Headache

last authored:
last reviewed:

Introduction

With over 300 different causes, 'headache' is the biggest differential in medicine.

headache

Marcos Arinatwe (age 10, Uganda)

The Case of...

return to top

Differential Diagnosis

primary headaches
secondary headaches

Primary Headaches

	migraine	tension	cluster
epidemiology	12% of adults; F>M 20% with aura; 80% without	40% of adults can be episodic or chronic	<0.1% of adults M>>F
duration	5-72 hours	variable duration; may be isolated or daily	<3hrs; same time of day
aura	lasts 20-25 min lights most common slow migrainers march: hand, face, legs smell
pain	classically unilateral and throbbing 40% bilateral moderate-severe intensity nausea/vomiting photo/phonophobia	mild-to-moderate pain bilateral fronto-occipital or generalized bandlike +/- contracted neck muscles associated with little disability	sudden, unilateral, severe usually centred around eye frequently awakens patient
family history	strong
associated features	strong correlation with sleepwalking and motion sickness
triggers	numerous: food, sleep disturbance, stress, hormonal, fatigue, weather, altitude aggravated by physical activity post-menopausal women can experience intense migraine, with possible only	stressful events not aggrevated by physical activity	often alcohol can't sit or lay down - walking, agitation
treatment	1st: acetaminophen, ASA +/- caffeine 2nd: NSAIDs 3rd: 5HT agonists, +/- amtiemetics	R and R NSAIDs	imitrex ergotamine inhaled O2 lidocaine by nasal installation
prophylaxis	1st: beta blockers 2nd: TCAs 3rd: anticonvulsants	R and R, physical activity, biofeedback	lithium carbonate, prednisone, methysergide

Secondary Headaches

Secondary headaches account for less than 10% of all headaches, but can be life-threatening.

They include:

space-occupying lesions (50-60% of cases of brain tumour have headache)
systemic infections: meningitis, encephalitis
subarachnoid hemmorhage or other stroke
systemic disorders: thyroid disease, hypertension, phaeochromocytoma
temporal arteritis
traumatic head injuries
TMJ or C-spine pathology
serious opthalmological/otolaryngological causes
glaucoma

Avoid suggesting symptoms

return to top

History and Physical Exam

history
physical exam

History

Patient demographics: age, race, occupation

History of presenting illness

pain: OPQRST
course over time
past events
medications

Risk factors

constitutional symptoms: night sweats, weight loss, fatigue
infectious symptoms: fever, changes in LOC, travel, sick contacts, myalgias, recent infection, immunosuppression
subarachnoid hemorrhage: trauma, alcohol, age
possible toxic exposure: anyone else around with the same type of symptoms

Specific presentations

Brain tumours or other space-occuping lesion

headache present upon wakening, or worse in morning
nausea, vomiting
visual changes
new headache after age 50
focal signs
papilledema
triggered by cough, exertion, Valsava

Hemorrhage

worsening pattern
sudden onset ("thunderclap")
worst headache ever
systemic illness

Physical Exam

Vital signs: fever? hypertension? HR, RR (decreased with increased ICP)

neurological exam

return to top

Investigations

lab investigations
diagnostic imaging

Lab Investigations

Warranted if red flags are present. They include:

CBC for systemic/intracranial infection
ESR for temporal arteritis
neuroimaging (CT/MRI) to r/u intracranial pathology
CSF analysis for suspected hemorrhage, infection, tumour

Lumbar puncture for suspected meningitis or subarachnoid hemorrhage; contraindicated if mass suspected or seen on CT, or if skin at site of injection is infected.