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HEADACHE

At the end of this tutorial, you should be able to:

1. Define headache
2. Form a differential diagnosis for the aetiology of headache.
3. Differentiate between the different types of headache based on duration.
4. Take a history from patients with headache, looking for features which
may assist in narrowing the differential.
5. Examine patients with headache to elicit features suggestive of
underlying aetiology.
6. Choosing and justifying appropriate investigations of the patient with
headache.

INTRODUCTION: Headache is among the most common clinical complaints.

DIFFERENTIAL DIAGNOSIS:

Peracute (Seconds to 1. Subarachnoid haemorrhage

Minutes) 2. Carotid artery dissection
3. Intracerebral haemorrhage
4. Hypertensive crisis
5. Barosinusitis
6. Thuderclap headache
7. Trigeminal neuralgia

Acute (Minutes to 1. Meningitis/Encephalitis/Abscess

Hours) 2. Occlusive hydrocephalus
3. Pituitary apoplexy
4. Sinusitis
5. Acute glaucoma
6. Cervicocephalic syndrome
7. Intracerebral haemorrhage
8. Migraine
9. Cluster headache

Chronic 1. Subdural haematoma

2. Venous sinus thrombosis
3. Chronic, intracranial
hypertension/pseudotumour cerebri
4. Giant cell arteritis
5. Refractive anomaly
6. Chronic sinusitis
7. Sinus/pharyngeal carcinomas
8. Mandibular joint affections
9. Tension headache

HISTORY:

1. How long have you been having headaches?

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2. When did you first notice a change in the pattern or severity of your
headaches?
3. How has the pattern of your headaches changed?
4. How often do your headaches occur?
5. How long does each headache last?
6. Which part of your head aches?
7. What does the headache feel like?
8. How quickly does the headache reach its maximum?
9. When you get headaches, do you have any other symptoms?
10. Are you aware of anything that produces the headaches?
11. Are there any warning signs?
12. Does anything make the headaches worse?
13. What makes the headaches better?

Onset
Sudden onset of severe pain is usually due to a vascular cause, especially SAH
from a ruptured berry aneurysm. Cluster headache and migraine intensify over
minutes and may last severe hours, while meningitis tends to evolve over hours
to days. Progressive severe headaches that develop over days or weeks should
lead to the consideration of raised ICP from tumour or chronic SAH. The onset
of headache may be preceded by an aura with migraine.

Site

1. Unilateral: Migraine headache

2. Bilateral: Tension headache
3. Superficial Temporal Artery: Temporal arteritis in association with jaw
claudication
4. Ocular Pain: Glaucoma
5. Retro-orbital Pain: Cluster headaches

Character
The intensity of pain contributes litter when discriminating between the causes;
however the character of the pain may be useful. Patients with tension
headache often complain of a tight band like sensation; this is in contrast to the
pain experienced with raised ICP, which is often reported to have a bursting
quality. Migraine-related headaches have a throbbing character.

Precipitating Factors
Headache originating from raised ICP is precipitated by changes in posture,
coughing or sneezing, and is often worse in the mornings. Photophobia may be
experienced by patients suffering with migraine, meningitis or glaucoma. They
may prefer to lie in a darkened room when headaches arise. Certain food such
as cheese is known to precipitate migraine.

It is very common for headache to be precipitated by systemic illnesses such as

cold or flue. Headache precipitated by touch occurs with superficial temporal
artery inflammation from temporal arteritis. A drug history may elucidate the
relationship between the administration of drugs with headache as a side effect
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such as GTN and nifedepine. Alternatively, headache can also result from
substance withdrawal in substance-dependent patients.

Precipitants of Migraine: Mnemonic = CHOCALATE

1. CHeese
2. Oral Contraceptive pill
3. AlcohOL
4. Anxiety
5. Travel
6. Exercise

Associated Symptoms
Neck stiffness (meningism) is experienced with both meningitis and
subarachnoid hemorrhages. Visual disturbances in the form of haloes occur
with glaucoma. Flashing lights and alterations in perception of size may be
reported in patients suffering with migraine, and this may be accompanied by
photophobia, nausea and vomiting. Transient neurological deficits may also
occur. However, progressive neurology associated with headache is more
suggestive of an intra-cranial space occupying lesion, such as hemorrhage,
abscess and tumour. Unilateral visual loss may result as a complication of
temporal arteritis, and this may be accompanied by proximal muscle weakness
or tenderness. Conjunctival injection is experienced with both glaucoma and
cluster headaches, along with lacrimation, which is a feature of the latter. With
normal pressure hydrocephalus in adults, headaches are associated with
dementia, weakness, vomiting and ataxia.

Red Flags
Peracute Onset Severe persistent headache that reaches maximal
intensity within a few seconds or minutes after the onset
of pain warrants aggressive investigation. Subarachnoid
haemorrhage, for example often presents with an abrupt
onset of excruciating pain.

Absence of The absence of a similar headache in the past is another

Similar Headache finding that suggests a possible serious disorder. The
in the Past 'first' or 'worst' headache of my life is a description that
sometimes accompanies an intracranial haemorrhage or
CNS infection.

Infection Infection in a non-intracranial location may serve as a

nidus for the development of meningitis or intracranial
abscess. Fever is not characteristic of migraine
headache.

Change in Mental A change in mental status, personality or fluctuation in

Status consciousness level suggests a serious abnormality.

Exercise Onset following strenuous exercise raises the possibility

of carotid artery dissection or intracranial haemorrhage.
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Neck Pain Pain that radiates to the lower neck (C3) may indicate
meningeal irritation secondary to meningitis or sub-
arachnoid blood.

Visual 1. Haloes: Seeing haloes around light suggests the

Disturbance presence of glaucoma.
2. Visual Field Defect: Suggests compression of optic
pathway, e.g., due to a pituitary mass.
3. Blurred Vision: Blurring of vision on bending of the
head, headaches upon waking in the morning that
improve on sitting up and double vision, or loss of co-
ordination or balance should raise the suspicion of
raised intracranial pressure. This disorder should be
considered in patients with chronic, daily,
progressively worsening headache associated with
chronic nausea.
4. Vision Loss: Sudden, severe, unilateral visual loss
suggests the presence of optic neuritis.

Nausea and Suggests raised intracranial pressure.

Vomiting:

Characteristic of Common Headache Syndromes

Symptom Migraine Tensions Cluster

Headache Headache Headache
Location Unilateral in 60- Bilateral Always unilateral,
70% of cases. usually begins
Bifrontal in 305 around the eye or
temple
Characteristics Gradual in onset, Pressure or Pain begins
crescendo tightness which quickly, reaches a
pattern; moderate waxes and wanes crescendo within
to severe minutes; pain is
intensity; deep; continuous,
aggravated by excruciating and
routine physical explosive in
activity nature.
Patient's Patient prefers to Patient may Patient remains
attitude rest in dark quiet remain active or active
room may need a rest
Duration 4-74 hours Variable 30 minutes to 3
hours
Associated Nausea, vomiting, None Ipsilateral
Symptoms photophobia, lacrimation and
phonophobia, may redness of the
have aura (usually eye; stuffy nose;
visual, but can rhinorrhea; pallor;
involve other sweating;
senses or cause Horner's
speech or motor syndrome; focal
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deficits). neurological
symptoms rare;
sensitivity to
alcohol.

EXAMINATION:

Temperature
Pyrexia may indicate the presence of systemic infection or meningitis

Inspection
An assessment of the conscious state should be undertaken and quantified on
the GCS. Impairment of consiousness is a sign of a serious underlying
pathology, such as meningitis,SAH and raised ICP. Inspection of the eyes may
reveal conjunctival injection with glaucoma and cluster headaches during an
acute attack. With acute angle closure glaucoma the cornea is hazy and the
pupil is fixed and semidilated. Petechial hemorrhages on the skin are visible
classically with meningococcal meningitis.

Palpation
Tenderness along the course of the superficial temporal artery, with absent
pulsation, is consistent with temporal arteritis.

Neurological Examination
A detailed neurological examination is performed to identify the site of any
structural lesions. Unilateral total visual loss can be precipitated by temporal
arteritis due to ischemic optic neuritis. Visual field defects (hemianopia) can be
caused by contralateral lesions in the cerebral cortex. Fundoscopy is performed
to identify papilledema from raised ICP.

Transient hemiplagia can occur with migraine, but progressive hemiplegia is

more indicative of a space occupying lesion, such as a tumour or ICH. Neck
stiffness is a feature of both meningitis and SAH. With meningitis, Kernigs sign
may be present.

INVESTIGATIONS:

Bloods
1. CBC: WCC raised in meningitis, cerebral abscess and systemic infection.
2. ESR: Raised in temporal arteritis, infection, intra-cranial bleeding.
3. U&Es: Hypertensive headaches with renal disease
4. Blood Cultures: With meningitis, systemic infection

Imaging
1. CT/MRI: Visualisation of the anatomical structures in the cranium is very
useful in the presence of neurological deficit. Cerebral tumours may be
visualized as high or low density masses. Intra-cranial bleeding can be
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identified as areas of high density during the first 2 weeks. An extradural

hematoma presents as a lens shaped opacity, and subdural hematoma as
a crescent shaped opacity. After 2 weeks, intracranial hematomas
become isodense and more difficult to visualize. Following SAH, blood
may be visualized in the subarachnoid space. Occasionally the offending
aneurysm or AVM may be imaged. Enlargement of the ventricles may be
an indication of hydrocephalus. Contrast-enhanced CT scanning will
increase the sensitivity to diagnose cerebral abscesses.

Other
1. LP: An LP may be undertaken following the exclusion of raised ICP when
there is suspicion of meningitis or SAH. The CSF obtained is inspected
for consistency and colour.

(a)Colour: The consistency of the CSF is turbid with meningitis, and

yellow staining of the CSF occurs with SAH, owing to the
breakdown of hemoglobin from the red blood cells.
(b) Microscopy/C&S: The CSF is then sent for microscopy,
culture, cytology and biochemical analysis for glucose and protein.
An abnormal increase in white cells may be seen on microscopy
with meningitis. With bacterial or tuberculous meningitis, the
glucose is low and protein concentration high. With viral
meningitis the glucose content is normal and the protein content is
mildly elevated.
2. Temporal Artery Biopsy: Inflammation and giant cells may be seen with
temporal arteritis. A normal biopsy does not, however, exclude the
disease, as there may be segmental involvement of the temporal artery.
3. Intra-ocular pressure measurements: Tonometry will reveal high
intra-ocular pressures with glaucoma.