Headache

In real life, many people will have a single headache due to a viral URTI or dehydration etc that will require some paracetamol, fluids and some TLC.  If a patient comes to you with headache- it is far more likely to be a more chronic/episodic/severe headache that will possibly need some form of management.

History

• Wash hands, Introduce self, check patient name and DOB, begins with an open question.
• HxPC
  • Site: Frontal, temporal, occipital, unilateral/bilateral,
  • Character and radiation: throbbing; stabbing; burning
  • Radiation: Behind the eyes; neck; ear; jaw; forehead
  • Onset: Hyperacute; Acute; subacute; chronic; episodic
  • Timing: When is the headache worst? How have the symptoms progressed?  How many episodes? Duration/Frequency?
    • Acute onset and rapidly developing headache is more likely to be sinister
  • Exacerbating factors: photophobia; phonophobia; movement; lying down/standing
  • Relieving factors: lying down/standing up; drugs (paracetamol/NSAIDs)
  • Severity
• Associated Symptoms:
  • Nausea & Vomiting
  • Neck pain/stiffness
  • Fever
  • Double vision
  • Photophobia
  • Rash
  • Tender temporal artery/Jaw pain
  • muscle pain
  • altered level of consciousness
  • other neurological problems

RED FLAG SYMPTOMS: 
SUPER-ACUTE ONSET (Subarachnoid haemorrhage; cerebral venous sinus thrombosis; meningitis)
FOCAL NEUROLOGICAL SYMPTOMS (other than typical of migraine): Intracranial mass lesion (vascular, neoplastic, infective)
CONSTITUTIONAL SYMPTOMS (e.g. weight loss; malaise; pyrexia; meningism; rash): Meningoencephalitis; neoplasia; inflammatory e.g. vasculitic
FEATURES OF RAISED INTRACRANIAL PRESSURE (e.g. worse on wakening/lying down, associated vomiting, papilloedema): Intracranial mass lesion
NEW ONSET AGED >60 YEARS: Temporal arteritis

• Other Hx e.g. PMHx, RHx, FHx, SHx
• Ideas, concerns and expectations

Examination

Most cases can be diagnosed either on history alone or with investigation, but examination is rarely a big part of dealing with cases of headaches.

see Cranial Nerve Examination and other neurological examination may be required.  Fundoscopy is of importance if worried about increased intracranial pressure (papilloedematous optic disc).

Causes

• Primary Headache Syndromes
  • Migraine
  • Tension-type Headache
  • Trigeminal autonomic cephalalgia (including cluster headache)
  • Primary stabbing/coughing/exertional/sex-related headache
  • Thunderclap headache
• Secondary causes
  • Medications
  • Intracerebral bleeding e.g. in subdural, subarachnoid or intracerebral haemorrhage
  • Raised intracranial pressure e.g. brain tumour, idiopathic intracranial hypertension
  • Infection e.g. meningitis, encephalitis, brain abscess
  • Inflammatory diseases e.g. temporal arteritis, other vasculitides
  • Referred pain e.g. from orbit, TMJ, neck

A note about facial pain

• Can be due to a number of problems
  • Sinusitis is a common cause of transient facial pain (rarely persistent)
  • TMJ joint/dental issues
  • Trigeminal neuralgia- bouts of brief (seconds) lancinating/electric shock type pain, commonly in the V2/3 distribution and elicited by talking/chewing
  • Herpes zoster- most common V1; pain usually precedes the rash but the pain can often persist long after resolution of the rash (post-herpetic neuralgia- conitnuous burning pain)