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Headache

Table of Contents

Overview #

  • Headache is a common symptom and a large contributor to functional disability.
  • Patients should be diligently worked-up through clinical history, examination and investigations to rule out life-threatening causes.
  • Headaches can be classified as: primary, red flag and other. This may vary depending on your clinical setting (e.g. on the ward, versus as a presenting complaint in ED). Regardless, the key part of your evaluation (as with most reviews) will be your history and exam to determine whether your patient is displaying red flag signs that may necessitate escalation to a senior clinician/ require more extensive imaging or urgent management.

Triage #

A senior colleague should always be consulted if a patient presents with a headache plus one or more red flag features (see below).

Low-risk:

  • Age < 30 years
  • Features of primary headache
  • Previous experience of similar headache 
  • No red flags for headache 

High-risk:

  • Any red flags for headache

Cause #

Primary headache(1)Red flag headacheOther (secondary, non red-flag)
Tension  Migraine Trigeminal Autonomic Cephalgias e.g. cluster headache Primary exertional headachePrimary headache associated w sexual activityPrimary Cough HeadacheMedication overuse headacheInfective:MeningitisEncephalitisVascular:Subdural or epidural hematoma Subarachnoid hemorrhage (SAH) Cerebral venous sinus thrombosis Carotid dissectionPituitary apoplexyReversible Cerebral Vasoconstriction SyndromePre-eclampsiaRaised ICP:Space-occupying lesion Hypertensive encephalopathy/posterior reversible encephalopathy syndromeIdiopathic intracranial hypertensionInflammatory:Temporal arteritis Acute angle-closure glaucoma Drugs e.g. Nitrates, CCB, NSAIDsCervicogenic headacheTMJ disease Concussion SinusitisTrigeminal neuralgia Dental pain Spontaneous intracranial hypotensionHeadache and Neurologic Deficits With Cerebrospinal Fluid Lymphocytosis (HaNDL syndrome) 

Clinical features  #

  1. Tension: bilateral band-like, pericranial tenderness 
  2. Migraine: unilateral throbbing, N/V, phono/photophobia +/- preceding aura. Patients want to lie still in dark room 
  3. Trigeminal Autonomic Cephalgias e.g. Cluster: recurring attacks with ipsilateral autonomic symptoms (conjunctival injection, lacrimation, rhinorrhea) and thalamic symptoms (restlessness, agitation)
  4. Meningitis: fever and neck stiffness (Kernig & Brudzinski sign, see https://www.physio-pedia.com/Kernig%27s_Sign & https://www.physio-pedia.com/Brudzinski%E2%80%99s_Sign) +/- immunodeficient , rash. 
  5. Encephalitis: fever, focal neurological signs (e.g. hemiparesis, aphasia, ataxia), altered mental status 
  6. Subdural: diffuse (worse on side of trauma), impaired consciousness and focal neurological signs 
  7. Epidural: initial loss of consciousness after head trauma followed by lucid interval and subsequent further neurological deterioration 
  8. SAH: thunderclap, meningism (neck stiffness, photophobia), focal neurological signs +/- Hx of PCKD
  9. Temporal arteritis: age >50yo, unilateral over temporal area, visual loss, jaw claudication and tender temporal artery  
  10. Acute angle-closure glaucoma: sudden onset frontal headache with a unilateral red and extremely painful eye
  11. TMJ disease: constant unilateral pain over TMJ worsened by jaw opening +/- ear discomfort 
  12. Idiopathic intracranial hypertension: diffuse headaches worse in morning and lying down, transient vision loss, papilloedema, pulsatile tinnitus +/- CN VI palsy (diplopia).  
  13. Sinusitis: fever, facial pain and/or erythema +/- rhinorrhea (if rhinosinusitis) 
  14. Trigeminal neuralgia: paroxysmal stabbing pain strictly located to trigeminal nerve branches(1)

Red flags: PHANTOMS 

  • Pattern change, progression, papilledema
  • History of cancer, HIV (or immunosuppression), head trauma 
  • Altered mental status, analgesics refractory, anticoagulant use 
  • Neurological deficits (e.g. altered mental status, weakness, paresthesia)
  • Temporal artery tenderness, triggers (cough, lying down)
  • Onset (> 50 yr, sudden, thunderclap)
  • Meningeal signs: neck stiffness and photophobia 
  • Systemic features (e.g. fever, malaise), seizures 

Examination #

  • Vitals: temperature, pulse oximetry, RR, HR & BP – Bradycardia, hypertension & irregular breathing = Cushing reflex(2)
  • Mentation and consciousness (AVPU or GCS)
  • Fluid assessment: JVP, capillary refill time, mucous membranes, skin turgor – dehydration can contribute to tension headache 
  • Inspect for rashes e.g. maculopapular rash (meningococcal septicaemia)  
  • Fundoscopy: papilloedema 
  • Neurological assessment: Focal neurological signs, motor strength testing, deep tendon reflexes, sensation & pathological reflexes (e.g. Babinski, see 
  • https://www.youtube.com/watch?v=iV_a2WSbdM8)
    • Cranial nerve testing
    • Cerebellar function: nystagmus, ataxia (truncal e.g. gait, and limbic e.g. dysmetria, dysdiadochokinesia)  

Investigation #

Most causes of headache do not require additional investigation. However, if there is a suspicion for a sinister cause, consider the following:

  1. Bloods: FBE, UEC, LFT, CRP/ESR, Blood culture (aerobic & anaerobic) from 2 sites
  2. CT brain (without contrast) *for further imaging consider discussing with a senior clinician first 
  3. Lumbar puncture with CSF analysis: if you are suspecting meningitis, malignancy or SAH

Discuss with senior clinician for any further investigations e.g, temporal artery biopsy

Management – tension headaches #

Immediate management(3)

1. Paracetamol 1g PO QID
Consider adding
2. Aspirin 600-900mg PO (maximum 2g in 24h) OR ibuprofen 400mg PO TDS

Prophylaxis 

1. Amitriptyline* 10mg PO nocte for 8 weeks
OR
2. Mirtazapine* 15-30mg PO nocte for 8-12 weeks OR venlafaxine MR* 75mg PO daily for 8-12 weeks

Management – migraine #

Non Pharmacological treatment(4)

  • Cold packs over neck or back of skull, hot packs over neck and shoulders, resting in quiet room

Immediate management of migraine

  • Migraines can mimic serious neurological disorders such as stroke and seizure. Escalate early if focal neurological deficits are noted.
  • AVOID opioid analgesia
1. Paracetamol 1g PO QID
Consider adding
2. Aspirin 600-900mg PO (maximum 2g in 24h) OR ibuprofen 400mg PO TDS
Consider adding
3. Metoclopramide 10mg PO/IV TDS
Consider adding
4. Sumatriptan* 50-100mg PO OR 20mg intranasally OR 6mg subcut (dose can be repeated after 2h)CONTRAINDICATED – migraine with brainstem aura, hemiplegic migraine, coronary artery disease, peripheral vascular disease, cerebrovascular disease, uncontrolled hypertensionDifferent formulations of the same triptan can be used within a 24h but NOT different triptansDO NOT give within 24h of ergotamines
If status migrainosus (migraine that lasts for >72h OR requiring inpatient management for migraine), consider adding
5. Chlorpromazine* 12.5 mg in 100mL of normal saline over 30 minutesOR prochlorperazine* 20mg PO OR 12.5mg IV in 1000mL of normal saline

Prophylaxis 

Amitriptyline* 10mg PO nocte for 8-12 weeksOR Propranolol* 20mg PO nocte for 8-12 weeksORTopiramate* 25mg PO nocte for 8-12 weeks
  • Advise to limit triptan use to 10 days per month, and non-opioid analgesia use to 15 days per month to avoid medication overuse headache

Management – cluster headache  #

Immediate management(6)

1. Oxygen 10-12L/min for 15-20min via nonrebreathing mask
Consider adding
2. Sumatriptan* 6mg subcut OR 20g intranasally CONTRAINDICATED – migraine with brainstem aura, hemiplegic migraine, coronary artery disease, peripheral vascular disease, cerebrovascular disease, uncontrolled hypertension

Prophylaxis

1. Verapamil* 80mg TDS for 2 weeks

Management – secondary headaches #

Seek immediate assistance if a secondary or red flag cause of headache is suspected. 

References #

  1. AMBOSS.com. 2021. Headache [Internet]. Available from: ​​https://next.amboss.com/us/article/YL0nwg?q=headache#Z67ba0252fff6842349617790ed19ae54
  2. Clinch, CR. Am Fam Physician [Internet]. 2001. Evaluation of Acute Headaches in Adults. Available from: https://www.aafp.org/afp/2001/0215/p685.html
  3. eTG complete [Internet]. Melbourne (Vic): Therapeutic Guidelines Ltd; 2016. Tension-type headache [cited 2021 Sep 15]. Available from: https://tgldcdp-tg-org-au.ezproxy-f.deakin.edu.au/viewTopic?topicfile=tension-type-headache&guidelineName=Neurology&topicNavigation=navigateTopic 
  4. eTG complete [Internet]. Melbourne (Vic): Therapeutic Guidelines Ltd; 2016. Migraine [cited 2021 Sep 15]. Available from: https://tgldcdp-tg-org-au.ezproxy-f.deakin.edu.au/viewTopic?topicfile=migraine&guidelineName=Neurology&topicNavigation=navigateTopic 
  5. Department of Health Western Australia [Internet]. 2017. Adult Medication Monograph. Available from: https://www.kemh.health.wa.gov.au/~/media/Files/Hospitals/WNHS/For%20health%20professionals/Clinical%20guidelines/Pharmacy/medications/prochlorperazine.pdf
  6. eTG complete [Internet]. Melbourne (Vic): Therapeutic Guidelines Ltd; 2016. Cluster headache [cited 2021 Sep 15]. Available from: https://tgldcdp-tg-org-au.ezproxy-f.deakin.edu.au/viewTopic?topicfile=cluster-headache&guidelineName=Neurology&topicNavigation=navigateTopic

  • Contributors

  • Reviewing Consultant/Senior Registrar

Dr James Gaston

Dr Davor Davlin-Premrl

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