HEADACHE 4 th year module

Introduction Headaches are very common – who hasn’t had one? We see a lot of patients with headache in the ED and the trick is to work out those that have a benign cause for their headache vs those who have a potentially devastating diagnosis. An excellent history and thorough examination will greatly help in differentiating these two group of patients

Headache – a framework Primary headache Recurrent and (generally)benign Secondary headache Due to an underlying disease process Potentially very serious/fatal

Primary headache Migraine Tension headache Cluster headache Rebound or analgesia associated headache

Secondary headache Vascular Subarachnoid haemorrhage AVM Stroke Cavernous sinus thrombosis Carotid or vertebral artery dissection Temporal arteritis Tumour Trauma Epidural/subdural/subarachnoid haemorrhage Infection Meningitis Encephalitis Brain abscess Benign intracranial hypertension Ophthalmological Glaucoma Optic neuritis Iritis Toxins Carbon monoxide poisoning Metabolic Hypoxia Hypercapnoea Hypoglycaemia Preeclampsia Other Sinusitis Dental TMJ dysfunction Trigeminal neuralgia Post LP headache

History A good history is essential in the diagnosis of the cause of the patient’s headache Onset Sudden vs gradual What were they doing when they headache started? Intensity/severity ? Worst ever Location Uni or bilateral, frontal/occipital Pattern Recurrent/previous similar headaches vs new onset Improving/worsening Worse at particular time of the day? Associated features Fever Nausea/vomiting Visual changes Photophobia Neck pain Loss of consciousness/syncope Focal neurological deficit

Examination Vital signs Temperature, BP Full and thorough neurological examination Cranial nerves including fundoscopy Limb neurology Gait Skin ? Rash Look for signs of meningism Neck suppleness/movement Kernigs: with patient flat bend thigh/knee to 90 degrees, positive if painful to straighten knee Brudenskis: involuntary lifting of the legs when lifting a patient's head off the examining couch, with the patient lying supine.supine. Also should include….. Eye examination ENT examination Dental/TMJ examination Temporal artery palpation if indicated

Investigations Most patients with a benign cause for their headache require no investigations Further workup might include….. Blood tests Particularly looking at inflammatory markers (WCC, CRP, ESR) Lumbar puncture Neuroimaging CT (with or without contrast) MRI/MRA

Notes on a few of the big players…..

Migraine May be preceded by an aura (10-20%) Typically visual symptoms: eg - scintillating scotoma More common in females, often have family hx Typically Recurrent in nature Same or similar onset/severity/triggers/associated symptoms Gradual onset Moderate to severe intensity Frontal, unilateral, pulsating in nature Accompanied by photo/phonophobia, nausea/vomiting Lasts up to 72 hours Sometimes may be preceded or accompanied with focal neurological deficits But this is a diagnosis of exclusion!

Cluster headache Typically affects young men Intense unilateral periocular headaches that come in clusters with complete recovery between attacks Eg: mins 1-6x/day for 2 weeks Often associated with unilateral autonomic symptoms Ptosis/miosis Lacrimation/rhinorrhoea/nasal congestion Conjunctival injection High flow oxygen therapy is a very effective treatment Also sumitriptan

Subarachnoid haemorrhage Typically sudden onset, worst ever headache “thunderclap” Most commonly occiptonucal in location Can just present with sudden onset neck pain Can be associated with syncope, vomiting, decreased LOC, focal neurological deficit ½ will present to ED with a completely normal neurological examination A “sentinel bleed” (ie: leak) can completely resolve with no or very little analgesia The next bleed is generally catastrophic Standard of diagnostic care at present is a CT head followed by a LP at least 12h after onset of headache if this is normal (looking for blood in the CSF/xanthochromia) *watch this space: there is some evidence that if the CT is performed within 6h of onset of headache, that a normal CT may be enough to rule out SAH

Tumours Around 50% of people with brain tumours will have no headache May present with signs of increased ICP Worse in the morning Associated vomiting Can present with seizure May have associated neurological deficits Focal deficits, visual symptoms, ataxia Can be uni or bilateral, continuous or intermittant Think of this if a patient has presented with a subacute onset of worsening headaches unlike those experienced before

Temporal arteritis Usually occurs in women >50 years Typically unilateral piercing temporal pain with tenderness over the (often non-pulsitile) temporal artery May have associated claudication symptoms TMJ pain with chewing Strongly associated with polymyalgia rheumatica Inflammatory markers (ESR/CRP) typically raised Diagnosis is by temporal artery biopsy Failure to diagnose and treat (with high dose steroids) can lead to blindness (ischaemic optic neuritis)