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Headaches are defined as pain originating anywhere in the head or neck. They are a common presenting complaint in primary care and carry a high level of morbidity. The most common type of headache is tension HA, whereas, the most common presenting HA to primary care is migraine. Headaches can subdivided into primary or secondary based on etiology.

Primary Headaches are benign, recurrent headaches that are not caused by underlying medical disorder.

Secondary Headaches are the result of an underlying medical disorder

General Approach to HeadacheEdit

History Edit

  • History is key. It guides the physical examination and further investigations
  • Age of onset
  • ChLORIDE FPP (characteristic, location, onset, radiation, intensity, duration, events associated, frequency, palliating/provoking factors)
  • Triggers (valsalva, menstrual cycle)
  • Previous treatment
  • Constitutional symptoms
  • Associated symptoms (aura, neurological symptoms, N/V, photo/phonophobia, visual changes)
  • History of head trauma
  • Past medical history: immunosuppression, HIV, malignancy, HTN, sinusitis
  • Medications: anti-coagulants, OCP, anti-platelet, corticosteroids, analgesics
  • SHx: substance use
  • FamHX: migraines

Physical exam Edit

  • Depends on history
  • Vitals
  • MSK (C-spine, shoulders)
  • Neuro exam
  • Meningeal signs
  • Temporal and neck arteries
  • Bruits in the neck/eye/head for AV malformations

Investigations Edit

  • Depend on history and physical
  • Blood work: CBC, ESR, TSH, tox screen, septic w/u
  • Imaging: CT/ MRI
  • Lumbar puncture
  • Temporal artery biopsy

Red Flags of Headaches Edit

  1. Change in LOC
  2. Focal Neurological findings
  3. Fever, neck stiffness, meningeal signs
  4. New onset HA or progressive HA > 50 years old or <5 years old
  5. Sudden onset, severe HA, intensity 10/10
  6. Signs/symptoms increased intracranial pressure (morning HA, wakes you from sleep, N/V, worse with exercise/valsalva, papilledema)
  7. History of cancer, immunosuppressions
  8. HA associated with head trauma
  9. HA increasing in frequency and severity (change in pattern)
  10. Jaw claudication, scalp tenderness, visual loss
  11. HA associated with pregnancy/postpartum period
  12. Severe eye pain, halos around light, decreased visual acuity, N/Vm cilliary flush, fixed mid dilated pupil (think acute angle closure glaucoma)

Primary HeadachesEdit

Tension Headache Edit

History Edit

  • bilateral, mild-moderate intensity, band-like characteristic
  • Non-pulsatile
  • 40 minutes - 7 days in duration
  • No associated N/V
  • No associated photo/phonophobia
  • Not aggravated by physical activity
  • Often has triggers
  • Not caused by underlying medical disorder

Physical Edit

  • Normal physical examination

Investigations Edit

  • None required

Classification Edit

  • Infrequent < 1 day/month
  • Frequent 1-14 days/month
  • Chronic 15+ days/month

Management Edit

  • May not require treatment
  • Non-pharm
    • avoid triggers, stress management, physiotherapy, CBT
  • Pharmacotherapy
    • Acute: first line - tylenol, NSAIDS
    • Chronic: Effexor, amitriptyline
    • Muscle relaxants have NO evidence for mngt

Migraine Edit

History Edit

  • Unilateral, pulsating, moderate-severe intensity
  • Worse with physical activity
  • Duration 4-72 hours
  • Associated with N/V
  • Associated with photo/phonophobia
  • +/- aura
  • +/- family history
  • Often associated with triggers: food, exercise, sexual activity, weather changes, sleep changes, substance use, emotional stress, hormone therapy, menstrual cycle, lights
  • Not caused by underlying medical disorder

Physical Edit

  • Migraine variants may show focal neurological signs

Investigations Edit

  • NO CT if >4/5 POUND (pulsatile, onset 4-72 hours, unilateral, nausea, disabling)

Classification Edit

  • Classic Migraine: migraine with aura
  • Common Migraine: migraine without aura

Management Edit

  • Migraine diary
  • Avoid triggers
  • Stress reduction, regular exercise/sleep/meals
  • Acute:
    • NSAIDs - naproxen
    • Tylenol
    • Triptans: avoid in HTN/CVD. Expect relief in 2 hours
    • Lidocaine 4% nasal 0.4-0.5ml IN for 30 seconds
    • Severe: prochlorperazine, DHE, ketorolac IM
  • Prophylaxis:
    • B-Blockers (propranolol, metoprolol)
    • Anti-epileptics (valproic acid, topiramate)
    • Anti-depressants (amitriptyline, Effexor)
    • OTC vitamins
      • Riboflavin 400mg PO/day
      • Magnesium Citrate 600mg PO/day

Cluster Headache Edit

History Edit

  • >5 attacks lasting 15-180 minutes
  • Severe intensity, unilateral orbital/supraorbital/temporal
  • Frequency every 2-8 days
  • Unable to lie down
  • Males>Females
  • Autonomic dysfunction (e.g. lacrimation, rhinorrhea, facial swelling, ptosis)

Physical Edit

  • Often normal. May have autonomic dysfunction signs

Investigations Edit

  • None required

Management Edit

  • Acute
    • Start prophylactic medications and bridging medications at the same time
    • 100% oxygen - non-rebreather 12 L/min for 15 minutes
    • Triptan (subcutaneous, intranasal)
      • sumatriptan 6mg SC or zolmitriptan 5mg Intranasal (contraindications: cardio d/o or cerebrovascular d/o)
  • Bridging
    • Steroids
    • Ergotamine
    • Occipital nerve block
  • Maintenance
    • Verapamil (#1)
    • Steroids
    • Lithium
    • Topiramate

Secondary Headaches Edit

***NOTE: This is not an exhaustive list****

Headache History Physical Investigations Management
Rebound HA (medication overuse) -use of chronic analgesia

- NSAIDS or tylenol > 9 days/month

-DHE/triptan/opioids > 10days/month

N Neuro exam Nil -stop offending Rx (taper opioids)

-educate patient

-+/- pain specialist referral

-consider bridging with b-blocker, tricyclic, topiramate

Temporal Arteritis (Giant Cell) ->50 years old

-Unilateral temporal

-Severe, throbbing

-+/- systemic features

-+/- history PMR

-+/- jaw claudication and visual changes

- +/- scalp tenderness

-Can be N

-Tender or decreased pulse over temporal artery

-ESR >50

-biopsy

-DO NOT DELAY RX for biopsy

-risk vision loss (ischemic optic neuritits)

-Rx long-term high dose steroids

-Refer for ophthalmology assessment

Meningitis -HA diffuse

-fever

-neck pain/stiffness

-photophobia

- N/V

-Decrease LOC

-vitals: sepsis

-kernigs***

-brudzinski***

-jolt accentuation***

-rash

-Septic w/u

-CT (if concern for mass) then Lumbar puncture

-DO NOT DELAY ABX for LP

-abx based on age group

SAH -Sudden onset

-worst HA of life

-Thunderclap

-diffuse

-N/V

-Can be N

-LOC

+/-meningeal signs

Non- contrast CT

+/- LP

Refer to Neurosurgery
Epidural Hematoma -history of trauma

-period of alertness then rapid neuro compromise

-LOC changes Non- contrast CT (lens shaped)
IPH* -history of HTN, anticoagulation

-features of CVA on history

-features of CVA Non-contrast CT
Subdural Hematoma -recent/remote trauma

-high risk: elderly, ETOH, anticoags

-progressive HA

Non-contrast CT (crescent or banana shaped)
Brain Tumor -features of increased ICP**

-new/ progressive HA

- +/- history of Ca

- Can be N

-localizing neuro findings

- papilledema

-Initial CT (can be normal)

-MRI

Refer to Neurosurgery

Rad onc

Med onc

Pseudotumor cerebri -features of increased ICP

-obesity

papilledema -N CT

-N LP – high opening pressure

-MRI N

-diagnosis of exclusion

-weight loss, salt/fluid restrict

-acetazolamide/ thiazide diuretics

-serial LPs/shunt

-optic nerve sheath decompression

CSF Leak/ Post LP HA -Dull, throbbing HA

-Worse with sitting/standing

-Relieved with lying flat

-Often 12-24 hours post procedure

Normal neuro exam Nil -Conservative: rest

-Caffeine

-Epidural blood patch

Venous Sinus Thrombosis -Risk factors: hypercoaguable state, OCP, pregnancy

- HA variable, features ICP, focal neuro changes, seizures

Can be N

Focal neuro sx

Signs increase ICP

CT N (30%): delta sign

MRI venography

-Risk Herniation

-Rx anticoagulants

*IPH: intra-parenchymal hemorrhage

**Features of Increase ICP: morning HA, N/V, ocular palsies, altered LOC, seizures, papilledema, Cushings triad (bradycardia, hypertension and irregular breathing pattern)

*** Kernigs: pain with passive extension of flexed knee

***Brudzinski's: flexion of neck --> involuntary flexion of knee + hip

***Jolt accentuation: turn head horizontally at rate of 2-3/second = increase in HA

Common cancers that metabolize to brain: LUNG>breast>GU> Bone> Melanoma

Other differentials for HA that should be considered Edit

TMJ dysfunction/ dental issues, substance intoxication/withdrawal, carotid/vertebral artery dissection, AVM, post-traumatic, psyche, cerebral abscess, encephalitis, metabolic (hypoxia, hypercapnia, hypoglycemia), cavernous sinus thrombosis, HTN, fever, Chiari malformation, normal pressure hydrocephalus (triad: dementia, urinary incontinence and gait instability)

References/Resources Edit

1. International Headache Society

2. Migraine Diary

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