Headache

 Tension headache is the most common cause of headaches

 It is commonly relieved by stress relief

Causes
 Primary headache disorders
 Migrane
 Cluster headaches
 Incl. chronic paroxysmal hemicrania
 Hemicrania continua
 Short lasting unilateral neuralgiform headache with conjunctival infection and tearing
 Tension
 Secondary headaches
 Extracranial causes
 Carotid or vertebral artery dissection
 Causes neck pain
 Dental disorders
 E.g. infection, joint dyfunction
 Glaucoma
 Sinusitis
 Intracranial disorders
 Brain tumours and other masses
 Chiari type 1 malformations
 CSF leak with low pressure headaches
 Haemorrhage
 Intracerebral
 Subdural
 SAH
 Idiopathic intracranial HTN
 Infection
 Abscess
 Encephalitis
 Meningitis
 Subdural empyema
 Non-infectious causes of meningitis e.g. carcinoma, chemicals
 Obstructive hydrocephalys
 Vascular disorders
 Vascular malformations
 Vasculitis
 Venous sinus thrombosis
 Systemic disorders
 Acute severe HTN
 Bacteremia
 Fever
 Temporal arteritis aka Giant cell arteritis
  Hypercapnia
 Hypoxia
 Altitude sickness
 Viral infections
 Viremia
 Drugs
 Analgesic overdose
 Caffeine withdrawal
 Carbon monoxide
 Hormones e.g. oestrogen
 Nitrates
 PPIs

Acute single episode

 With meningism – admit the patient for CT head (1st) if neg, do LP (signs for infection or blood)
 If the headache is acute, severe, felt over most of the head, neck stiffness and other signs of
meningeal irritation, must exclude the following
 Meningitis
 Fever
 Photophobia
 Stiff neck
 Purpuric rash
 coma
 Encephalitis
 Fever
 Odd behaviour
 Fits
 Decreased consciousness
 SAH
 Sudden onset of worst ever headache aka thunderclap headache
 Occipital usually
 Stiff neck
 Focal signs
 Decreased consciousness

 Head injury
 Thi is common at the site of trauma but it can also be generalised
 It lasts approx. 2 weeks
 Often resistant to analgesia
 CT head to exclude subdural

Signs and symptoms of headaches

Cluster headaches
 Unilateral orbitotemporal attacks
 Usually in and around 1 eye
 Often at the same time of day
 Deep
 Severe
 Lasting 30-180min
 Sympathetic sympoms
 Lacrimation
 Facial flushing
 Restlessness
 Horner’s syndrome

Migraine
 It is a neurovascular disease caused by inflammation and characterised by severe recurrening
headaches
 Severe pain on one side of the ehad compared to the pain in the rest fo the head
 More frequent in females
 Usually episodic headaches with
 Frequently unilateral and pulsating
 Lasts 4-72hrs
 Occasional aura
 Usually associated with
 Nausea and vomiting
 Photophobia
 Sonophobia
 Osmophobia
 Worse with activity
 Patients prefer to lie in the dark
 Resolves with sleep
 Visual changes
 Can be initiated or amplified by
 Glare
 Bright lights and sounds
 Other stimulations
 Hunger
 Stress
 Exertion
 Stormy weather
 Barometric pressure changes
 Hormone fluctuations in menses
 Lack or excess sleep
 EtOH
 Chemical
 It can present with or without an aura
 With aura
 This is a warning sign before the headache begins
  Usually visual and consists fo both positive and negative visual field stuff
 Without aura
 Does not give any signs
 Most common 70-80%

Tension
 Frequent or continuous headache
 Mild
 Bilateral and viselike
 Occipital or frontal pain that spreads to the entire head
 Worse at the end of the day

AACG
 Unilateral frontal or orbital pain
 Halos around lights
 Decreased VA
 Conjunctival infection
 Vomiting
 Ix
 Tonometry

Encephalitis
 Fever
 Altered mental status
 Seizures
 Focal neurological deficits
 Ix
 MRI
 CSF

Temporal arteritis
 Often aged >55
 Unilateral thrombbing pain
 Pain when combing hair
 Visual disturbances
 Jaw claudication
 Fever
 Weight loss
 Sweats
 Temporal artery tenderness
 Proximal myalgias
 Ix
 ESR
 Temporal artery biopsy
 Neuroimaging
Idiopathic intracranial HTN
 Migrane like headache with diplopia, pulsatile tinnitus
 Loss of peripheral vision
 Papilloedema
 Ix
 MRI with venography
 CSF opening pressure and MCS

Medication overuse
 Headache with variable location and intensity
 Present >15days
 Often present on waking
 Typicall develops after overuse of analgesics taken for an episodic headache

Post LP and other low pressure headache

 Intense headache
 Meningismus
 Vomiting
 Worse by sitting or standing
 Alleviated by lying completely flat

Sinusitis
 Positional facial or tooth pain
 Fever
 Purulent rhinorrhea
 Pain is usually behind the forehead and cheekbone

SAH
 Peak intensity a few secondas after onset ‘thunderclap’
 Vomiting
 Syncope
 Obtundation
 Meningismus
 IX
 Imaging
 CSF if image is not diagnostic and LP is not contraindicated

Sub-dural ahematoma
 Sleepiness
 Altered mental state
 Hemiparesis
 Loss of spontaneous venous pulsations
 Papillodema
 Presence of other risk factors
 Old age
  Coagulopathy
 Dementia
 Anticoadulation
 EtOH

Tumour or mass
 Eventual altered mental status
 Seizures
 Vomiting
 Diplopia when looking laterally
 Loss of spontaneous vneous pulsations or papillodema
 Focal neurological deficits