Approach to Headache

Author: Learning in 10

The presentation is on headache, one of the most common symptoms we encounter in general medicine and neurology. This presentation will cover the approach to headache in a clinical setting. The main objectives are to learn about the causes and classification of headache, the pertinent history and physical examination for a patient presenting with headache, and most importantly, how to identify features of headache, which may suggest a sinister cause. By the International Headache Society classification, headache can be classified as primary and secondary. Diagnosis of primary headache is made when there is no identifiable cause found. Chronic stereotypical headaches, without associated fixed anomolies on neurological examination, usually represent benign primary headache syndromes. The most common causes for primary headache are migraine, tension headache, and cluster headache. Secondary headaches have an underlying cause.

New onset headaches, associated with neurological dysfunction, are worrisome for underlying brain lesions, or disease processes. Causes of secondary headaches include trauma, intracranial bleed, central nervous system infection, and space occupying lesions. Once should not forget local causes, such as sinusitis, temporal mandibular joint arthritis, dental, and ear infection.

History taking is crucial when approaching a patient with headache. A detailed history of headache will provide clues to the underlying cause. For instance, history of [INAUDIBLE] unilateral headache, nausea and vomiting, photophobia, phonophobia, and aura is highly suggested for migraine with aura. On the other hand, occipital or bilateral headache, often described as a tight squeezing band, is more suggestive of tension-type headache. Always look out for red flags in patients with headache, which may indicate dangerous, and even life threatening causes such as meningitis, space occupying lesion, and subarachnoid or intracranial hemorrhage.

These red flags from the history include the worst headache ever, symptoms suggestive of raised intracranial pressure, or focal neurological deficits, altered mental state, fever, and neck stiffness to suggest [INAUDIBLE]. Physical examination of a patient with headache is to mainly detect clinical signs suggestive of a secondary cause. Physical examination of a primary headache is usually normal. With meningitis, the patients may be febrile with nuchal rigidity and Kernig's sign. Temporal artery tenderness , may indicate giant cell arthritis. Altered mental status, focal neurological signs, and papilloedema will suggest possibility of a space occupying lesion. Subhyloid hemorrhage may be associated with sub-arachnoid hemorrhage. Most patients with primary headache do not require any specific investigations.

Approach to Headache

Further work-up is usually indicated for patients with secondary headache. The necessary investigations depend on the presentation and suspect the etiology of headache. A full blood count is usually performed to look for raised white counts, suggesting infection. Elevated serum erythrocyte site sedimentation rate is also seen with temporal arteritis. Brain imaging is indicated for patients with secondary headaches, or with a red flag feature.

A lumbar puncture should be performed when infection, or subarachnoid hemorrhage is suspected. One of the most common causes of headache is migraine. Migraine presents the recurrence stereotypical headache. It usually lasts for hours, and may have features including unilateral pain, pulsating nature, moderate or greater severity, and aggravation by physical activity. Migraine headache is usually accompanied with nausea, vomiting, photophobia, or phonophobia. Migraine is three times more common in women. A positive family history often exists. Migraine symptoms can overlap with those of tension and cluster headaches.

Another common cause of primary headache is tension headache. Tension headache typically presents a bilateral pain of a pressing or tightening nature, which is of mild to moderate severity, and is usually not related to physical activity. As its name implies, the most common trigger for tension headache is stress. Acute abortive treatment, with analgesics such as NSAIDs, relaxation training, stress management, and counseling, as well as prophylactic medications have to be shown to be beneficial in reducing the frequency of tension headaches.

Cluster headache usually presents with attacks of severe unilateral pain in the orbital, supraorbital, and temporal regions, or any combination of these sites. The headache usually lasts for 15 to 180 minutes, and recurs from one to eight times per day. The attacks are associated with one or more of the following symptoms, conjunctivital injection, lacrimation, nasal congestion and rhinorrhea, eyelid edema, forehead and facial setting, miosis and ptosis, which are typically in ipsilateral to the site of the headache.

Most cluster headache patients appear restless and agitated during an attack. In summary, it is important to know then there are serious causes of headache that require urgent treatment. New-onset severe headaches and those associated with neurological deficits suggest a possible sinister cause. One should evaluate for red flags in the history and physical examination, which suggest a secondary cause. These patients require further investigation for the underlying cause. On the other hand, chronic stereotypical recurring headaches, with no neurological deficits, which fit a profile of one of the primary headaches are benign, and may not require further work-up. We hope this presentation provided you a useful summary on approach to patients presenting with headache. Thank you for your attention.

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