Contents
Headache is a very common presenting problem. The vast majority of headaches, even though they can be disabling for patients, will be benign. Patients may often associate headache with hypertension or poor visual acuity, but these are typically only very rare causes of a headache. Also be cautious of patients who use the term migraine synonymously with headache when the headache may not truly be a migraine.
Most headaches can be diagnosed on the basis of history and examination alone, but it is important to know when to investigate with imaging (usually first a CT and later, if indicated, an MRI). Headache with vomiting +/- dizziness +/- seizures is more likely to indicate a serious cause and needs prompt investigation.
Differential diagnosis for headache can include:
- Tension headache
- Migraine
- Sinusitis
- Meningitis
- Cluster headache
- Raised intra-cranial pressure
- May be due to an intracranial mass
- Can be benign
- Venous sinus thrombus
- Trigeminal neuralgia
- Temporal arteritis
- Subarachnoid haemorrhage
- Medication overuse headache
- Cervical / TMJ pathology
- Depression
Patterns of pain can be particularly useful in discerning the type of headache:
Almostadoctor has individual articles for almost all of the above differentials, and also has a summary of headaches, and a differential comparison for headaches.
Below, we consider the history of work-up for headache.
Epidemiology
Tension headache and migraine are probably the two most common type of headache.
- 85% of the population experiences headache annually
- 45% of children will have headache by the age of 7, and 75% by the age of 15
- Migraine affects 10% of the population
- Only about 25% of these patients will seek medical help – migraine is largely undiagnosed
- 75% of cases have a family history
- Headaches can often be secondary to cervical or TMJ dysfunction
- The most common cause of intracerebral malignancy is bronchial carcinoma
- Respiratory tract infection is the most common cause of acute headache
History
- Pattern
- Intermittent
- Continuous
- Diurnal variation / time of day with maximum pain (see patterns of headache above)
- E.g. a tension headache is more likely to occur towards the middle of the day – and patients are unlikely to wake with symptoms
- How often do headache occur?
- Speed of onset
- E.g. sudden onset (thunderclap) – subarachnoid haemorrhage
- Effect of posture and movement
- Location of pain
- Unilateral vs bilateral
- Radiating from neck?
- Facila pain?
- Sinus region pain?
- Temporal region pain? Pain when combing hair?
- Associated symptoms
- Nausea or vomiting?
- Running nose – can be cluster headache, or could be associated with sinusitis
- Recent URTI
- Other sinus symptoms / sinusitis
- Medication use
- Overuse of analgesia
- SSRI and SNRI use and sudden cessation
- Long acting nitrates
- Combined oral contraceptive pill
- Calcium channel blockers
- Steroids
- Phosphdiesterase inhibitors – e.g. sildenafil (viagra)
- Red flags (see below)
- Consider a headache diary to try to match to one of the headache patterns above
Red flags for headache
- Sudden onset, especially in the absence of previous history of headaches
- Thunderclap onset headache
- Fever
- Vomiting
- Seizure
- Focal neurological signs
- Pain is severe and disabling
- Altered level of consciousness
- Personality change
- Wakes patient from sleep at night
- Worse in the morning
- Worse with bending forwards
- Head injury
- New onset headaches in patient aged >50
- Progressively worsening headaches
Differentiating migraine and tension headache (the two most common types of headache):
| Migraine | Tension | |
|---|---|---|
| Location | Unilateral – can later become bilateral | Bilateral |
| Prodrome | Yes | No |
| Nature | Throbbing | Constant |
| Frequency | Typically < weekly | Daily |
| Duration | Usually hours – can be days | Typically days |
| Alcohol | Makes it worse | Makes it better |
| Nausea or vomiting | Yes | No |
| FHx | Yes | No |
| Age of onset | Often < 20 years | Usually > 20 years |
Headaches in children
Headaches in children are less common than in adults.
- Sinuses do not develop until later in childhood – until at least age 5 – and thus sinusitis cannot occur before this age and is rare in children
- Migraine is rare in children – 1% of under 7s, rising to 5% of 15 year olds
- Headache more common with prolonged periods of overeating – i.e. children who skip breakfast
Examination
- Vital signs
- Temperature
- HR
- RR
- BP – always check for hypertension
- This is an assessment for malignant hypertension
- Only assume that this is the cause of the headache if there are other sings of end-organ damage
- If hypertension and headaches co-exist -the hypertension is not usually the cause fo the headache
- Palpate over temporal arteries as well and frontal sinuses
- Ewing’s sign – refers to pain elicited when applying pressure to the orbital roof and is suggestive of sinusitis
- Palapte TMJ
- Examine cervical spine and check for tenderness
- Check the funds with ophthalmoscope for papilloedema
- Assess for signs of meningism
- Photophobia
- Neck stiffness
- Kernig and Brudzinski signs
- Neurological examination
- Eyes – visual fields, acuity, photophobia, pupil reactions
- CN – power and sensation in face
- Limbs – tone, power, reflexes, co-ordination and sensation
- Asses mental state
- For signs of depression or other mental illness
Investigations
Investigations are not necessary in the majority of cases – most headaches can be diagnosed clinically. If any red flags are present consider urgent referral to the emergency department and / or discussion with neurologist on call.
Consider the following:
- Bloods
- FBC – for anaemia
- WCC – for evidence of infection
- ESR / CRP – for evidence of infection or inflammatory cause (e.g. temporal arteritis)
- This should be done for all patients aged >50 with new onset headache
- Imaging
- CXR – if concerned about malignancy (most common cause is secondaries from lung cancer)
- CT brain
- To detect intracranial pathology, including mass, subarachnoid haemorrhage and CVA
- MRI
- Typically more sensitive than MRI – but more expensive, more time-consuming and less easy to access
- Lumbar puncture
- If concern for meningitis or SAH
- Can be dangerous if raised ICP – typically CT performed first to reduce this risk
Estimating risk
Assessing the immediate risk of the headache can be done by stratifying the onset and features of the headache
High risk
- Acute onset (seconds to minutes)
- Unlike previous headaches
- Differentials include:
- SAH
- Meningitis
- Venous sinus thrombosis
- Stroke
- Primary angle-closure glaucoma
- Acute intracranial bleed – e.g. dissection
- These patients need assessment in the emergency department and same-day investigation (i.e. imaging)
Medium Risk
- Onset over hours to days
- New headaches – dissimilar to previous headaches
- Not responding to simple analgesia
- Likely to require CT – assess on individual basis – some may be suitable for out-patient CT, some may need referral to hospital
Low risk
- The majority of headaches
- Recurrent or chronic headaches
- History of previous similar headaches
- Imaging unlikely to be of benefit
References
- Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
- Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.
- Beers, MH., Porter RS., Jones, TV., Kaplan JL., Berkwits, M. The Merck Manual of Diagnosis and Therapy
