Headache

 

• Headache history

  Key features

  • SOCRATES
  • Red flags.
  • Past history of headaches and responses (treatment, psychosocial effects).
  • Risk factors.

  Headache SOCRATES

  Site:

  • Bilateral: tension headache.
  • Unilateral: migraine, temporal arteritis (TA).
  • Occipital: sub-arachnoid haemorrhage (SAH).

  Onset:

  • Sudden: SAH.
  • Progressive: TA.
  • After prodrome or aura: migraine.
  • After triggers. Sleep, ↓H2O, or eyestrain for tension headache. Alcohol, exercise, or certain foods for migraine. Stress for either.

  Character:

  • Throbbing: migraine, TA.
  • Pressure: tension headache.

  Radiation:

  • Jaw claudication and scalp tenderness: TA.

  Associated symptoms:

  • Nausea and vomiting: migraine, meningitis, SAH.
  • Fever: meningitis, TA.
  • Stiff neck: meningitis, SAH, migraine.
  • Drowsy: subdural haematoma, SAH.
  • Unusual sensations or autonomic signs: migraine.
  • Morning joint stiffness: TA.
  • Visual symptoms: TA, ↑ICP, migraine.

  Time course:

  • Tension headache can have almost any time course.
  • 4-72 hours for migraine.

  Exacerbating factors:

  • Light, sound, and movement: migraine.
  • Coughing, bending, straining: ↑ICP.

  Severity:

  • Rate out of 10.

  Red flags

  • Thunderclap: sudden onset headache which peaks in seconds to minutes.
  • 1st or worst headache of life.
  • Short progressive time course, especially if new in an old or cancer patient.
  • Signs of cauda equina, ↑ICP, systemic illness, or focal neurological deficits.

  Risk factors

  • HTN → SAH.
  • Family history → SAH, migraine.
  • Patent foramen ovale → migraine.
  • Combined contraceptive pill → migraine.

• Tension headache

  Causes

  • Stress
  • Lack of sleep.
  • Dehydration
  • Eyestrain is traditionally thought to be a cause, though the evidence for this is weak.

  Presentation

  Headache which is bilateral, episodic or continuous, and has a 'pressure' quality.

  Management

  • Simple analgesia: NSAIDs are preferable to opiates, as the latter may cause medication overuse headache.
  • Stress relief.

• DDx: Single acute headaches

  Thunderclap: peaks in second to minutes. The important causes are vascular:

  • Sub-arachnoid haemorrhage (SAH) or its sentinel headache.
  • Intracranial venous thrombosis, especially cortical vein thrombosis. Mimics SAH but without meningism.
  • Carotid or vertebral artery dissection.
  • Reversible cerebral vasoconstriction syndromes.
  • Pituitary apoplexy.
  • Non-vascular: primary cough headache, coital cephalgia, exercise-induced headache, cluster headache.

  With fever:

  • Meningitis
  • Encephalitis
  • Abscess or empyema. Focal signs.

  Post-trauma with drowsiness:

  • Acute subdural haematoma.
  • Extradural haemorrhage. Interspersed with lucid periods.

  Important headaches not to miss, SHIT ME:

  • SAH
  • ↑ICP
  • Temporal arteritis.
  • Meningitis
  • Eyes: acute glaucoma and other site-threatening conditions such as anterior uveitis, optic neuritis.

• DDx: Progressive subacute headaches

  • ↑ICP
  • Temporal arteritis: consider for any new headache in patients aged >50.
  • Chronic subdural haematoma.
  • Thyroid eye disease: retro-orbital pain, worse with eye movement.

• Episodic acute headaches

  Causes:

  • Migraine
  • Trigeminal neuralgia.
  • Trigeminal autonomic cephalgias: cluster headache, paroxysmal hemicrania, SUNCT.

  Trigeminal neuralgia

  • Severe shooting pain that lasts for seconds.
  • May have CN51, CN52, or CN53 distribution.
  • Triggered by wind, cold, or touch.
  • Epidemiology: commonest in men aged >50.
  • Management: carbamazepine or microvascular decompression.

  Trigeminal autonomic cephalgias

  Cluster headaches

  Clinical features:

  • 1-3 month clusters of daily headaches, interspersed with long remissions.
  • Usually 1-2 per day (but can be more) and lasting between 15 minutes to 2 hours.
  • Unilateral ('side-locked'), affecting the orbit or temple.
  • ANS symptoms: lacrimation, rhinorrhea, ptosis, pupillary changes, red ear.
  • Alcohol can be a trigger.

  Management:

  • Acute: subcut sumatriptan and 100% O2.
  • Prophylaxis: verapamil or prednisolone.

  Paroxysmal hemicrania

  • 2-20 minutes, 5-20/day.
  • Unilateral headache with ANS symptoms.
  • Responds to indomethacin.

  SUNCT

  • Short-lasting Unilateral Neuralgiform headaches with Conjunctival injection and Tearing.
  • 15-60 seconds, 3-200/day.
  • Other features: forehead sweating, rhinorrhea.
  • Management: NSAIDs, antiepileptics.

• Chronic daily headaches

  Definition

  ≥15 headache days per month.

  Causes

  Chronic tension headache.

  Chronic migraine:

  • ≥15 headache days per month, of which ≥8 are migrainous, for ≥3 months.
  • Often overlaps with medication-overuse headache. Onset is usually 6-12 hrs after medication use. Ask exactly how much used and when.
  • Can be 'transformed' type whereby it is less migraine-like (nausea and vomiting, photophobia) and more tension-like.

  Hemicrania continua:

  • Constant, unilateral headache with ANS symptoms.
  • Responds to indomethacin.