diagnostic approach to headache

8/10/2019 Diagnostic approach to Headache

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Approach to headache

Primary headache syndromesmost common

o Tension type headache

o Migraine

o

Trigeminal autonomic cephalalgias

o Other

Secondary headache syndromes

o Head & neck traumathere 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 lesiontumour, 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 itfront 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 & severealways consider subarachnoid haemorrhage)

o Sudden (secs-mins e.g. migraine, cluster)

o Gradual/insidious (hrs-days e.g. tension headache, cericogenic)

Character & tempoo 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)


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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

Timingduration, 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 headachessimilar or different to current headache?

Family historymigraine, SAH

Current medications & medications triedconsider medication-overuse headache

Social historydepression, 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 featuresweight 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)


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Physical examination (mainly looking for secondary causes)

Observe behaviour if having headachemental 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 historybasic observations, rash, fever, etc.

Vitals esp blood pressure

Investigations

FBC + CRP for infection

Lumbar puncturemeningitis

Imaging if suspiciousCT 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 patientsusually 1-2 hours before the headache there

is mood/behavioural change, yawning, hunger, cravings, fatigueo Auraaffects 30%; typically precedes the headache but may occur with headache or

following the headache & usually subsides in


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o Aura can occur without headachemust then be differentiated from seizure &

cerebral ischaemia; focal seizures last secs-mins; TIAs/strokes do not evolve &

typically causeve 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 oestrogenmost 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 TACothers 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 featuresconjunctival 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 sleepo Cluster last weeks-months with months-years remission, can have chronic variant

Other TAC:

o Paroxysmal hemicraniassee 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 picturedull, 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


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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 downor 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 (weeks-

months) 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 strokeusually 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 strokedifferent to SAH, associated headache more

common than in ischaemic stroke

Subarachnoid haemorrhagethunderclap 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


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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

diagnostic approach to headache

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