Headaches

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

⚠️ A first-ever severe (worst ever) headache of sudden onset = Subarachnoid haemorrhage (SAH) or Cerebral venous sinus thrombosis or rare conditions until proven otherwise. 🚑 Prompt evaluation is essential to prevent life-threatening complications.

📖 About

• 🧠 Headache is a very common complaint in clinical practice.
• ⚡ Categorised into:
  • Primary headaches → not secondary to another condition.
  • Secondary headaches → due to underlying pathology (e.g. vascular, infection, trauma).

🔹 Primary Headaches

• 🌩️ Migraine: Unilateral throbbing ± aura, nausea, photophobia, phonophobia.
• 🎀 Tension-type: Bilateral “band-like” tightness, mild–moderate, often stress-related.
• 🔥 Trigeminal autonomic cephalgias: Severe unilateral (e.g. cluster headache) with autonomic features (tearing, rhinorrhoea, ptosis).
• ❄️ Other: Primary cough headache, cold-stimulus headache.

🔹 Secondary Headaches

• 💥 Trauma/injury (post-concussive, intracranial bleed).
• 🩸 Vascular: SAH, venous sinus thrombosis, giant cell arteritis.
• 🧬 Non-vascular intracranial: IIH, tumours.
• 💊 Substance-related: alcohol, cocaine, medication overuse.
• 🦠 Infections: meningitis, encephalitis, abscess, systemic illness.
• ⚖️ Homeostasis disorders: hypoxia, hypertension, pre-eclampsia/eclampsia.
• 👃/👁️/👂 Cranial structures: sinusitis, glaucoma, otitis, dental abscess.
• 🧩 Psychiatric: somatisation.
• ⚡ Painful cranial neuropathies: trigeminal neuralgia, post-herpetic neuralgia.

🧠 Headache Comparison — Acute vs Recurrent

🩺 Clinical History Taking

• ⏱️ Onset/duration/frequency: Sudden vs gradual; episodic vs chronic.
• ⚡ Associated features: Aura, nausea, photophobia (migraine); autonomic signs (cluster); fever/neck stiffness (infection).
• 🏠 Environmental factors: Multiple people affected → think CO poisoning.
• 📌 Triggers/relievers: Trauma, posture, menstruation, medication change.
• ⚖️ Comorbidities: Immunosuppression, malignancy, pregnancy increase risk of secondary causes.
• 💊 Drug history: Anticoagulants, corticosteroids, illicit drugs.
• 🎭 Impact on life: Migraines → withdrawal; tension-type → usually functional; cluster → agitation/restlessness.

🧾 Examination

• 📊 Vital signs: BP, HR, RR, temp, O₂ sats.
• 🧍 General: Rash, confusion, reduced GCS = red flags.
• 🔎 Extracranial: carotids, temporal arteries, sinuses, TMJ.
• 🦴 Neck: meningism, stiffness, tenderness.
• 🧠 Neurological: cranial nerves, motor/sensory, fundoscopy (papilloedema). ➡️ Abnormal exam = urgent referral.

🔬 Investigations

• Primary headaches → usually clinical diagnosis, no tests required.
• 🚨 Red flags → urgent neuroimaging (CT/MRI) ± lumbar puncture.
• 📖 Headache diary may help in uncertain cases.
• 🤝 Refer to neurology if diagnostic uncertainty remains.

💊 Management

• Migraine: Triptans + NSAIDs/antiemetics; preventive therapy if frequent.
• Tension-type: Simple analgesia, stress management, relaxation therapy.
• Cluster headache: High-flow O₂, SC sumatriptan.
• Secondary headaches: Treat underlying cause (e.g. antibiotics for meningitis, steroids for GCA, surgery for haemorrhage/tumour).

📌 UK Exam Pearls

• ⚠️ “Thunderclap headache” = SAH until proven otherwise → CT head ± LP if CT normal.
• 👁️ New temporal headache in >50 y/o = suspect GCA → check ESR/CRP, urgent steroids.
• 💊 Medication overuse headache = common exam trap (esp. triptans, opioids, simple analgesics).
• 🧠 IIH → young obese women, papilloedema, headache worse on waking/lying flat.
• ❄️ Cluster headache hallmark = unilateral periorbital pain + autonomic features; treatment = O₂ + triptan.

🚩 Headache Red Flags (SNOOP):

• ⏱️ Sudden onset (“thunderclap”).
• 👴 New onset in age >50.
• 🧠 Other neuro symptoms (seizures, confusion, focal deficit).
• 🔁 Order change (different character, progressive, worsening).
• 📜 Previous cancer, immunosuppression, pregnancy, clotting disorders.

📚 References

• NICE CKS – Headache Assessment