Makindo Medical Notes

Related Subjects:Migraine |Basilar Migraine |Cluster Headaches |Sumatriptan |Tension Headache |Analgesic Overuse Headache |Headaches in General

A first-ever severe headache of sudden onset should be considered a subarachnoid haemorrhage (SAH) until proven otherwise. Prompt evaluation is critical to avoid life-threatening complications.

About

• Headaches are a very common complaint in clinical practice, affecting millions of individuals worldwide.
• They can be grouped into two broad categories: primary headaches (which are not associated with underlying health conditions) and secondary headaches (which result from other medical issues).

Primary Headaches

• Migraine: May occur with or without aura, characterized by unilateral throbbing pain, often accompanied by nausea, vomiting, and sensitivity to light or sound.
• Tension-type headache: The most common form, presenting with mild to moderate, bilateral, pressing or tightening pain, often described as a "band" around the head.
• Trigeminal autonomic cephalgias: These include cluster headaches and paroxysmal hemicranias, which are characterized by severe, unilateral pain often around the eye, with associated autonomic symptoms like tearing or nasal congestion.
• Other primary headache disorders: These include less common headaches like primary cough headache or cold-stimulus headache, typically triggered by external factors like coughing or exposure to cold.

Secondary Headaches

• Trauma or injury: Secondary to head or neck trauma.
• Cranial or cervical vascular disorders: Such as intracerebral haemorrhage, central venous thrombosis, or giant cell arteritis.
• Non-vascular intracranial disorders: These include conditions like idiopathic intracranial hypertension (IIH) or brain tumours.
• Substance exposure/withdrawal: Headaches due to substances like carbon monoxide, alcohol, cocaine, or medication overuse (including ergotamine, triptans, simple analgesics, and opioids).
• Infections: Intracranial infections (e.g., meningitis, encephalitis, or cerebral abscess) or systemic infections like influenza or COVID-19 can cause secondary headaches.
• Disorders of homeostasis: Conditions like hypoxia or hypertension, including pregnancy-related disorders like pre-eclampsia and eclampsia.
• Disorders of cranial structures: Involvement of structures such as the sinuses (sinusitis), eyes (glaucoma), ears (otitis media), or teeth (dental abscess).
• Psychiatric disorders: Headaches related to conditions like somatization disorder.
• Painful cranial neuropathies: These include trigeminal neuralgia, post-herpetic neuralgia, and optic neuritis.

Clinical History Taking is Key

• Onset, duration, and frequency: Ask about the pattern (episodic, daily, or unremitting), severity, and location of the pain.
• Associated symptoms:
  • Migraine may be indicated by aura (visual, auditory, or gustatory disturbances), nausea, photophobia, or phonophobia.
  • Cluster headaches often present with autonomic features such as tearing, drooping eyelids, nasal congestion, or rhinorrhoea.
  • Neurological features such as fever, neck stiffness, or visual disturbances may point towards infections or neurological emergencies.
• Contacts with similar symptoms: Consider environmental factors, such as possible carbon monoxide poisoning if household members or pets have similar symptoms.
• Precipitating and relieving factors: Look for links to trauma, posture, stress, menstruation, or recent changes in medication.
• Comorbidities and medical history: Consider compromised immunity, systemic illnesses, malignancies, or pregnancy as risk factors for secondary headaches.
• Drug history: Review medications the patient is taking for headaches and any other prescribed or over-the-counter drugs. This includes anticoagulants, corticosteroids, or illicit substances like methamphetamines and cocaine.
• Impact on daily activities: Determine how the headache affects the patient's lifestyle. For example, migraines often lead to withdrawal from activities, while tension-type headaches may not limit daily functioning. Cluster headaches, on the other hand, may result in agitation and restlessness.

Examination

• Vital signs: Assess blood pressure, pulse, respiratory rate, temperature, and oxygen saturation.
• General appearance and mental state: Look for serious red flags like confusion, skin rash, or altered consciousness that could indicate a severe underlying cause.
• Extracranial structures: Examine the carotid and temporal arteries, sinuses, and temporomandibular joints for abnormalities.
• The neck: Look for signs of meningeal irritation, tenderness in the cervical muscles, or limitations in neck movement.
• Neurological examination: Perform fundoscopy to check for papilloedema and assess cranial and peripheral nerve function. An abnormal exam warrants urgent referral to secondary care.

Investigations

• Most primary headaches do not require investigations. However, red flags or suspicion of a serious underlying condition should prompt urgent referral for imaging or specialist review.
• If the diagnosis remains unclear, ask the patient to keep a headache diary recording frequency, duration, severity, associated symptoms, medications used, and potential triggers.
• If uncertainty persists, seek advice from a neurologist.

Management

• Acute and preventive treatments vary depending on the type of headache. Primary headaches like migraines may be treated with triptans or nonsteroidal anti-inflammatory drugs (NSAIDs), while chronic tension-type headaches may benefit from stress management and relaxation techniques.
• Cluster headaches may require high-flow oxygen therapy or subcutaneous injections of sumatriptan.
• For secondary headaches, management involves treating the underlying cause, whether it’s infection, trauma, or a vascular issue.

References

• Headache Assessment - NICE UK Guidance