Headache

Back to Medical School 2011

The Approach

Don’t despairRule out emergencies (History)Brief examGet the patient to keep a diaryGet the patient to see optician?book longer appointment

Warning features in the history

• Headache that is new or unexpected in an individual patient• Thunderclap headache (intense headache with abrupt or “explosive” onset)• Headache with atypical aura (duration >1 hour, or including motor weakness)• Aura occurring for the first time in a patient during use of combined oral contraceptives• New onset headache in a patient older than 50 years• New onset headache in a patient younger than 10 years• Persistent morning headache with nausea• Progressive headache, worsening over weeks or longer• Headache associated with postural change• New onset headache in a patient with a history of cancer• New onset headache in a patient with a history of HIV infection.

1. How many different headache types does the patient experience?Separate histories are necessary for each. It is reasonable to concentrate on the most bothersome to the patient but others should always attract some enquiry in case they are clinically important.2. Time questions a) Why consulting now?b) How recent in onset?c) How frequent, and what temporal pattern (especially distinguishing between episodic and daily or unremitting)?d) How long lasting?3. Character questions a) Intensity of painb) Nature and quality of painc) Site and spread of paind) Associated symptoms4. Cause questions a) Predisposing and/or trigger factorsb) Aggravating and/or relieving factorsc) Family history of similar headache5. Response questions a) What does the patient do during the headache?b) How much is activity (function) limited or prevented?c) What medication has been and is used, and in what manner?6. State of health between attacksa) Completely well, or residual or persisting symptoms?b) Concerns, anxieties, fears about recurrent attacks, and/or their cause

42 yr old man

2 weeks ago developed very severe headache during sexual intercourse. Wife wanted to call an ambulance but he resisted as headache slowly subsided. Phoned up today because pain wasn’t settling and when he attempted sex again, he felt the pain building up and had to stop.

Key questions in the history?

42 yr old man (2)

Did you lose consciousness?Any visual disturbance? Vomiting?Persistent headache? Neck pain/stiffness?Previous history?Family history?Examination findings?Do you send to hospital?

42 yr old man (3)

What is emergency doctor supposed to do?(because this does have a bearing on acute and

subsequent management and you will almost certainly have to explain it to him!)

Supplementaries:Family member with subarachnoid haemorrhagePatients with aneurysmsPatients with polycystic kidneys

48 year old woman

New, rather chronic headache and feels terribleCan’t concentrate, moody, appetite affectedP.M.H. Migraine but they were entirely different

Key questions in the history?

48 year old woman (2)

Menstrual historyMenopausal symptomsCan you give her HRT?

(N.B. Similarities with polycystic ovary syndrome)

Investigations and management?

62 yr old woman

Persistent, nagging left-sided head pain for 3 weeks

Fed up with it- gone off food, not sleeping wellNo previous history of headache

Key questions in the history? Important examination findings?

62 yr old woman (2)

Tender? Pain on eating? Muscle stiffness?

P.V. and/or E.S.R.

Methylprednisolone 500 mg reducing rapidly while biopsy is arranged

Should be dramatic relief

35 yr old man

12 months constant pain “Not a headache – it’s a pain”

Tight hat or head explodingMay be intermittent in someMakes him frownTakes painkillers, “To take the edge of it”“Like a 6 inch nail” stabbing pains Pain up neck

etc

35 yr old man (2)

History is of pain without feeling unwellFurrowed browCords in neck regionRippling muscles in temples and jawMay overlap with migraine

Do you scan?

25 yr old woman

Headache started when she was a teenagerMay feel elated or weird the day beforeMay wake up with pain in foreheadGradually worse – has to go to bedDreadful pain – only relieved when I go to sleepMay come back the next day2-3 per monthKey questions?

25 yr old woman (2)

Take a detailed historyCar sick? IBS? Family history? Related to

periods?Premonitory symptomsAuraPainAssociated symptoms?examination

25 yr old woman (3)

Plenty of exceptions:Basilar migrainePain isn’t bad enough for migraineCan be bilateral

Aura may be strangeOnset may be >40 without headache

40 yr old man

Agonising needle pain in left eyeBanging head on wallEvery night it wakes him at 2 amSettles within 1 hourHad it once before for 6 weeks; then it wentFamily all have migraine

Key questions?

40 yr old man (2)

Does the eye go red or water?Does the lid droop?Nasal congestion or runny nose?Effect of alcohol?Smoker?Do you want to go to bed when it strikes?

30 yr old woman

Generalised headache building up over weeks Feel sick with itWorse when I wake upEases later in dayNot feeling right – a bit off balance

Key questions?

30 yr old woman (2)

General health and previous historyBalance Speech VisionEffect of neck position

35 yr old woman

Chronic head painWorse every morning but no nauseaThe only thing that helps a bit is to take

painkillers

Examination

Spend as much time as you can on history but direct questions

General features ?frowning? Blood PressureVision Fields Pupils DiscsHead and NeckLimb postureReflexesBalance

Investigations

Blood tests?Head scan?Lumbar puncture?

Treatments

Physical treatmentsAnalgesiaSpecific migraine treatmentProphylaxisReassurance and understanding

If no improvement, review

Migraine

?avoid caffeine etc ? Regular food and sleepStratified strategy Use for at least 3 attacksParacetamol or aspirin plus domperidoneNSAIDs ?suppositoriesTriptan (Bandolier) N.B. 30% may not respondProphylaxisPizotifen, Betablockers, Amitriptyline,

Topiramate, Valproate

Tension headache

Check eyes at optometrist (I.I.H.)Rule out anaemia, Carbon monoxide,Healthy lifestyle?Physical treatments ?BiofeedbackAmitriptyline/ Mirtazapine/ Venlafaxine

Review diagnosis

Cluster headache

ReassureTriptan drug ?nasal ? Subcut?ProphylaxisVerapamilSteroidsOxygenLithiumMethysergide

Special circumstances

YoungPregnantContraception HRT

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