Secondary Headache

Question 1

When are headaches strong indicators of intracranial pathology?

Answer 1

• When they are new, onset suddenly, change pattern or type or have associated trauma
• Longstanding episodic headache usually doesn’t indicate an underlying pathology

Question 2

Red flags that support headache as an indicator of underlying pathology?

Answer 2

• New headache / change in headache character
• Presence of neurological symptoms / abnormal neurological examination
• Neck stiffness / fever
• High / Low Pressure: body positioning, physical exercise, valsalva manoeuvre precipitate headache
• GCA (giant cell arteritis - form of vasculitis, prominent arteries, visual disturbance, jaw claudication)

Question 3

What is a thunderclap headache?

Answer 3

• A high intensity headache reaching maximum intensity in less than 1 minute
• May be primary or secondary headache

Question 4

Differential diagnoses for thunderclap headache?

Answer 4

• Primary
• Subarachnoid / intracerebral haemorrhage
• TIA / Stroke
• Carotid / vertebral dissection
• Cerebral venous sinus thrombosis
• Meningitis / encephalitis
• Pituitary apoplexy
• Spontaneous intracranial hypotension

Question 5

If a patient presents with thunderclap headache and normal examination / history, what should be done?

Answer 5

• CT head
• 1/10 thunderclap headaches are subarachnoid haemorrhage, examination often normal. Early coiling of aneurysm saves lives

Question 6

What should be considered when a patient presents with headache and a fever?

Answer 6

• CNS infection: meningitis and encephalitis
• Meningitis: nausea, maybe vomiting, photo/phono phobia, stiff neck
• Encephalitis: altered mental state / consciousness, focal symptoms, seizures

(look for a rash)

Question 7

What symptoms are associated with space occupying lesions / raised ICP?

Answer 7

• Progressive headache + associated symptoms

Red flags:

• Headache worse in the morning / after sleep / after valsalva
• Focal / non-focal symptoms
• Seizures
• Visual obscurations + pulsatile tinnitus

Question 8

What headache characteristics can indicate intracranial hypotension?

Answer 8

• Clear postural component to headache (worse when standing, better when lying down)
• Once headache becomes chronic it can lose postural component

Question 9

Investigations and treatment for headache suggesting intracranial hypotension?

Answer 9

• Investigations: MRI brain and spine

- Treatment: caffeine, bed rest and analgesia

Question 10

What are the symptoms of a patient with GCA? (giant cell arteritis)

Answer 10

• Diffuse, persistent and possibly severe headache
• Scalp tenderness, jaw claudication and visual disturbance
• Prominent, beaded or enlarged temporal arteries may be present

Question 11

What are some investigations for GCA? If the diagnosis is considered what course of action should be taken?

Answer 11

• ESR, Platelet count and CRP (usually all raised)

- If diagnosis is considered start patient on high does prednisolone and arrange temporal artery biopsy