Headache
“The history is the key to diagnosis in headache”
Below are a few videos that will be helpful. Tale a look at this great lecture below and then back it up with a revision of two important physical exams.
Take away points
Take away points
Primary headaches are those where the head pain is the main problem… take that away and there is no underlying pathology. Secondary headaches are those where the head pain is caused by an underlying pathological feature.
80% of headaches presenting to ED are primary in nature
Isolated headache without other neurological signs and symptoms is extremely unlikely to be tumour or intracranial pathology related
Differentiation can be challenging but relies upon a comprehensive focused history and physical examination to illicit red flags and the need for further investigations.
We need to ensure we perform a comprehensive neuroexam
Some red flags to consider are:
Thunderclap (sudden onset/ severe) headache, meaning maximal within 5 minutes but normally quicker within 1 min. Put simply its an excruciating headache of instantaneous onset.
Associated focal neurological
Associated systemic features
Patients over the age of 50 presenting with new/ different headache
Headaches that wake patient from sleep (not prevent them from sleeping) worse in the early moring and settle as the day progresses
Change in pattern to previous established headache.
Fever, confusion, drowsiness, rash
Focal neurological sx - weakness cna be seen in haemiplegic migraine however if this isn’t known then its a pretty irresponsible decision to put this down to migraine until further evaluation has determined the rule out of more serious causes.
Tenderness to the scalp/ temple
Worsening visual acuity reported/ visual loss
New headache in those with known primary CA.
Is there any recent hx of head injury - mild headaches can be normal but severe or progressive are red flags.
BE WARY of the patient who presents with NEW daily persistent headache, if no other red flags they still need f/u refer to primary care with your concerns.
Worse on laying flat
We discussed types of primary headache
Tension Type Headache: - Mild to moderate, bilateral often described as a band around the front of head. Slowly develop over hours to days, sleep rarely disturbed.
Migranes - can be bilateral, moderate to severe, often pulsatile. Often associated with nausea and vomiting, photo and phonophobia and preodromal auras.
We discussed the management plans for these primary headaches which may include
Paracetamol (consider IV if vomiting can still discharge if given IVP)
NSAIDs or Aspirin (900mg dose in BNF) → Not in under 16s reyes syndrome.
Always give antiemetics even if not vomiting to migraine patients ideally metoclopramide if you carry this
Consider high-flow oxygen to TACs/ Migraine
Consider IV Fluids (again can leave at home despite giving this)
Avoid opiates if possible (not effective for neuralgia, can worsesn headahce)
Consult primary care for triptans, ongoing antiemetics (can get buccal proc OTC). headache clinic referrals via GP, refer back to primary care.
We need to ensure detailed safety netting advice is given to these patients
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