HEADACHE

1. NYHIRABA IRENE
2. MONNIE MAXWELL JUSTICE
 OUTLINE
Scope of problem

Classifications

Diagnosis – History & Examination

Types – Clinical features, Management

Investigations

Management

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 SCOPE OF PROBLEM
• Headache is a very common complaint, with three out of four of patient
who present to the emergency
• A patient with a headache may have a serious or minor aetiologies.
• Most patients presenting to the ED have a benign headache requiring
symptomatic treatment and referral when necessary.
• A small subset of patients who present with a headache will have a life-
threatening illness; it is the primary goal of the treating clinician to
identify these patients and provide appropriate care.
• The pain from headache can originate from extracranial or intracranial
structures. Extracranial structures that can cause pain include skin, blood
vessels, muscles, and bone. Intracranial structures with pain fibres
include venous sinuses, the dura at the base of the skull, dural arteries,
the falx cerebri, and large arteries at the base of the brain.
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 CLASSIFICATION
• Headache can be divided
into primary or secondary
disorders.
• Secondary headache may
be due to structural,
infective, inflammatory or
vascular conditions
• Primary headaches may not
have a specific causative
agent, these includes
migraines, cluster, and
tension-type headaches
account for 90% of
headaches in clinical
practice.
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DIAGNOSIS
Where is your pain?
• Unilateral headaches are suggestive of migraines or a mass on the ipsilateral side,
Headaches that progress from unilateral to bilateral may be from increased ICP
• Orbital headaches suggest glaucoma, optic neuritis, cluster headache, and cavernous
sinus thrombosis.
• Occipital headaches suggest cerebellar lesions, muscle spasm, and cervical radiculopathy.
However, an acute occipito-cervical headache can be associated with intracranial
pathology
How did the pain begin (sudden vs. gradual onset) and how long has it been
present?
• A patient with sudden onset headache should be investigated for ruptured
aneurysm or subarachnoid haemorrhage (SAH).
• Gradual onset of headaches that have persisted for weeks or months suggest of
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• What does the pain feel like?
• Severe, intense, sudden onset, or “thunderclap” headaches may be the result
of SAH
• Pulsatile pain that correlates with the patient’s pulse is usually vascular in
origin. If the pain is pulsatile but does not correlate with the pulse, it is
nonspecific.
• A dull, constant band-like occipitofrontal headache is characteristic of tension
headache.
• What time of day is your headache worse?
• If a patient complains that they wake up with a headache, one must
consider hypertension, cluster, or neoplastic aetiologies.
• However, patients with tension headaches often awaken pain-free
and develop their headache as the day progresses.
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Does anything make the pain better or worse
• A headache that worsens with coughing, bending, or turning the head may be
associated with a mass lesion or sinusitis.
• Post-dural puncture headaches generally improve or disappear with recumbence
and worsen when the patient is upright.
What medications are you taking or have you changed any medications?
• Medications that commonly cause headaches include nitroglycerine, hydralazine,
calcium channel blockers, digitalis, and estrogen.
• Patients who stop drinking coffee may develop a headache within 24–48 hours of
abstinence. The headache resolves following ingestion of caffeine
• Alcohol, marijuana, and amphetamines may also induce headaches.
A patient who uses cocaine may have a headache due to an intracranial bleed.
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Have you had the pain before?
• Patients with migraine, cluster and tension headaches often have a history of similar
headaches
• A significant change in intensity, location, or character from prior headaches may
indicate serious new pathology, such as a SAH.
Associated signs and symptoms?
• Nausea/Vomiting – with migraine headaches, in patients with SAH, meningitis,
post-LP headaches, or those with increased ICP.
• Photophobia – irritation from SAH or meningitis, migraine and can also arise from a
pathologic problem with the eyes, such as iritis, uveitis, or acute angle closure
glaucoma.
• Fever – Meningitis
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• Neck stiffness & Seizures - can be a sign of meningeal irritation from SAH or
 Past Medical & Family History
• A positive family history is present in 70% of patients with
migraines. There is no family history with cluster
headaches.
• A family history of SAH is a risk factor for SAH. There is a
familial association of cerebral aneurysms with several
diseases, including autosomal dominant polycystic disease,
coarctation of the aorta, Marfan’s syndrome, and Ehlers–
Danlos syndrome type IV.
• A previous history of neurosurgery or malignancy (with
potential for metastases) should raise concern for
intracranial pathology, including a malfunctioning
indwelling shunt
 PHYSICAL EXAMINATION
Vitals
General appearance
Vital signs can be
• Distress ? abnormal in patients with a
headache.
• Signs of shock ? • Tachycardia and
tachypnea may be
• Signs of ICP? – cushings triad
secondary to pain.
• An elevated blood
pressure may be seen
with SAH.
• An elevated temperature
may indicate an
intracranial infection
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Head : Inspect and palpate for tenderness, Temporal arteritis may present
only with a complaint of headache. A tender area of the scalp that exactly
reproduces the head pain may indicate neuralgia
Eye: General eye examination maybe necessary, visual acuity, pupil size,
extraocular movements, and for evidence of photophobia, retinal
haemorrhages.
Skin : Look for rash associated with meningococcaemia, vasculitis?

Neurologic: This includes assessment of mental status, cranial nerves,

motor, sensory, and cerebellar function.
Meningeal signs: neck stiffness, Brudzinski's sign, Kernig’s sign, Jolt
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accentuation of headache
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 TYPES OF HEADACHES
 PRIMARY HEADACHES

• Tension headache
This is the most common type of headache and is experienced to some degree by
the majority of the population.
• S/S : The pain of tension headache is characterised as ‘dull’, ‘tight’ or like a
‘pressure’, and there may be a sensation of a band round the head or pressure
at the vertex, it is of constant character and generalised, but often radiates
forwards from the occipital region.
• Rx [ Advise on the possible precipitants]
[ head muscle massage ]
[Low dose amitriptyline]
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• Migraine
Migraine usually appears before middle age, or occasionally in later life; it affects about
20% of females and 6% of males at some point in life.
S/S : Some patients report a prodrome of malaise, irritability or behavioural change for
some hours or days, temporary visual field loss, language function can be affected,
Migraine headache is usually severe and throbbing, with photophobia, phonophobia and
vomiting lasting from 4 to 72 hours. Movement makes pain worse and patients prefer to
lie in a quiet, dark room
Rx [ Advise on the possible precipitants. E.g. – contraceptive use]
[Simple analgesia with aspirin, paracetamol or non-steroidal anti-inflammatory agents.
]
[Nausea may require an antiemetic such as metoclopramide or domperidone]
[If attacks are frequent (more than two per month), prophylaxis should be considered
vasoactive agents,(β-blockers),candesartan, lisinopril, antidepressants (amitriptyline) and14
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Cluster headache
Cluster headaches (also known as migrainous neuralgia) are much less common than
migraine Although uncommon, it is the most common of the trigeminal autonomic
cephalalgia syndromes. Functional imaging studies have suggested abnormal
hypothalamic activity. Patients are more often smokers with a higher than average
alcohol consumption
S/S : Cluster headache is strikingly periodic, featuring runs of identical headaches
beginning at the same time for weeks at a stretch (the ‘cluster’). Patients may
experience either one or several attacks within a 24-hour period, and typically are
awoken from sleep by symptoms (‘alarm clock headache’). Cluster headache causes
severe, unilateral periorbital pain with autonomic features, such as ipsilateral tearing,
nasal congestion and conjunctival injection
• Rx [Acute attacks can usually be halted by subcutaneous injections of sumatriptan or
inhalation of 100% oxygen]
[Patients with severe debilitating clusters can be helped with lithium therapy,
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 DDX - SECONDARY HEADACHE

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 Investigations
 Radiological

1. CT scan
2. MRI
3. Cerebral angiogram
 Laboratory

1. Full Blood Count

2. ESR
3. Arterial Blood Gases
4. CSF analysis
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 MANAGEMENT
SECONDARY HEADACHE MANAGEMENT

Carotid and vertebral artery dissection Resuscitation

Stabilization with antiplatelets
Emergent neurosurgical consultation

Carbon monoxide Treatment is with 100% oxygen. Some patients may require
hyperbaric oxygen therapy depending on the CO level and their
symptomatology

Pregnant women Antihypertensives

Anticonvulsants

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 THANK YOU
FOR YOUR ATTENTION

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