Headache

Phone Call/Presentation Questions

• Was the onset sudden or gradual? Sudden onset of a severe headache is a SAH until proven otherwise?
• How bad is the headache?
• What are the vital signs?
• Is there an altered level of consciousness?
• Are there any associated symptoms? Fever is associated with meningitis, vomiting with raised ICP and phonophobia plus photophobia with migraine headache.
• Does the patient regularly suffer from headaches? Do the features of this headache differ from previous headaches?
• Has the patient had a recent LP? Post-LP headache occurs in 10–30% patients.
• What was the reason for admission?

Instructions Over the Phone

• Ask the nurse to take a full set of vital signs and to assess the patient’s neurological status
• Request medication that has relieved the headache in the past, or prescribe a non-narcotic analgesic such as paracetamol 1 g PO or aspirin 300 mg with codeine 8 mg two tablets PO
• Give metoclopramide 10–20 mg IV, together with dispersible aspirin 300 mg three tablets (900 mg) PO if migraine is likely
  • Metoclopramide reduces the pain of migraine in addition to its antiemetic effect
• Ask the nurse to call back in 1 hour if a headache without concerning features has not been relieved by the medication

Prioritisation

• A sudden severe headache and a headache associated with fever, vomiting or a decreased level of consciousness mandate seeing the patient immediately
• A patient with a chronic or recurrent headache should have analgesia prescribed and be reviewed non-urgently

Common Causes (Corridor Thoughts)

• Secondary headaches:
  • Intracranial
    • Haemorrhage (subarachnoid, intracerebral, subdural)
    • Infection (abscess, meningitis, encephalitis)
    • Posttraumatic (subdural, extradural, cerebral contusion)
    • Cerebral space-occupying lesion (secondary metastasis, primary benign or malignant tumour, abscess, tuberculoma)
    • Cerebral venous sinus thrombosis
    • Idiopathic (benign) intracranial hypertension
    • Cerebral vasculitis such as SLE, RA, PAN, Wegener’s granulomatosis
    • Post-LP
  • Local
    • Glaucoma (always examine for a painful red eye, with a cloudy cornea and ovoid, fixed pupil)
    • Temporal arteritis
    • Vertebral artery dissection
    • Neuralgia (greater occipital, glossopharyngeal, trigeminal)
    • Sinusitis, otitis media, mastoiditis
    • Dental caries, tooth abscess
    • TMJ dysfunction
    • Cervical osteoarthritis
  • Systemic
    • Severe hypertension
    • Systemic infection
    • Hypercapnia
    • Preeclampsia (is the patient pregnant?)
  • Drugs
    • Nitrates
    • Calcium channel blockers
    • NSAIDs
    • Medication overuse headache
• Primary headaches
  • Tension headache
  • Migraine
  • Cluster headache

Assessment

End of Bed

• Patients with SAH, meningitis or intracranial herniation look sick, are often in significant pain and frequently have altered mental status
• Patients with migraine are also distressed and sick, but remain fully conscious

A to E Assessment

• Blood pressure?
  • Severe hypertension (SBP >180mmHg and DBP >120 mmHg) can result in a headache
  • Otherwise, headache is not a symptom of headache unless there has been a sudden increase in BP or an associated intracranial bleed
• Heart rate?
  • Hypertension + bradycardia ⇒ ↑ ICP
• Temperature?
  • Fever + headache → immediate blood cultures, IV antibiotics, CT scan and LP if no contraindications

Initial Examination: Signs of ↑ ICP or Meningitis?

Examination	Notes
HEENT	Nuchal rigidity (meningitis, SAH)
Fundoscopy	Absent venous pulsations (earliest sign of raised ICP)
	Papilloedema
	Retinal haemorrhages ⇒ hypertension, SAH
Mental status
Neuro	Test for Kernig’s sign and Brudzinski’s sign ⇒ meningitis, SAH
	Unequal pupils + ↓ level of consciousness → life threatening. Call for senior help and arrange for intubation, a CT head scan and urgent neurosurgical consult
Skin	Maculopapular rash (early), petechiae or purpura (later) ⇒ meningococcaemia → call for senior help, take blood cultures immediately and give benzylpenicillin 2.4g IV or ceftriaxone 2g IV if penicillin hypersensitive

Immediate Management

• Attach monitoring (non-invasive ECG, BP and pulse oximeter)
• Commence oxygen therapy to maintain oxygen saturation >94%
• Obtain IV access with large-bore 14-16G peripheral cannulae
  • Draw and send blood samples for FBC, coags, UEC, LFT, group and hold and if ? infection two sets of paired blood cultures
• Give antibiotics for suspected meningitis and titrate morphine 2.5mg IV boluses with metoclopramide 10mg IV for SAH
• Request immediate CT head scan if secondary intracranial cause suspected
• LP contraindicated when:
  • Papilloedema
  • Focal neurology incl. altered conscious level
  • Immunosuppression
  • Coagulopathy

Immediate Specific Management

• Patient unwell with fever, altered mental status, nucal rigidity or photophobia ⇒ bacterial meningitis:
  • Give normal saline to support low BP
  • Give dexamethasone 0.15mg/kg IV with ceftriaxone 4g IV as soon as the diagnosis is suspected
    • Do not delay initial management while awaiting for an LP
  • If altered behaviour, speech disorder, focal neurology or CSF shows atypical leucocytosis (predominantly monocytes) or negative Gram stain for bacteria ⇒ herpes simplex encephalitis → aciclovir 10mg/kg IV
• Patient unwell with fever and there is subdural empyema, brain abscess, suspected infected ventriculoperitoneal shunt → call neurosurgery immediately
• Severe headache, confusion or altered conscious level, nuchal rigidity but no fever ⇒ ? SAH
  • Request urgent non-contrast CT head scan
• Typical aura, no fever, no nuchal rigidity, no confusion and no papilloedema ⇒ migraine headache
  • Other features common: vomiting with photophobia and phonophobia and past history of migraine
  • Never make a first diagnosis of migraine with a defintiive history of previous similar attacks
  • Give metoclopramide 10-20mg IV + NSAID (e.g. aspirin 300mg three tablets = 900mg PO) + commence normal saline at 500mL/h if volume depleted

Selective History and Chart Review

• Onset sudden or insidious?
  • Sudden onset ⇒ vascular cause e.g. subarachnoid or intracerebral haemorrhage, cerebral venous sinus thrombosis or vertebral or carotid artery dissection
• Headache severity?
  • Sudden onset worst headache ever ⇒ SAH until proven otherwise
  • Migraine headache causes pain bad enough to interfere with normal daily function
  • Muscle contraction headaches (tension) are band-like, mild and rarely incapacitating
• Main site of pain?
  • Unilateral throbbing headache ⇒ migraine
  • Tight band around the head or ache acorss the forehead ⇒ tension headache
  • Lancinating or electric shock pain ⇒ neuralgia
  • Extreme facial or eye pain in short recurring bouts, many months apart ⇒ cluster headache
  • Retro-orbital pain may be caused by orbital lesions including glaucoma, cavernous sinus venous thrombosis, berry aneurysm and SAH, and sphenoid or ethmoid sinusitis
• Affect of posture on headache severity?
  • Tension headache is improved by lying down and resting
  • Headache worse by lying or bending down ⇒ ↑ ICP
  • Headache worse by standing up ⇒ low-pressure syndrome such as post LP headache or spontaneous CSF leak
• Other associated symptoms?
  • Visual aura such as scintillations, zigzag lines, migratory scotomata and tunnel or blurred vision precede a ‘classic migraine’ headache
  • Cluster headaches are associated with unilateral parasympathetic signs such as conjunctival injection, lacrimation, rhinorrhoea, ptosis and miosis on the same side as the pain
  • Clicking or popping when opening or closing the jaw indicates TMJ dysfunction
  • Hearing loss is associated with otitis media and mastoiditis
• Past history of chronic, recurring headaches and what is their pattern?
  • Tension headache is generally mild in the morning and becomes more severe over the day
  • Headache from raised ICP is worse on wakening, with effortless vomiting
  • Migraine headache is commonly unilateral, pulsating or throbbing in nature, is aggravated by movement and is associated with nausea and/or vomiting, photophobia or phonophobia
• Unwell for weeks or months
  • Malaise, scalp tenderness or hyperaesthesiae, jaw claudication, weight loss and shoulder girdle ache ⇒ temporal (giant cell) arteritis ± polymyalgia rheumatica (PMR) in patients older than 50 years
    • Send blood for an ESR, and if raised >50 mm/h start prednisone 60 mg PO immediately
  • Acute angle-closure glaucoma may be precipitated by pupil dilation
    • The patient complains of a severe unilateral headache located over the brow and may develop nausea, vomiting and abdominal pain that can be mistaken for an acute abdomen
• Medication charts
  • Nitrates, calcium-channel blockers, oral contraceptives and NSAIDs can cause headache
  • Anticoagulant therapy (e.g. warfarin or a NOAC) ⇒ ? intracranial haemorrhage → urgent CT head scan + seek senior help to reverse the anticoagulation
    • A low threshold for investigation should also be maintained in elderly patients taking aspirin or clopidogrel, particularly following a fall

NOTE

Relief of pain with analgesia does not aid diagnosis. Do not discount the seriousness of a headache just because it has responded to analgesia, as it can still be a SAH

Examination

Examination	Notes
Vitals	Repeat now
HEENT	Red eye ⇒ acute angle-closure glaucoma, cluster headache
	Tender, raised temporal artery ⇒ temporal arteritis
	Tenderness on percussion over the frontal or maxillary sinuses ⇒ sinusitis
	Inability to fully open the jaw and the tenderness over the TMJ ⇒ TMJ dysfunction
	Evidence of recent head trauma ⇒ subdural or extradural haematoma
	Haemotympanum or blood in the ear canal, raccoon eyes ⇒ basal skull fracture
	Palpate the scalp muscles for evidence of tenderness or contraction ⇒ tension headache, occipital neuralgia
	Tenderness at the apex of the suboccipital triangle that exacerbates the pain ⇒ greater occipital neuralgia
Neuro	Complete neuro exam
	Unequal pupils or abnormality of conscious level, visual fields, eye movements, limbs, tone, reflexes or plantar responses suggests structural brain disease → make certain an urgent CT head scan has been arranged and you have called your senior

Investigations

• Bloods
  • FBC may be unhelpful, as a proportion of patients with meningitis will have a normal WCC and differential
  • Arrange an ESR in patients >50 with suspected temporal arteritis
  • Check coagulation profile if the patient is on anticoagulants or is septic with DIC
• Imaging
  • Arrange urgent CT head scan for:
    • Sudden onset ‘thunderclap’ headache (SAH)
    • Neurological deficits (other than migrainous aura), altered mental status, papilloedema, nuchal rigidity or seizures, haemorrhage, abscess, vasculitis
    • Recent head trauma (subdual, extradural or intracranial bleed)
    • Patient is on anticoagulation medication
• Proceed to LP and CSF analysis in suspected meningoencephalitis, SAH or benign intracranial hypertension
• If CT scan inconclusive and suspected cerebral venous sinus thrombosis, vasculitis or vertebral or carotid artery dissection → MRI/MRA

Specific Management

Meningoencephalitis

• Presentation: Generalised headache, fever and vomiting with altered mental status, irritability and drowsiness progressing to coma, neck stiffness and photophobia
• Most often viral but if bacterial: Neisseria meningitidis, Streptococcus pneumoniae, Haemophilus influenzae (non-vaccinated) and Listeria monocytogenes
  • Viral infection usually causes less severe headache, and may have a typical prodrome, but always do an LP if in any doubt.
  • Suspect herpes simplex virus (HSV) encephalitis if altered level of consciousness, behavioural disturbance, focal neurological deficits or seizures
• Commence antibiotics and/or antiviral therapy as soon as two sets of paired blood cultures have been drawn
  • Do not delay by waiting for a CT scan or LP
• Perform a non-contrast CT head scan before an LP to exclude SAH or unexpected focal mass lesion such as a cerebral abscess

Subarachnoid Haemorrhage

• Presentation: Sudden or ‘thunderclap’, severe, ‘worst-ever’ headache, sometimes following exertion or straining, with nausea, vomiting, altered conscious state and meningism
  • Oculomotor palsy or other focal findings are common
• Give the patient oxygen (aim for oxygen saturation >94%) and nurse head upwards
• Gain IV access and send blood for FBC, coagulation profile, UEC, blood glucose and group & hold
• Attach cardiac monitor and pulse oximeter to the patient
• Give paracetamol 500mg and codeine phosphate 8mg
  • Avoid any NSAID
  • Can give morphine 2.5-5mg IV boluses
• Call senior
• Control agitation or seizure with IV benzodiazepine
• Perform an ECG, request CXR and urgent non-contrast CT head scan
• If CT head normal → LP after >10-12 hours after the headache
  • Send CSF for microscopy, culture, glucose, protein and xanthochromia studies
• Refer to neurosurgery if
  • Diagnosis is confirmed by red cells with xanthochromia or
  • If the CSF analysis for xanthochromia was equivocal

Space-Occupying Lesion

• Headaches become progressively more frequent and severe, worse in the mornings and exacerbated by coughing, bending or straining
  • Vomiting without nausea and focal neurological signs develop, including subtle personality change, changes in concentration or even disinhibited behaviour
• Fundoscopy can show loss of spontaneous venous pulsation int he central retinal vein and blurring of the optic disc margin
• Arrange an immediate CT head scan and perform CXR to look for primary tumour
• Refer to neurosurgery when confirmed mass lesion

Temporal Arteritis

• Patients aged >50 years, with diffuse or bitemporal headache associated with a history of malaise, weight loss and myalgia plus shoulder girdle weakness from associated polymyalgia rheumatica
  • Sometimes pain on chewing
• Assess for localised scalp tenderness and hyperaesthesia with temporal artery tenderness
• Send blood for ESR and give prednisolone 60mg immediately
• Arrange for temporal artery biopsy within the next 7 days

Migraine

• Ask the patient what is usually taken for the migraine and prescribe this immediately
• Alternatively, give an oral analgesic such as aspirin 300mg three tablets (900mg) PO, ibuprofen 600mg PO or paracetamol 1g
• Add metoclopramide 10–20 mg IV and avoid inappropriate opioid analgesia
• If oral analgesia plus metoclopramide fail, give chlorpromazine 12.5–25 mg IV diluted in 500 mL normal saline over 30 minutes and keep the patient in bed (∵ risk of postural hypotension)

NOTE

if you consider a triptan such as sumatriptan 6 mg SC for a resistant headache, make certain there is no risk of coronary artery disease and no ergotamine has been given in the last 24 hours

Cluster Headache

• Often difficult to treat, discuss with senior and try the following:
  • High flow oxyegn by non-rebreather mask as early as possible to abort an attack
  • Intranasal local anaesthetic spray (e.g. 5% lignocaine bilaterally)
  • Sumatriptan 6mg SC
• Avoid giving morphine

Post Lumbar Puncture Headache

• Low pressure headache on standing up, within 48 hours of LP usually 2° to continuing CSF leak
• Treat with strict bed rest (no toilet priviledges), oral or IV fluids and regular paracetamol 500mg with codeine phosphate 8mg two tablets PO
• If unsuccessful consider anaesthetist applied epidural blood patch

Tension Headache

• Oral analgesic such as paracetamol 500mg with codeine phosphate 8mg two tablets 6 hourly PO or ibuprofen 400mg 6 hourly PO