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🌟 Headache

 🎯 Types of headaches

  • primary headache

    • the headache has no underlying cause

  • secondary headache

    • the headache is caused by an underlying condition

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💡 Causes

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Primary headache

  • tension headache

  • migraine

  • cluster headache

 

Secondary headache

  • haemorrhage

    • extradural haematoma

    • subdural haematoma

    • subarachnoid haemorrhage

  • infection

    • meningitis

    • encephalitis

    • brain abscess (which is also associated with raised intracranial pressure)

    • acute sinusitis

  • raised intracranial pressure

  • other causes

    • temporal arteritis

    • acute-angle closure glaucoma

    • trigeminal neuralgia

    • medication overuse headache

 

🕵️‍♂️ Assessment

  • bedside

    • thorough history

    • full neurological and eye examination

    • ophthalmoscopy to inspect for papilloedema

  • bloods

    • FBC, U&E, CRP and ESR

  • neuroimaging

    • CT/MRI head

  • invasive

    • temporal artery biopsy of temporal arteritis is suspected

    • lumbar puncture (remember it’s contraindicated in the case of raised intracranial pressure)

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🧩 Differential diagnosis of primary headache

 

Tension headache

  • most common type

  • bilateral, dull and constricting

  • described as a “tight band” around the head

  • may be precipitated by stress, lack of sleep and not eating on time

 

Migraine

  • unilateral and pulsating, and may be accompanied by photophobia and phonophobia

  • a visual aura may precede the attack

  • can last up to 3 days

  • common triggers: caffeine, alcohol, chocolate, oral contraceptives, red wine

 

Cluster headache

  • unilateral severe headache concentrated around the eye

  • associated with redness of the eye and profuse lacrimation

  • linked with alcohol

  • can last up to 2 hours

 

🧩 Differential diagnosis of secondary headache

 

Extradural haematoma

  • caused by a laceration of the middle meningeal artery

  • “loss of consciousness —> lucid interval (patient regains consciousness) —> loss of consciousness once again”

  • shape of haematoma is convex on a CT as blood does not cross suture lines

 

Subdural haematoma

  • rupture of the bridging veins

  • can also present with “fluctuating confusion”

  • accumulation of blood is slower than extradural haematoma as it is a venous bleed

  • alcoholism and age are risk factors as they cause the brain to shrink in size, increasing the susceptibility to acceleration-deceleration brain injury

  • the haematoma is crescentic on a CT as it crosses suture lines

 

Subarachnoid haemorrhage

  • common causes: trauma, rupture of an aneurysm or an arteriovenous malformation

  • “thunderclap headache” or “the worst headache ever”

  • may cause signs of meningism such as neck stiffness

  • linked to autosomal dominant polycystic kidney disease (ADPKD) and Ehler-Danlos syndrome (EDS)

 

Meningitis

  • inflammation of the meninges

  • “headache + neck stiffness + photophobia + fever”

  • non-blanching purpuric rash points towards meningococcal septicaemia

 

Encephalitis

  • inflammation of the brain itself

  • presents similarly to meningitis but with the addition of focal neurological deficits depending on the region of the brain affected

  • if the temporal lobe is affected (e.g. causing aphasia) it may be a sign of herpes simplex (HSV) encephalitis

 

Brain abscess

  • presents similarly to encephalitis but with the addition of raised intracranial pressure

 

Raised intracranial pressure

  • headache that is worse in the morning, coughing and with any Valsalva manoeuvre

 

Temporal arteritis

  • “> 60 years + headache + scalp tenderness + jaw claudication”

  • associated with polymyalgia rheumatica

 

Acute sinusitis

  • “headache worse with bending forward + nasal obstruction + rhinorrhoea”

 

Trigeminal neuralgia

  • “unilateral intense electric shock pain (along dermatomes V2 and V3) lasting for a few seconds triggered by light touch, shaving and washing”

 

Acute-angle closure glaucoma

  • “acute pain red eye + decreased visual acuity + halos around lights + dilated pupil”

  • tonometry is used to evaluate intraocular pressure

  • gonioscopy assesses the angle

 

Medication overuse headache

  • the excessive use of analgesics (e.g. paracetamol, NSAIDs, triptans and opioids) leads to a headache

  • symptoms resolve with the cessation of analgesics

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