Presentation: male, 20-50yo, smoker, patient look agitated
o VERY severe unilateral pain usually centered around the orbit that peak rapidly
within mins & lasts 30-180 mins with often abrupt offset
o Pain over one eye or temple lasting mins-hours a/w lacrimation, rhinorrhoea &
flushing of the forehead & occurring in bouts lasting several weeks a few times a
year or less suggests cluster headache
o Ipsilateral autonomic features conjunctival injection, tearing (lacrimation), miosis,
ptosis, nasal stuffiness
o No visual disturbances or vomiting
o Recurrent attacks (cluster) at least once every 24 hours that typically wakes patient
from sleep
o Cluster last weeks-months with months-years remission, can have chronic variant
Other TAC:
o Paroxysmal hemicranias see slides
o Short-lasting unilateral neuralgiform headache with conjunctival injection and
tearing (SUNCT) see slides

Tension type headache

Episodic or chronic; most common

Muscle contraction
Vague clinical picture dull, non-throbbing ache, tightness, pressure, belt/band like or
vice-like co-morbidity common
Commonly bilateral, occurs over frontal, occipital or temporal areas, and may be described
as a sensation of tightness lasting hours & recurs often (commonly daily)
Usually no associated symptoms i.e. nausea, vomiting, weakness or paraesthesiae (tingling
in the limbs), and the headache usually doesnt wake the patient at night from sleep
May respond to simple analgesics (aspirin, Panadol) & alcohol
Management: patient education & reassurance, counselling for relaxation, massage, address
stress

Important secondary headaches

Raised ICP headaches

o (brain, dura & CSF are in a fixed space so increasing volume in this space can present
as a high pressure headache)
o Characteristically worse when lying down or with Valsalva
o Also typically generalused headache worse in the morning a/w drowsiness or
vomiting
o May have: transient episodes of visual loss; pulse synchronous tinnitus; diplopia due
to CN VI paresis; other focal signs depending on aetiology; depressed conscious
state; persistent nausea/vomiting (in migraine, this clears)
o Causes include:
Mass lesion: tumour, abscess
Cerebral venous sinus thrombosis
Needs to be considered in any young-middle-aged patient with
recent persistent headache +/- subtle focal neurology +/- focal or
generalized seizures
Risk factors for prothrombotic state: smoker, OCP, inherited clotting
disorder, cancer
Papilloedema may be the only sign
Diagnosis with CT/MR venogram
Idiopathic intracranial hypertension (IIH)/benign intracranial
hypertension/pseudotumour cerebri
Elevated CSF pressure without ventriculomegaly
Aetiology unclear (idiopathic) but strongest association with obesity
typically women of childbearing years
Primary presenting symptoms is usually chronic headache (weeksmonths) with symptoms & signs of raised pressure in an alert
patient without localizing neurological findings
Can develop more rapidly
Examination finds papilloedema
Diagnosis with imaging to exclude structural abnormality then
lumbar puncture to measure the opening pressure of SF
Can result in permanent visual loss if untreated
Headache a/w stroke
Ischaemic stroke usually in strokes involving posterior fossa &/or
patients with prior headache history e.g. migraine; pain often felt
over occipital region with radiation to ipsilateral orbit
Haemorrhagic stroke different to SAH, associated headache more
common than in ischaemic stroke
Subarachnoid haemorrhage thunderclap onset often impaired
conscious state, meningism; diagnosed with CT +/- LP for
blood/blood products; initially localised but becomes generalized &
a/w neck stiffness
o History
Ask if has a postural component

Examination
Important to look for papilloedema
Low pressure headache
o Improves significantly with lying down & worsens in upright position when pressure
is lowered due to gravity (contrast to high pressure headache)
o dragging drawing headache, variable location
o Over time the postural symptoms may lessen therefore important to ask about
these at onset of the headache
o May only notice headache towards the end of the day after a long period upright
o Other symptoms: dizziness, change in hearing, cranial nerve palsies,
encephalopathy, ataxia, Parkinsonism
o Cause: post lumbar puncture headache/SF leaks
Most common LP complication caused by persistent leak of CSF from LP site
Diagnosis usually straight forward with onset of typical headache low
pressure features after a LP so no investigation usually needed
Often resolve on their own or may require treatment with bed rest, fluids,
analgesia +/- blood patch
o Other causes include trauma
Medication overuse headache/rebound headache
o Very common in patients with other headache syndromes
o Meds that may cause headache: codeine, opiates, triptans
o Stopping the acute medication results in withdrawal symptoms & a period of
increased headache
Cervicogenic headache
o Often felt over occipital region but also frontally
o Neck pain
o Examination finds neck movements stiff with reduction in movement
o Treatment include massage, physiotherapy
o MSK disorders of the neck can exacerbate other headache disorders esp migraine &
tension headache
Meningitis & encephalitis
o Generalised headache a/w photophobia & fever & neck stiffness of more gradual
onset suggestive of meningitis
Occipital neuralgia
o Intermittent lacinating pain in the distribution of the greater occipital nerve
o May be a dull background ache radiating to the fronto-orbital area
o Diagnosis by pressure over GON causing reproducible pain
Other to consider:
o Temporal arteritis consider in older patients with new onset headache (headache
tends to decrease with age); this is typically a persistent unilateral headache over
the temporal area a/w tenderness over the temporal artery & blurring of vision; also
a/w jaw claudication, jaw pain during eating, and LOW

Headache in GP setting

Probability diagnosis:
o Acute: respiratory infection
o Chronic: tension-type headache, combination headache, migraine, transformed
migraine
Red flags:
o Cardiovascular: haemorrhage (SAH, intracranial haemorrhage), carotid or vertebral
artery dissection, temporal arteritis, cerebral venous thrombosis
o Neoplasia: cerebral tumour, pituitary tumour
o Severe infections: meningitis, encephalitis, intracranial abscess
o Haematoma: extradural/subdural
o Glaucoma
o Idiopathic intracranial hypertension
Pitfalls/often missed: many
7 masquerades: depression & drugs more likely the other 5