HEADACHE

What is it like?
Where?
How severe and how long does it lasts?
Progression


DDX

Common Acute: respiratory infection
Chronic:
o Tension-type headache
o Combination headache
o Migraine
o Transformed headache
Cervical dysfunction causing referred pain to head
Must rule Vascular: SAH, haematoma (subdural, extradural), cerebral venous sinus thrombosis,
out VIVID cerebellar infarct
Infection: meningitis, encephalitis
Vision threatening: temporal arteritis, acute glaucoma, cavernous sinus thrombosis,
pituitary apoplexy, posterior leucoencephalopathy
Intracranial pressure (raised): SOL (eg tumour, abscess, cyst), cerebral oedema (eg
trauma, altitude), hydrocephalus, malignant HTN, idiopathic intracranial HTN
Dissection: carotid dissection


Hx Taking

DDX Hx taking Ix/Tx
SOL Focal seizure, focal deficit
SAH Has it begun very suddenly and severely? Diagnosis:
Initially localized then become generalised CT scanning
Associated with neck stiffness If CT scan negative, do LP

Management:
Immediate referral for possible
surgical intervention
Review within 12-24 hours


Migraine Is it unilateral? Explanation, reassurance
Do you get any warning that is it about to Avoid trigger factors: tension,
start? Eg flashing lights or zigzag lines in fatigue, hunger, physical+mental
the vision? stress
Is it associated with sensitivity to light? Keep a diary of food/drinks that
(photophobia) trigger migraine
Consider low amine diet:
Remember POUND: eliminate chocolate, cheese, red
P: pulsatile headache wine, walnuts, tuna, spinach
O: 4-72 hours Healthy lifestyle: relaxation
U: unilateral programme, meditation
N: nausea, vomiting Non drug therapies:
D: diabling headache acupuncture, hypnotherapy


Acute attack
Lie down in quiet, dark room
Cold pack on forehead/neck
Avoid coffee, tea, orange juice
Avoid moving around too much
Avoid/less TV
If relief by sleeping, consider
temazepam 10mg or diazepam
10mg
Med: aspirin or PCM + anti
emetics: soluble aspirin 600-
900mg + metoclopramide 10mg
OR sumatriptan (serotonin
receptor agonist 50-100mg)
Increase ICP Generalised headache worse in the
morning
Do you feel drowsy or nauseated?
Temporal Is the pain on one side over the temple? Diagnosis:
arteritis (GCA) Have you had double vision? Biopsy and histological exam of
Any pain in the jaw when chewing? superficial temporal A (can be
Pain when combing the hair/pain of the normal)
scalp? ESR high or N
Any blurred vision? /visual disturbance MRI
(mononuclear blindness)
Sx of polymyalgia: shoulder stiffness, Treatment
weakness Prednisolone 40-60mg in 2
divided dose daily, 2-4 weeks
Monitor ESR and CRP
H2 receptor antagonist;
Ranitidine
Sinusitis Is the pain worst over the cheek bone? Drain sinus using steam
Pain or fullness behind the eyes, over the inhalations
cheeks or forehead A/b: amoxicillin or doxycycline
Analgesics
Refer to ENT
Cluster Are the attacks likely to occur in clusters? Acute attack
headache (occurring in bouts that lasts several weeks 100% O2 10L/min for 15mins
(M>F) a few times a year or less) Sumatriptan 20mg intranasal
Is the pain over one eye (or over the Avoid alcohol
temple) lasting for minutes to hours?
Is it associated with watering of one eye? Prophylaxis
(lacrimation) Methysergide 1mg once daily
Rhinorrhea, flushing of forehead Prednisolone 50mg/day for 10
Patient usually cannot sit still days then taper over 3 weeks
Lithium 250mg bd
Verapamil 160mg to 320mg
Pizotifen
Indomethacin
Na valproate
Tension type Episodic or chronic, commonly bilateral Counselling & CBT
headache Occurs over frontal, occipital, or temporal Relax mind and body
areas Relax in hot bath, meditation
Sensation of tightness that lasts for hours, Be less of a perfectionist
recur often Dont bottle things up, stop
No associated symptoms feeling guilty, approve yourself,
Does not wake the patient at night from express self and anger
sleep Stress reduction, relaxation
therapy, yoga, meditation classes
Massage with analgesic rub
Mild med: PCM, analgesic
Discourage stronger analgesic,
tranquilisers, antidepressants
Beware of depression
Meditation programme
Tension Is there a prolonged feeling of tightness
headache over the head but no other symptoms?
Stress?
Reduce with alcohol
Hangover Did you drink large amounts of alcohol last
night?
Cervical Headache over the occiput Physiotherapy: mobilization,
spondylosis Associated with neck stiffness manipulation, neck exercises
Supportive neck pillows
NSAIDs for cervical spondylosis
Coital During intercourse close to orgasm
headache Middle aged men
Sudden onset
Last about 15 minutes, can persist as
milder discomfort for a few hours
No nausea, no neck stiffness
 Meningitis Generalised headache associated with Ix: LP
photophobia
Fever
Neck stiffness
Gradual onset
Idiopathic IC Morning headache worse with coughing
HTN Visual loss may occur
TB/lymphoma Fever, LOW, night sweats