Acute Headache 31

of migraine: without aura and with aura. The characteristics of

migraine without aura are shown in Box 8.2.
In migraine with aura the patient may experience visual symp-
toms, such as lines in the vision or loss of vision, sensory symptoms,
or dysphasia. The aura lasts between 5 and 60 minutes and is fol-
lowed within an hour by a headache fullling the criteria in Box 8.2.
Some patients are able to identify particular triggers for their
migraine. These may include alcohol, certain foods, alterations in
sleep pattern or menstruation.
Caution should be exercised in attributing focal neurological
abnormalities, e.g. dysphasia or weakness to migraine, unless the
patient has previously experienced a number of similar episodes
from which they have recovered. In the acute setting migraine is a
diagnosis of exclusion.
Meningitis
The headache in meningitis is not typically of sudden onset but
given the dangers of missing the diagnosis it is a condition that
should always be considered in the differential diagnosis of a patient
presenting with a severe headache.
Meningitis may result from bacterial, viral, or less commonly
fungal or tuberculous infection. The diagnosis is suggested by the
complaint of a headache in association with fever and neck stiffness,
which is found in two-thirds of patients with bacterial meningitis.
In addition, signs of meningeal irritation (see Table 8.1) should also
be sought but may be absent early in the course of the illness. A high
index of suspicion therefore needs to be maintained, particularly in
the elderly or immunocompromised patient.
In contrast, the absence of fever, neck stiffness and change in
mental state reliably excludes meningitis.
Space-occupying lesions
It is uncommon for intracranial mass lesions to present with
sudden severe headache. Such lesions only cause pain once they are
large enough to cause traction on intracranial vessels or invade sen-
sitive structures such as the dura. As a result, such lesions will often
present with other features before headache becomes prominent.
The headache caused by space-occupying lesions is usually the
result of raised intracranial pressure. Typically this headache will
be of gradual onset, progressively severe, worse in the morning,
and aggravated by activities which raise intracranial pressure, for
example coughing or straining.
A careful neurological examination may reveal subtle abnormali-
ties of which the patient is unaware. The presence of papilloedma
supports the diagnosis but its absence does not rule it out.
Sudden onset of headache may occur in a patient with a
space-occupying lesion if there is haemorrhage into a tumour (see
Figure 8.2).
Other causes of headache not suggested
by the history
Tension headache
It is estimated that 80% of people will experience a tension head-
ache at some time during their life. In contrast to migraine, the
headache may last up to 7 days.
The key features of tension headache are shown in Box 8.3 and
these headaches tend to be precipitated by stress.
Table 8.1 Signs of meningeal irritation.
Neck stiffness With the patient supine the head is held by the examiner.
The neck is passively exed and the amount of resistance
noted. The sign is positive when there is objective stiffness,
not when the patient reports a subjective feeling of stiffness.
Painful inammatory conditions of the pharynx, such as
tonsillitis or quinsy may result in a false positive nding.
Brudzinskis sign In Brudzinskis sign exion of the hips and knees occurring
in response to passive exion of the neck indicates
meningeal irritation.
Kernigs sign With the patient supine the hip and knee are passively exed
to 90 degrees. The knee is then passively extended. The sign
is positive when there is resistance to extension.
This test usefully distinguishes meningeal irritation from
the local cause of neck stiffness described above.
Box 8.2 Features of migraine
The headache has at least two of the following features:
unilateral location
pulsating quality
moderate or severe intensity
aggravation by physical activity
At least one of the following occur during the headache:
nausea and/or vomiting
Photophobia or phonophobia
Figure 8.2 CT scan of an intracerebral metastatic neoplasm.
32 ABC of Emergency Differential Diagnosis
Differentiating between migraine and tension headaches can
be difcult and the two may coexist in the same patient. The non-
pulsating quality and lack of aggravation by physical activity may
usefully distinguish between the two. However, in the acute setting
tension headache is not usually included in the differential diagno-
sis of acute severe headache as it is rarely of sudden onset.
Systemic illness
Severe infections such as pneumonia and pyelonephritis are a fre-
quent cause of headache. Diagnosis in such patients is rarely dif-
cult. As the headache is not of sudden onset, a careful history and
examination will identify the cause.
Dental and ENT disease
Pain in the head or face is a key feature in many dental and ENT
problems, e.g. sinusitis. Although the diagnosis may be appar-
ent from the history, inspection of the mouth, pharynx and
tympanic membranes is required to exclude these as possible sources
of pain.
Temporal arteritis
Temporal arteritis typically presents with gradual onset of a con-
stant band-like headache and tenderness over the temporal arteries.
It may also be associated with visual loss. Typically, patients will be
over 55 years of age and feel generally unwell. The erythrocyte sedi-
mentation rate is usually markedly raised. Urgent treatment with
corticosteroids reduces the risk of visual loss.
Case history revisited
The history outlined by this woman suggests a number of possible
diagnoses. The patient has a history of migraine, but this headache
is clearly different to her usual migraine headache, so this is an
unlikely cause. The history of breast cancer raises the possibility of
a cerebral metastasis. Given the sudden onset of the headache and
its severity, haemorrhage into a metastasis or into the subarachnoid
space should be considered.
Her history of fever preceding the headache suggests that menin-
gitis should be considered although the sudden onset of the head-
ache makes this diagnosis less likely.
Examination
On examination the patients observations are normal. Her
temperature is 36.5C, blood pressure 107/60 mmHg and pulse
rate 90 beats/minute.
Box 8.3 Features of tension headache
Headache has at least two of the following characteristics:
bilateral location
pressing/tightening (non-pulsating) quality
mild or moderate intensity
not aggravated by routine physical activity such as walking or
climbing stairs
And both of the following:
no nausea or vomiting (anorexia may occur)
no more than one of photophobia or phonophobia
(a) (b)
Figure 8.3 Intracranial aneurysm before (a) and after coiling (b).
Acute Headache 33
Her neck was stiff but there is no other abnormality on
neurological examination. Examination of the fundi and tympanic
membranes is normal and there is no rash.
Question: Given the history and
examination ndings what is your
principal working diagnosis?
Principal working diagnosis subarachnoid
haemorrhage
Management
The sudden onset of headache and the nding of neck stiffness
suggest subarachnoid haemorrhage is the cause of her symptoms.
The next step will be to obtain a CT scan. In patients with sub-
arachnoid haemorrhage this will be abnormal in around 95% of
cases if the scan is performed within the rst 24 hours, but only
in 50% 1 week after onset of the headache. CT should also reliably
exclude the possibility of a space-occupying lesion.
If the CT scan is normal a lumbar puncture should be per-
formed. When investigating possible subarachnoid haemorrhage
this should be delayed until 12 hours after onset of the headache,
when its sensitivity will be maximal. If subarachnoid haemorrhage
is not found, examination of the cerebrospinal uid (CSF) should
also identify cases of meningitis. In addition, the measurement of
CSF pressure may also identify some uncommon diagnoses that
might otherwise be missed, such as venous sinus thrombosis or
spontaneous intracranial hypotension.
Outcome
The patient underwent a CT scan which demonstrated a subarach-
noid haemorrhage (see Figure 8.3a). She was referred urgently to a
neurosurgeon for further treatment. The causative aneurysm was
subsequently coiled (see Figure 8.3b).
Further reading
Dowson AJ. Your Questions Answered: Migraine and Other Headaches.
Churchill Livingstone, Edinburgh, 2003.
Lance JW, Goadsby PJ. Mechanism and Management of Headache, Seventh
Edition. Elsevier, New York, 2005.