Headaches

and
Differentials

Resources:
http://emedicine.medscape.com/article/792384-
overview#showal
Murtagh J. General Practice, 5th ed. 584-600
• Headaches: 1 - 4% of all emergency department (ED) visits
• The 9th most common reason for a patient to consult a physician
• Tension Type Headache (TTH) is the most common type of chronic recurring head pain,
approximately affect 20% of population
• Often occurs during the teenage years and affects three women to every two men

Differentials:

Most Probable cause / Diagnosis:

Acute Headache:
- Respiratory Infection
Chronic Headache:
- Tension type Headache
- Combination Headache
- Migraine
- Transformed migraine
Differentials (continued):

Serious causes not to be missed: Often missed disorders: Other causes:

Cardiovascular: Cervical spondylosis / dysfunction - Depression
- Subarachnoid hemorrhage Dental disorders - Diabetes
- Intracranial hemorrhage Refractive errors of eye - Drugs
- Carotid or vertebral artery Sinusitis - Anemia
dissection Opthalmic herpes zoster (pre-eruption) - Thyroid disorder
- Temporal arteritis Exertional headache - Spinal dysfunction
- Cerebral venous thrombosis Hypoglycemia - UTI
Neoplasia: Post-traumatic headache - Cervicogenic
- Cerebral tumor Post-spinal procedure (epidural, lumbar puncture)
- Pituitary Tumor Sleep apnea
Severe infections: Rare causes:
- Meningitis - Paget disease
- Encephalitis - Post-sexual intercourse
- Intracranial abscess - Cushing syndrome
Hematoma: extradural / subdural - Conn syndrome
Glaucoma - Addison disease
Benign intracranial hypertension - Dysautonomic cephalgia
 Drugs that can cause headache:
The clinical approach: - Alcohol
History: - Analgesics (rebound): aspirin, codeine
- Site - Antibiotics & antifungals
- Onset & Offset - Antihypertensives: methyldopa, beta blockers, hydralazine, reserpine,
- Quality Calcium channel blockers
- Radiation - Caffeine
- Aggravating & relieving factors - Combined oral contraceptive pill
- Frequency - Corticosteroid
- Duration - Cyclosporin
- Severity - Dipyridamole
- Precipitating factors - Ergotamine (rebound)
- Associated symptoms - H2-receptor antagonist (cimetidine, ranitidine)
- MAO inhibitors
- Nicotine
- Nitrazepam
- Nitrous oxide
- NSAIDs (indomethacin)
- PDEs inhibitors (sildenafil, tadalafil)
- Retinoids
- Sympathomimetics
- Theophylline
- Vasodilators (Calcium channel blockers, nitrates)
General Pitfalls:
• Over investigating the patient with headache, as a substitute of careful history and examination
• Failing to consider a combination of factors and cervical dysfunction are common causes of headache
• Omitting blood pressure check in patient complaining of headache
• Rushing in with antibiotics for a patient (especially children) with fever and headache – bacterial meningitis may be masked
• Attributing the early headache of a space-occupying lesion to tension or hypertension
Investigations:
- Hemoglobin: anemia
- WCC: leukocytosis with bacterial infection
- ESR: temporal arteritis
- Radiography:
- Chest x ray for intracerebral malignancy
- Cervical spine
- Skull x ray for brain tumor, Paget disease, deposits in skull
- Sinus x ray for sinusitis
- CT scan to detect brain tumor, cerebrovascular accidents, Subarachnoid hemorrhage
- Radioisotope scan (technetium-99m) to localize specific tumors and hematoma
- MRI for intracerebral pathology, detects intracranial vasculitis in temporal arteries
- Lumbar puncture for meningitis, suspected Subarachnoid bleeding only if CT scan normal
Tension type Headache

The International Headache Society (IHS) diagnostic criteria for tension-type headaches:
1. The patient should have had at least 10 of these headaches
2. The headaches last from 30 minutes to 7 days
3. The headaches must have two of the following four:
a. Nonpulsating quality
b. Mild/moderate intensity
c. Bilateral location
d. No aggravation with routine physical activity
4. The headaches must have both of the following:
a. No nausea or vomiting
b. Photophobia and phonophobia are absent, or one but not the other is present
5. There should be less than 15 days of headache per month and less than 180 days per year
6. Secondary causes are excluded

Management:
- Patient education, counselling and relevant advice
- Medication: aspirin or paracetamol
- Avoid, but consider when necessary: amitriptyline 10-75 mg oral nocte or short course of diazepam
Migraine

• Classic migraine with aura = headache + vomiting + visual aura

IHS criteria: There should be at least 2 attacks including at least 3 of the following:
1. Reversible brain symptoms (cortical or brain stem)
2. Gradual development over 4 minutes
3. Aura duration less than 60 minutes
4. Headache follows aura in less than 1 hour

• Common migraine (without aura), IHS criteria:

1. The patient should have had at least 5 of these headaches
2. The headaches last 4-72 hours
3. The headaches must have at lest 2 of the following:
a. Unilateral location
b. Pulsing quality
c. Moderate / severe intensity, inhibiting / prohibiting daily activities
d. Headache worsened by routine physical activity
4. The headache must have at least 2 of the following:
a. Nausea and / or vomiting
b. photophobia & phonophobia
5. Secondary causes of headache are excluded
Medication (if necessary):
• First line: Aspirin or paracetamol + antiemetic (metoclopramide 10 mg oral)
• NSAIDs (ibuprofen, diclofenac)
• Alternatives: Ergotamine or triptan preparation
Note: Avoid triptans in patients with coronary artery disease, Prinzmetal angina, uncontrolled hypertension or
during pregnancy. Do not use it with ergotamine simultaneously and cease if chest pain develops.
Use with caution in patients taking SSRI, MAOI and Lithium
• Treatment of severe attack: metoclopramide 10 mg (IV) + dihydroergotamine 0.5 mg IV slowly OR Sumatriptan 6
mg (SC) OR Chlorpromazine 0.1 mg/kg IV infusion over 30 min
Caution: Do not use ergotamine preparation if Sumatriptan used in previous 6 hours, and do not use Sumatriptan
if ergotamine preparations used in previous 24 hours

Prophylaxis guidelines: according to patient’s medical profile

• Propanolol 40 mg (O) bd or tds (max 320 mg/day), metoprolol, atenolol if hypertensive or tension
• Pizotifen if low or normal weight or food sensitive migraine
• Amitriptyline if depressed or anxious
• Naproxen if cervical spondylosis
• Naproxen or mefenamic acid or ibuprofen if menstrual migraine
Cluster Headache

• Retro-orbital headache + rhinorrhea + lacrimation

• Unilateral, cyclical attacks
• Typically in males (6:1)
• No visual disturbances or vomiting
• Management:
- Oxygen 100% 10 L/min for 15 min
- Sumatriptan 6 mg SC OR Ergotamine
- Metoclopramide 10 mg IV + dihydroergotamine 0.5 mg IV slowly or 1 mg IM
- Consider local anesthetic: greater occipital nerve block
• Prophylaxis:
• Ergotamine oral or dihydroergotamine IM
• Methylsergide 1 mg (O) once daily up to 3 mg bd
• Prednisolone 50 mg/day for 10 days
• Lithium 250 mg (O) bd
• Verapamil SR 160 mg (O) up to 320 mg
• Pizotifen
• Indomethacin (helps confirm diagnosis)
• Sodium valproate
Cervical dysfunction / spondylosis

• Often incorrectly diagnosed as migraine

• Usually present on walking
• Usually has a history of trauma including motor vehicle accident or blow to the head
• Associated with stiffness and grating of the neck
• On examination usually there is tenderness to palpation over C1, C2 and/or C3 level

Treatment:
• Physiotherapy
• Supportive neck pillow
• NSAIDs
• For intractable cases consider mobilization
under general anesthesia,
injections of corticosteroids
around or surgical section of
the greater occipital nerve
Temporal Arteritis

• Also known as giant cell arteritis or cranial arteritis

• Usually persistent unilateral throbbing headache in the temporal region and scalp sensitive with localized thickening,
with or without loss of pulsation of the temporal artery
• Related to polymyalgia rheumatica – 20% of sufferers will develop Temporal Arteritis
• Temporal Arteritis may also involve intracranial vessels, especially the ophthalmic artery or posterior ciliary arteries,
causing optic atrophy and blindness
• Vision is impaired in about one-half of patient of some stage. Once the patient goes blind it is usually irreversible

Diagnosis:
• By biopsy and histological examination of superficial temporal artery
• Erythrocyte Sedimentation Rate (ESR) may be markedly elevated but
maybe normal
• MRI has a high sensitivity & specificity
• Note: consider it with any ‘new’ headache

Treatment:
• Start early to prevent permanent blindness
• Prednisolone 60 mg oral daily in 2 divided doses for 2-4 weeks
• Dose reduction & progress is monitored by clinical state, ESR & CRP
• May take 1-2 years to resolve
Frontal Sinusitis

• Some patients do not have signs of respiratory infection, nasal obstruction or fever
• Frontal or retro-orbital headache, diurnal variation, developing in the morning,
most intense in middle of the day, then subsiding to offset around 6 pm
• Tenderness over frontal sinus and pain on percussion over the sinus

Management:
• Drain the sinus
• Antibiotics
• Analgesics

Raised intracranial pressure

• Generalized headache, usually worse in the morning, vomiting, drowsiness

• Seizure
• Cause: cerebral tumor and subdural hematoma
• Examination: Focal CNS signs, papilloedema
Intracerebral tumors

• Two peaks of incidence: children < 10 years and 35-60 years

• Main types of tumor:
- Children: medulloblastoma, astrocytoma (posterior fossa), ependymoma, glioma (brain stem)
- Adults: cerebral glioma, meningioma, pituitary adenoma, cerebral metastases (e.g. lung)
Investigations: CT scan and MRI

Subarachnoid Hemorrhage

• About 40% patients die before treatment

• Sudden onset occipital headache + vomiting + neck stiffness
• Kernig sign positive
• Neurological deficit may include: hemiplegia (if intracerebral bleed), third nerve palsy (partial or complete)
• Diagnosis: CT scan. If Ct is negative then Lumbar puncture (blood staining of CSF and xantochromia means positive)
• Note: immediate referral is required. If in doubt review patient in 12-24 hours
Meningitis

• Headache usually generalized and radiates to the neck

• Constant and severe, aggravated by flexion of the neck
• Kernig sign is positive
• Fever and neck stiffness is usually present
• Antibiotic must not be given until a lumbar puncture has been performed

Drug rebound headache

• Usually associated with analgesic and ergotamine dependence

• Example: aspirin, paracetamol, ibuprofen, opioids and caffeine
• Should be suspected in any patient who complains of headache ‘all day every day’
• A careful drug history should be taken
• Treatment includes gradual withdrawal of the drugs and
the substitution of antiemetic and amitriptyline or beta blocker over about 14 days
Chronic paroxysmal hemicrania

• Rare syndrome, overlaps with cluster headache and facial pain

• Unilateral pain, short (average 20-30 minutes) but frequent up to 14 times a day
• Etiology is unknown, often responds dramatically to indomethacin 25 mg (O) tds

Post traumatic headache

• Continuous, diffuse type of headache with associated psychological symptoms such as

dizziness, irritability and depression.
• Can persist for 6-12 months
• Best treated with aspirin or paracetamol, if unresponsive may use: amitriptyline or sodium valproate

Post lumbar puncture headache

• Common, usually present when standing or sitting and rapidly improves with lying flat
• Possibly due to CSF leakage
• Most resolution occurs within 2-7 days
• Treatment includes bed rest until resolution, if persistent, refer for epidural blood patch
Practice tips
• Patient > 55 years presenting with unaccustomed headache has an organic disorder such as Temporal Arteritis,
intracerebral tumor or subdural hematoma until proved otherwise
• The ESR is an excellent screening test to diagnose Temporal Arteritis but occasionally can be normal in the presence of
active Temporal Arteritis
• If a patient present twice within 24 hours to the same hospital with headache and vomiting, consider other causes
apart from migraine before discharging the patient
• If migraine attacks are severe and unusual (e.g. always on the same side) consider the possibility of cerebral vascular
malformation
• A severe headache of sudden onset is Subarachnoid Hemorrhage until proved otherwise
• If women with migraine demand the oral contraceptive, use low dose oestrogen preparation and monitor progress
• The use of narcotics for migraine treatment is to be avoided, the frequent use of ergotamine, analgesics or narcotics
can transform episodic migraine into chronic daily headache
• Danger signals with headache:
- Sudden onset without previous history
- Recent onset for first time in an older person
- Recurrent in children
- Progressive
- Wakes the patient at night
- Localized pain in definite area or structure (e.g. ear, eye)
- Precipitated by raised intracranial pressure (e.g. coughing)
- Associated neurological symptoms or signs: convulsion, fever, confusion, impaired consciousness,
neck stiffness, dizziness/vertigo, personality change