Headache

Question 1

Approach to Headache

Answer 1

Primary
Migraine
Tension
Cluster
Analgesia

Secondary
A. Generalised
- SOL
- ICB - trauma, aneurysm
- Meningitis / encephalitis
- Idiopathic intracranial hypertension
- Cerebral venous thrombosis - OCP, hypercoagulable state
- Hypertensive emergency

B. Localised
- Giant cell arteritis (temporal arteritis)
- AACG
- Sinusitis
- TMJ dysfunction
- Trigeminal neuralgia

C. Systemic
- Acromegaly and pituitary apoplexy
- Pituitary adenoma
- Phaeochromocytoma
- Hyperviscocity - PRV, myeloproliferative
- OSA

Question 2

History taking in headache

Answer 2

1. Site of headache
   - Where does the headache hurt?
2. Onset and timing
   - When did it first start?
   - What were you doing when the headache started?
   - When does the headache reaches maximal intensity?
   - How long does the headache last?
   - Does the headache recur? How often?
3. Character and radiation
   - Do you have just one type of headache or different types?
   - What is the pain like? pressure, throbbing, pounding, aching, stabbing
   - Pain score of headache
   - Radiation to other parts of head, neck, spine, arms
4. Associated symptoms
   - Vision before or during headache
   - Nausea, vomiting, light sensitivity, noise sensitivity
   - Autonomic symptoms
   - Fever, ptosis, miosis
5. Precipitating / relieving factors
   - Bright light vs dark room
   - Loud noise vs quiet room
   - Triggers: menses, stress, food, lack of sleep, overlseeping, strong odours, trigger zones
   - Cough, Valsalva, physical activity - worsens
   - Sleep, lying down, quiet - relieves
   - Caffeinated drinks
   - Stress, depression
   - Family history of headaches
6. Treatment or overtreatment
   - OTC medication, vitamins, herbs
   - Prescription medications
   - Alternative medications: acupuncture, chiropractic, stress management, massage
   - How many doctors have you visited in the past
7. Quality of life
   - Impact on work / school / family / activities

Question 3

Red flags to consider neuroimaging for headache (m: SSNOOP)

Answer 3

1. Systemic symptoms: fever, weight loss
2. Secondary risk factors: HIV, malignancy, pregnancy, postpartum
3. Neurologic symptoms: confusion, impaired alert/consciousness
4. Onset: sudden, abrupt or split-second thunderclap
5. Older: new onset and progressive headache in age > 50 years old (giant cell arteritis)
6. Previous headache history or headache progression - change in frequency, severity, clinical features