Approach to Headache

Differential diagnosis

• Inflammatory
  • Giant cell arteritis
  • Optic neuritis
• Vascular
  • Subarachnoid haemorrhage
  • Subdural haemorrhage
  • Epidural haematoma
  • Cerebral vein thrombosis
• Infectious
  • Meningitis
  • Septic carvenous sinus thrombosis
  • Brain abscess
• Headache syndromes
  • Migraine
  • Tension headache
  • Cluster headache
  • Analgesia misuse headache
  • Cervical headache
• Raised intracranial pressure
  • Brain tumour
  • Benign intracranial hypertension
  • Hydrocephalus
• Obstructive sleep apnoea
• Hyperviscosity
  • Polycythaemia
  • Acute leukaemia
  • Chronic lymphocytic leukaemia
  • Waldenström’s macroglobulinaemia
• Low pressure headache
• Hypertension
• Pre-eclampsia
• Traumatic
• Psychogenic

History

• Headache
  • How did it start?
  • Where is the headache?
  • Is it on one side of the head or both?
  • Did it start suddenly?
  • Was it most painful at the start, or does it gradually get more painful?
  • What does the pain feel like?
  • Have you noticed any other symptoms with the headache?
    • Any nausea or vomiting?
  • Does anything make it better?
  • Does anything make it worse?
  • How bad is the pain on a scale of 1 – 10?
  • If recurrent: how often do you get the headaches?
  • Have you ever had this before?
• Inflammatory
  • Do you have any fever?
  • Have you noticed any blurred vision?
  • Do you get pain in your jaw when you eat?
  • Does your head hurt if you brush your hair?
  • Have you ever noticed that colours are not as vibrant or bright as before?
• Raised ICP
  • Is the headache worse when you cough?
  • Is it worse in the morning?
  • Is it worse when you squat?
  • Do you have nausea or vomiting with the headache?

Investigation

• Computed tomography to rule out ICH
• Magnetic resonance imaging of the brain and venography to rule out space-occupying lesion
• BIH: papilloedema
• Lumbar puncture: raised opening pressure in BIH, meningitis
• Radioisotope cisternography for low pressure headache

Management

• Meningitis
  • Ceftriaxone 2g BD, acyclovir IV 5mg/kg 8H
  • Ampicillin if elderly
  • Streptococcus pneumoniae or TB meningitis: dexamethasone 0.15mg/kg 6H
• Migraine
  • Acute: NSAIDS with tryptans
  • Prophylaxis: propranolol or topiramate
    • When to start depends on patient factors and quality of life
  • Avoid OCP in patients with migraine and aura
• Cluster headache
  • Acute: oxygen, tryptans
  • Prophylaxis: verapamil
• Benign intracranial hypertension
  • Weight loss
  • Stop OCP
  • Stop smoking
  • Acetazolamide
  • Lumbar puncture (therapeutic)
  • Optic nerve fenestration