|Analgesic Overuse Headache
|Headaches in General
A first-ever severe headache of sudden onset should be considered to be SAH until proven otherwise
- Headaches are a very common complaint
- They can be grouped into primary and secondary
- Migraine with or without aura
- Tension-type headache.
- Trigeminal autonomic cephalgias for example cluster headache and paroxysmal hemicranias.
- Other primary headache disorders such as primary cough headache and cold-stimulus headache
Secondary headaches = headache attributed to an underlying condition including:
- Trauma or injury to the head and/or neck.
- Cranial or cervical vascular disorders for example intracerebral haemorrhage, central venous thrombosis or giant cell arteritis.
- Non-vascular intracranial disorders for example idiopathic intracranial hypertension or neoplasm.
- Exposure to, or withdrawal from, a substance such as carbon monoxide, cocaine or alcohol or medication overuse headache (which can be due to ergotamines, triptans, simple analgesics and opioids) is included in this category.
- Infection for example intracranial infection (including meningitis, encephalitis and cerebral abscess) or systemic infection.
- Disorders of homeostasis for example hypoxia or hypertension including pre-eclampsia and eclampsia.
- Disorders of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structure such as angle-closure glaucoma, temporomandibular disorder, dental problems, otitis media or sinusitis.
- Psychiatric disorders such as somatization disorder.
- Painful cranial neuropathies and other facial pains such as trigeminal neuralgia, post-herpetic neuralgia and optic neuritis
Clinical history taking is key
- Onset, duration, frequency and temporal pattern (episodic, daily or unremitting). Pain characteristics including severity, site and spread of pain. Associated symptoms such as:
- Aura (visual, auditory or gustatory disturbance), nausea, photophobia and intolerance of noise may indicate migraine .
- Autonomic features for example tearing, drooping or swollen eyelid, pain around one eye, nasal congestion or rhinorrhoea may indicate cluster headache .
- Systemic and neurological features such as fever, neck stiffness, weakness and visual disturbance.
- Contacts with similar symptoms: Consider possible carbon monoxide poisoning if household contacts or pets have similar symptoms.
- Precipitating and relieving factors such as:
Trauma, posture, Valsalva manoeuvres, fatigue or stress, menstrual cycle, and medication change or withdrawal.
- Comorbidities and past medical history including:
Compromised immunity, systemic illness, malignancy and pregnancy.
- Drug history including:
Drugs used for headache intake, response to, and side effects of acute and preventive medications that have been tried.
Other prescribed and non-prescribed drugs such as anticoagulants, glucocorticoids, methamphetamines, and cocaine.
- Effect on activities - ask what does the person 'do' during attacks? For example
Migraine is associated with withdrawal from daily activities due to incapacity.
Tension-type headache typically has no effect on activities.
Cluster headache is associated with agitation or restlessness.
- Vital signs: Assess blood pressure, pulse, respiration rate, temperature and oxygen saturation levels
- General appearance and mental state:Look for signs of serious causes of headache such as skin rash, changes in the level of consciousness or confusion.
- Extracranial structures: Assess the carotid arteries, temporal arteries, sinuses and temporomandibular joints.
- The neck: Look for signs of meningeal irritation, tenderness of cervical paraspinal muscles, limitation in range of movement and crepitation.
- Neurology: Carry out fundoscopy (looking for papilloedema, pupillary asymmetry and reactivity) and cranial and peripheral nerve examination including gait.
- Examination should be normal with primary or benign causes of headache if abnormal, refer the person for assessment in secondary care with urgency depending on the clinical situation.
- Investigations are generally not required to diagnose the primary headache. If there are any red flags or a serious cause of headache is suspected refer the person to secondary care for further assessment with urgency depending on the clinical situation. If the diagnosis is not clear and serious causes of headache have been ruled out:
- Arrange review and ask the person to keep a diary over a few weeks to record frequency, duration and severity of headaches; associated symptoms; all prescribed and over the counter medications taken to relieve headaches; and possible triggers.
- If the diagnosis remains unclear seek advice from a specialist in neurology.