Headache – Headache - Headache MOZZAR

NO LIST OF DIAGNOSIS SIMPLE PATHO CLINICAL PRESENTATION INVESTIGATION MANAGEMENT

FROM TUTORIAL HEADACHE
1 Cluster Headache - S  Unilateral, retro-orbital
- O  Suddenly at night, ‘alarm clock headache’ (2-4am)
- C  Stabbing pain, excruciating, tearing
- R  Can go to frontal or temporal
- A  Rhinorrhoea, lacrimation, flushing of forehead and
cheek, redness of ipsilateral eye, Horner’s syndrome,
nasal congestion, epiphora
- T  Cluster can last 4-6 weeks (can even last for months)
- E  Exacerbated by alcohol. Relieved spontaneously or
by meds
- S  Severe
2 Tension-type - Overactivity of muscles of scalp, - S  Bilateral
Headache forehead, and neck  dull - O  Often after waking up, worse during day
aches/tightness around the area - C  Band-like, pressing or tightening
- R  To occiput
- A  Light-headedness, neck ache or stiffness
- T  hours, can last daily, happens almost daily
- E  Exacerbated by stress, overwork, poor posture,
scrappy diet. Relieved by alcohol
- S  Mild or Moderate
- PE  Muscle tension, scalp often tender, ‘invisible
pillow’ sign may be postive
3 Migraine - Cause by dilatation or swelling of - S  Begin unilaterally, may progress to involve entire
blood vessels inside/outside the head
scalp more blood pumping - O
through vessels  throbbing - C  Pulsating, throbbing or dull aching pain
sensation (vascular headache) - R  To retro-orbital & occipital
- A  Nausea, vomiting, visual aura, photophobia,
phonophobia
- T  4-24 hours, rarely exceeds 72 hours
- E  Many exacerbating factors. Relieved spontaneously
often with sleep/ rest in quiet dark room/ vomiting
- S  Moderate to severe
Diagnostic criteria for cluster headache
a) At least five attacks
b) Severe pain lasting 15-180 minutes
c) Headache a/w at least one; conjunctival injection,
lacrimation, nasal congestion, rhinorrhoea, forehead and
facial sweating, miosis, ptosis, eyelid oedema
d) One attack every other day to 8 attacks per day
Diagnostic criteria for tension-type headache
a) At least 10 previous headache episodes
b) Lasting 30 minutes to 7 days
c) At least 2; pressing/tightening quality, mild/moderate
intensity, bilateral, NOT aggravated by walking stairs
d) No nausea and vomiting, photophobia and phonophobia
are absent
Diagnostic criteria for migraine WITHOUT aura
a) At least five attacks
b) Headache lasting 4-72 hours
c) At least 2; unilateral, pulsating, moderate/severe intensity,
aggravated by walking stairs
d) At least one; nausea, vomiting, photophobia, phonophobia
Diagnostic criteria for migraine WITH aura
a) At least 2 attacks
b) At least 3; >1 fully reversible aura symptoms, >1 aura
symptoms that develop over 4 minutes, no aura symptoms
lasts more than 60 minutes, free interval of less than 60
minutes
Acute attack; 100% oxygen (usually good
response), sumatriptan (serotonin receptor
agonist), ergotamine
Prophylaxis, verapamil (1st line treatment)
Paracetamol PRN, Simple analgesic
Non-pharmacological; counselling, relaxation
technique, advices on current occupation, yoga
or meditation classes
Acute attack; simple analgesic, sumatriptan
(serotonin agonist), ergotamine
Prophylaxis; Beta blocker (propranolol),
sodium valproate, calcium channel blocker,
erunumab (new drug)
Metoclopramide for nausea
Non-pharmacological; rest in dark room,
relaxation technique, place cold packs on
forehead

## RED FLAGS ##
 Headache after 50 years of age (temporal arteritis, mass lesion)
 Sudden onset headache (SAH, hemorrhage into mass lesion or vascular malformation)
 Headache increase in frequency and severity (mass lesion, subdural hematoma, medication overuse)
 New onset headache of pt with risk factors for HIV or cancer (brain abscess, meningitis, metastasis)
 With signs of systemic illness (eg fever, stiff neck, rash indicating meningitis)
 Focal neurologic signs (mass lesion, vascular malformation, stroke)
 Papilledema (mass lesion, meningitis)
 Headache subsequent head trauma (ICH, subdural hematoma, epidural hematoma, post traumatic headache)
 From Murtagh; severe and debilitating, fever, vomiting, confusion, personality change, max in morning, wakes patient
at night, neurological and visual symptoms, seizure, post head injury, young obese female, new onset in elderly
especially > 50 y/o
 From Murtagh, Red flags in physical examination; altered consciousness or cognition, meningism, abnormal vital signs,
focal neurological signs (pupils, fundi, eye movement), tender and poorly pulsatile temporal arteries
Headache – Headache - Headache MOZZAR

SECONDARY HEADACHE DISORDERS

TEMPORAL ARTERITIS/ GIANT FRONTAL SINUSITIS RAISED ICP SUBARACHNOID TRIGEMINAL MENINGITIS
CELL ARTERITIS (cerebral oedema, HEMORRHAGE (SAH) NEURALGIA
subdural hematoma)
Collagen disease that causing **Headache uncommon **Headache uncommon Due to rupture of berry Neurovascular compression in
inflammation presentation of sinusitis presentation of brain tumor aneurysm (70%) the trigeminal root entry zone,
-extracranial vessels (superficial which can lead to
demyelination and a
temporal artery) dysregulation of voltage-gated
-intracranial vessels (ophthalmic A or sodium channel expression in
posterior ciliary A  optic atrophy & the membrane
blindness)
Site Persistent unilateral Frontal or retro-orbital Generalised headache Occipital headache (from jaw to forehead) Generalised
Forehead and temporal region headache (pain around Often occipital
eyes/over cheek/forehead)
Onset Non-specific, tends to be worse in the Worse in the morning Dramatic onset, Abrupt Abrupt onset
morning May awaken from sleep
Character, Nature Severe burning pain Dull, deep steady ache Worse headache ever Excruciating, Intense Throbbing, constant, and severe
(thunderclap) pain
Radiation To down side of head towards occiput Retro-orbital To neck and back Jaw to forehead To the neck
Associated symptoms Malaise, vague aches, pain in muscles Drowsiness + vomiting Pain & neck stiffness Facial pain Fever & neck
(neck), weight loss (without nausea)  seizure No fever Stiffness, photophobia
Intermittent blurred vision, Early morning projectile Vomiting & LOC +ve Kernig sign
tenderness on combing hair, jaw vomiting +ve Kernig sign Purpuric rash, coma
claudication on eating, HPTN Papilloedema, unequal pupils Neurological deficit
(hemiplegia or 3rd nerve palsy) Triad: fever, neck
Nausea, vomiting stiffness, mental
status changes

Sign; non-blanching purpuric

maculopapular rash
Time, Duration, Usually constant (getting worse) Diurnal variation Maybe last hours in the Pain maximal within seconds or Each attack lasted few
Frequency Daily -develop in morning (9am) morning maximal seconds to 2 minutes
-most intense in middle of day Usually intermittent
-subside around 6pm
Exacerbating factor Stress and anxiety Coughing, sneezing, straining Chewing food By flexion of neck
in the toilet
Relieving factor Analgesics (aspirin), sitting, Sleep
standing
Predisposing factor Age over 50 years old After URTI or rhinitis
INVESTIGATION CT scan, MRI Blood C&S, LP then send for CSF
analysis, CT brain, FBC
MANAGEMENT Very responsive to corticosteroids, to Drain sinus conservatively using Immediate referral for Anticonvulsant e.g., Caution; antibiotics must not be
prevent permanent blindness steam inhalations possible surgical intervention carbamazepine given until a lumbar puncture has
Concomitant use of H2-recepto Antibiotics Painkiller been performed
antagonists Analgesics