Approach to HeadacheDR. AMAL ALKHOTANI

FRCPC NEUROLOGY, EPILEPSY

Headache

Headache is one of the 10 most common reasons for health care visits in USA.

It also account for 4.5% of ER visits.

Types of headache

Primary :-benign headache syndromes in which there are no structural cause for the headache e.g. migraine, tension, cluster.

Secondary :-headache is a symptom of underlying disease e.g. tumor.

Careful evaluation is required to recognize secondary causes of headache.

Secondary Headache

Headache attributed to head or neck trauma

Headache attributed to cranial or cervical vascular disorder

Headache attributed to nonvascular, noninfectious intracranial disorder

Headache attributed to a substance or its withdrawal

Headache attributed to infection

Headache attributed to disturbance of homeostasis

Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cranial structures

Headache attributed to psychiatric disorder

Cranial neuralgias and central causes of facial pain

Other headache, cranial neuralgia, central or primary facial pain

History

Types of headaches.

Onset of headaches.

Frequency & periodicity of episodic headaches.

Temporal profile.

Time of day & precipitating factors.

Location.

Quality & severity.

Aura & accompanying symptoms.

Aggravating factors.

Family history of headaches.

Other medical or neurological problems.

68 year old female present to ER with headache.

What historical points will let you worry about this headache?

Red Flags For Worrisome Headaches

New onset headache or onset of new type of headache or change of preexisting headache.

Progressive worsening headache.

Worst ever pain.

Age > 50.

Abrupt onset headache.

Headache initiated by exertion or valsalva.

Head trauma.

Neurological symptoms & signs.

Systemic symptoms & signs.

Secondary risk factors.

Examination

Vital signs

General appearance

Meningeal signs

Full neurological examination

DO NOT FORGET THE FUNDUS EXAMINATION

Skull and c spine examination

Palpate the paranasal sinuses

Temporal artery

High risk examination finding

Abnormal vital signs:-fever, severe hypertension

Toxic appearance

Localizing neurological finding

Decrease level of consciousness

Meningeal signs

High risk examination finding

Abnormal vital signs:-fever, severe hypertension

Toxic appearance

Localizing neurological finding

Decrease level of consciousness

Meningeal signs

Ophthalmic finding

Traumatic finding

Abnormalities of the temporal artery

Sudden severe headache

Non contrast CT brain

Normal Abnormal

Lumbar Puncture for xnthochromia

Neurosurgery

Yes NO

What is Xanthochromia?

Xanthochromia ( yellow or pink discoloration) represent Hg degradation.

The presence of xanthochromia is indicative that the blood has been present in CSF for at least 2hours prior to the tape.

Highly suggestive of SAH

What causes of xanthochromia other than SAH?

68 ear old female with one month history of headache and jaw pain while eating.

What other historical points will you consider?

What specific examination and investigation you will consider?

Constitutional symptoms

Visual symptoms

Shoulder and hip aching and stiffness

Examination of temporal artery

ESR

Temporal artery biopsy

In presence of high clinical suspicion and high ESR start steroid awaiting temporal artery biopsy

Temporal Arteritis

Chronic vasculitis of large and medium sized vessels.

Prevalence 1 in 500 individual.

Classification criteria:-- Age above or equal to 50 year of age- Localized headache of new onset- Tenderness or decrease pulse of the temporal artery- ESR >50- Biopsy revealing a necrotizing vasculitis

Why temporal arteritis should be treated promptly?

Primary Headache

Migraine

Tension headache

Cluster headache

Other primary headache

Take home messages

Carful evaluation is necessary when evaluating a patient with headache.

Be alert about headache red flags.