Key facts and checkpoints Flashcards
The key to analysing the symptom of headache is?
to know and understand the cause, for
‘one only sees what they know’.
Probability diagnosis
Acute:
- respiratory infection
Chronic:
- tension-type headache, so-called transformed migraine
- combination (mixed) headache
- migrain,e is not as common as in specialist practice
- transformed migraine
Key facts
85% of the population will have experienced headache within 1 year and 38% of adults will have had a headache within 2 weeks.
Headache can be classified as primary or secondary e.g. intracranial pathology, TMJ, cervical spine.
Migraine affects at least 10% of the adult population and 25% of these patients require medical attention for their attacks at some stage. It is under-recognised and poorly managed in the community.
5% of children suffer from migraine by the age of 11 years.
70% of sufferers have a positive family history of migraine.
Many headaches previously considered to be tension are secondary to disorders of the neck, eyes, teeth, TMJ or other structures.
Drug-induced are common
A typical triad of symptoms in an adult with a cerebral tumour (advanced) is headache, vomiting and convulsions.
Eye strain is not a common cause.
Secondary bronchogenic bronchial carcinoma is the commonest cause of intracerebral malignancy.
40% of children will have experienced one or more headaches by the age of 7 and 75% by the age of 15.
In children the triad of symptoms—dizziness, headache and vomiting—indicates medulloblastoma of the posterior fossa until proved otherwise.
Key history
A full description of the pain including a pain analysis, especially associated symptoms.
Get the patient to prepare a diary with a grid plotting the relative pain intensity with time of day.
FHx, psychosocial history and drug history.
Headache diary can be useful to assess self-medication and aid diagnosis
Key questions
- Can you describe your headaches?
- How often do you get them?
- Can you point to exactly where in the head you get them?
- Do you have any pain in the back of your head or neck?
- What time of the day do you get the pain?
- Do you notice any other symptoms when you have the headache?
- Do you feel nauseated and do you vomit?
- Do you experience any unusual sensations in your eyes, such as flashing lights?
- Do you get dizzy, weak or have any strange sensations?
- Does light hurt your eyes?
- Do you get any blurred vision?
- Do you notice watering or redness of one or both of your eyes?
- Do you get pain or tenderness on combing your hair?
- Are you under a lot of stress or tension?
- Does your nose run when you get the headache?
- What tablets do you take?
- Do you get a high temperature, sweats or shivers?
- Have you had a heavy cold recently?
- Have you ever had trouble with your sinuses?
- Have you had a knock on your head recently
Medications causing headaches
- Hormone replacement therapy (HRT) and the OCP.
- vasodilators esp. nitrates, sildenafil. Usually resolves within the first 2 weeks of therapy. Initiate at a lower dose and use paracetamol as required during this time.
- Alcohol
- Analgesics (rebound)
- Caffeine
- Antihypertensives (several)
- Corticosteroids
- NSAIDs (esp. indomethacin)
Key examination
- Blood pressure
- Temperature
- Inspect the head
- Palpate the temporal As, facial and neck muscles, cervical spine and sinuses, teeth TMJs.
- Search for signs of meningeal irritation.
- Eyes examination;
- Visual acuity and visual fields
- Reactions of the pupils and eye movements
- Fundoscopy – looking for papilloedema
- Neurological examination:
- Sensation and motor power in the face and limbs
- Symmetric reflexes and down-going plantar responses
- Tandem gait – whether the patient can walk heel-to-toe
8.A mental state examination is mandatory:
- looking for altered consciousness or cognition
- assessment of mood, anxiety–tension–depression
- any mental changes.
Special signs
• Upper cervical pain sign:
Palpate over the C2 and C3 areas of the cervical spine, especially two finger breadths out from the spinous process of C2. If this is very tender and even provokes the headache it indicates headache of cervical origin.
• Ewing sign for frontal sinusitis:
Press your finger gently upwards and inwards against the orbital roof medial to the supra-orbital nerve. Pain on pressure is a positive finding and indicates frontal sinusitis.
• The invisible pillow sign:
Pt lies on the examination table with head on a pillow. The examiner then supports the head with his or her hands as the pillow is removed. Pt is instructed to relax the neck muscles and the examiner removes the supporting hands. A + test indicating tension from contracting neck muscles is when the pt’s head does not readily change position. This is uncommon.
Key investigations
.
A detailed history and basic neurological examination is usually enough to differentiate between benign and serious causes.
Few patients require imaging to exclude a serious cause.
- FBE
- ESR/CRP, especially if aged > 50 years without past headaches (consider giant cell arteritis).
- Imaging is not usually required unless there are indications.
- Key investigation–non-enhanced CT + CT angiography
- Selective radiography (e.g. skull X-ray, sinus X-ray, CT scan or MRI scan).
- POAC does not usually fund CT head for headache
Investigations
- haemoglobin ? anaemia
- WCC: leucocytosis with bacterial infection
- ESR/CRP: ? temporal arteritis
- radiography:
— CXR, if suspected intracerebral malignancy
— cervical spine
— skull X-ray, if suspected brain tumour, Paget disease, deposits in skull
— sinus X-ray, if suspected sinusitis
— CT scan: detection of brain tumour (most effective), cerebrovascular accidents (valuable), SAH
— radioisotope scan (technetium-99m) to localise specific tumours and haematoma
— MRI: very effective for intracerebral pathology but expensive; produces better definition of intracerebral structures than CT scanning but not as sensitive for detecting bleeding; detects intracranial vasculitis in temporal arteries
— lumbar puncture: diagnosis of meningitis, suspected SAH (only if CT scan normal) Note: Dangerous if raised intracranial pressure.
Management
Manage patients with primary headaches in general practice
If any red flags, arrange ambulance and request emergency department assessment.
If any suspected serious secondary cause, manage appropriately.
For all primary headaches, avoid opioids, including codeine, due to the risk of medication overuse headaches.
Address any pt anxiety about serious pathology.
Provide reassurance and education.
If chronic headaches, monitor for depression.
Diagnostic tips
HTN is an uncommon cause of headache.
Where headaches and HTN coexist, assume that the headaches are not due to HTN
Combination headaches, which can last for days, have a mix of components such as tension, depression, vascular headache and drug dependence.
A patient >55 yrs presenting with an unaccustomed headache probably has an organic cause
Drugs that may cause headache:
- alcohol
- analgesics (rebound)
- caffeine
- antihypertensives (several)
- COCP
- corticosteroids
- NSAIDs (esp. indomethacin)
- vasodilators esp. nitrates,
- sildenafil
A comparison of typical clinical features of migraine and tension headache
Serious disorders not to be missed
Cardiovascular:
- subarachnoid haemorrhage
- intracranial haemorrhage, especially involving cerebellar, intraventricular and frontal lobe areas
- carotid or vertebral artery dissection
- temporal arteritis
- cerebral venous thrombosis
Neoplasia:
- cerebral tumour
- pituitary tumour
Infection:
- meningitis (esp. fungal)
- encephalitis
- intracranial abscess
Haematoma: extradural/subdural
Glaucoma
Benign intracranial hypertension
Worrying features
Recent onset over weeks (i.e., first, worst, different).
Severe enough to wake patient, or present on waking.
Progressive non-episodic headache without remission.
Vomiting, but no other indication of migraine.
Non-episodic headache with fixed focal neurological S/S
Personality or cognitive change.
Diurnal patterns of pain
Plotting the fluctuation of headache during the day provides vital clues to the diagnosis.
Pt wakes up with headache could have vascular headache (migraine), cervical spondylosis, depressive illness, HTN or a space-occupying lesion.
It is usual for migraine to last hours, not days, which is more characteristic of tension headache.
Frontal sinusitis pain follows a typical pattern, onset 9 am, building to a max by 1 pm, and then subsiding over the next few hours
Combination headache tends to follow a most constant pattern throughout the day and does not usually interrupt sleep.
