Br Med J (Clin Res Ed): first published as 10.1136/bmj.288.6426.1281 on 28 April 1984. Downloaded from http://www.bmj.
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BRITISH MEDICAL JOURNAL VOLUME 288 28 APRIL 1984 1281
Clinical Algorithms
Headache
MICHAEL JAMIESON
Headache, although a near universal experience, is a relatively (8) Headache due to overt cranial inflammation:
uncommon reason for consultation in general practice. The consul- A Intracranial,
tation rate for migraine, for example, is said to be 12 per 1000 B Extracranial (arteritis, cellulitis).
consultations, and it is estimated that the average general practi-
tioner will see 28 patients on account of headache yearly.' (9) Headache due to disease of ocular structures.
Most headache is of the migrainous or tension type. Fry estimates (10) Headache due to disease of aural structures.
that less than 1% of headaches presenting to a general practitioner
reflect "major intracranial disease."2 Despite its predominantly (11) Headache due to disease of nasal and sinusal structures.
benign nature, headache may, however, be the presenting feature of (12) Headache due to disease of dental structures.
potentially serious conditions such as cerebral tumour, meningitis,
giant cell arteritis, and glaucoma. Cervical spondylosis, chronic (13) Headache due to disease of other cranial and neck structures.
sinusitis, and refractory errors probably cause headache less often
than is commonly supposed. (14) Cranial neuritides (trauma, new growth, inflammation).
(15) Cranial neuralgias.
Classification
A useful classification is that of the National Institute of Neuro- Diagnosis
logical Disease and Blindness 1962.3 This is summarised below. History-Try to discover why the patient is presenting now. In
(1) Vascular headache of migraine type: many cases, particularly of acute onset headache, the reason will be
A Classic migraine, clear. In a considerable proportion of cases of longstanding headache
B Common migraine, the consultation will have been precipitated by other factors. In
C Cluster headache, particular, look for any underlying anxiety or depression. Attempt
D Hemiplegic and ophthalmoplegic migraine, to elicit obvious pointers to specific causes (detailed in the classifica-
E "Lower half" headache. tion and algorithm). From the history it is often not possible to
differentiate serious from more benign causes. Features such as
(2) Muscle contraction headache. intensity, response to head movement and to vasoactive drugs, and
the presence of a tender cervical spine with diminished movement
(3) Combined headache: vascular and muscle contraction. do not have discriminating value. There are, however, certain un-
common alerting features, which again do not clearly discriminate
(4) Headache of nasal vasomotor reaction. but which should give rise to suspicion of in particular an expanding
(5) Headache of delusional, conversional, or hypochondriacal intracranial lesion. These are: (a) sleep disturbance, (b) paroxysmal
states. headache, (c) cough headache.4
(6) Non-migrainous vascular headaches: Examination-One cannot be dogmatic about the approach to
A Systemic infections, examination in general practice. Nevertheless, it is reasonable to
B Miscellaneous disorders. measure the blood pressure in all cases. In older patients examination
of the superficial temporal arteries and of the intraocular tension
(7) Traction headache: would be appropriate. Examination will, on the whole, be guided by
A Primary or metastatic tumours of meninges, vessels, or the history.
brain, Investigations-There is no indication for routine investigation,
B Haematomas, other than the erythrocyte sedimentation rate in the older patient.
C Abscesses,
D Postlumbar puncture headache,
E Pseudotumour cerebri.
Royal College of General Practitioners/Office of Population Censuses and Surveys
1974. Morbidity statistics from general practice: second national study 1970-71.
London: HMSO, 1974. Studies on Medical and Population Subjects No 26.
2
Fry J. Common diseases, their nature, incidence and care. 2nd ed. Lancaster: MTP Press
Ltd, 1979.
Department of Therapeutics and Clinical Pharmacology, Aberdeen Royal Infirmary, Vinken PJ, Bruyn GW. Handbook of clinical neurology 5: headaches and cranial
Aberdeen AB9 2ZB neuralgias. Amsterdam: North Holland Publishing Company, 1968.
MICHAEL JAMIESON, MRCP, lecturer Raskin NH, Appenzeller 0. Headache. Philadelphia, WB Saunders, 1980. (Major
problemss in internal medicine; vol 19.)
Br Med J (Clin Res Ed): first published as 10.1136/bmj.288.6426.1281 on 28 April 1984. Downloaded from http://www.bmj.com/ on 5 July 2023 at AIIMS Mangalagiri. Protected by copyright.
1282 BRITISH MEDICAL JOURNAL VOLUME 288 28 APRIL 1984
|Your patient
complains of
HEADACHE
Chronic or No
recurrent
Yes
The most likely
diagnoses are
MIGRAINE
TENSION
HEADACHE
eNone of oistory Uneryng Hry of No Histo ry of N IIs there an N Are there
these? like or pressure _ paroxysmal_ unilateral (less l )bvious pointer unusual or
s ~~~~~headache: retro-orbital often bilateral), tto disease of alerting
bilateral, unilateral pain throbbing | |EEARS, NOSE, features in
frequent, with associated headaches in l SINUSES, EYES? history or on
perhaps eye/nasal episodes; i FPOSTCONCUS- examination?
constarnt? conges tion? nausea; familyI I SION? (see text)
history? FFOOD ALLERGY/
Yes Yes ICE CREAM
Yes|| HEADACHE?
DRUGS (including
Are there l l nitrates, in-
Reie hitr Unelyn Horer' premonitory domethacin)? Yes
No CERVICAL SPINE
visual, sensory,l l
examination depression? affected side motor l l DISEASE?
HYPOGLYCAEMIA?
| ~~~~~~~(uncommon) symptoms? | L HYPERTENSION?
Any evidence Yes
of: Yes
ANAEMIA? I Yoe
v LIS
RENAL
INSUFFICIENCY? a Consider:
CEREBRAL
|Do these persist |No EXPANDING
ARTERIO- CLUSTER during/after the| INTRACRANIAL
SCLEROSIS? HEADACHE headache? l LESION
SCLEROSIS7TENSIO
HEART DISEASE?
| | MIGRAINOUS|l (tumour,
HEADACHE
DEPRESSION? 1NEURALGIA) haematoma,
. ....~~~~~................. abscess)
Bear in mind: XCMLICATEDI
GLAUCOMA ||(HEMIPLEGIC/|
TEMPORAL |-§OPHTHALMO-|
ARTERITIS : COMMON .3PLEGIC) CL-ASSIC
l- (see 4) : MIGRAINF iMIGRAINE | MHGRAINE
b-.-....... _I1Vt
- ........*-
,.... ,
L. - s
These may be Treatment Treatment Treatment Detailed
relevant. If still no
obvious diagnosis, Positive attitude, Acute attack (brief- Acute attack discussion of
try simple patience, treatment seldom General measures (dark room, quiet) management of
measures and education beneficial). Drugs-simple analgesic these
reassurance. important Ergotamine. conditions
Avoid alcohol during (aspirin/paracetamol) ± antiemetic outside the
|Review later | Relaxation (metoclopramide, antihistamine)-early
cluster Ergotamine-sublingual, by mouth, per scope of this
methods
rectum, intramuscular, inhaled algorithm
Prophylaxis (during
Drugs (simple cluster) Prophylaxls
analgesia) ergotamine, Identify precipitants-stress,
paracetamol etc methysergide menstruation, drugs (oral contraceptive,
(dose and timing indomethacin), dazzling lights, exertion,
Consider tailored to individual) fatigue, hunger, ? food sensitivity
anxiolytic, anti- Consider local Refer if appropriate
depressants, anaesthetic Drugs
and formal Others: 100% 02 Clonidine, methydergide, pizotifen,
psychotherapy methoxyfluorane diuretic (for premenstrual episodes).
(acutely), lithium, Not ergotamine
amitriptyline, Consider anxiolytic, antidepressant
propranolol,
indomethacin, Others: propranolol.
prednisolone Consider neurological referral if
(infrequently used) complicated migraine
Br Med J (Clin Res Ed): first published as 10.1136/bmj.288.6426.1281 on 28 April 1984. Downloaded from http://www.bmj.com/ on 5 July 2023 at AIIMS Mangalagiri. Protected by copyright.
BRITISH MEDICAL JOURNAL VOLUME 288 28 APRIL 1984 1283
Headache
Recent
onset
Yes
The most likely
diagnoses are:
FIRST MIGRAINE
HEADACHE
SECONDARY TO
ACUTE INFECTIVE
ILLNESS
Is there No Older patient, N 0o Is there an Is there a No
Young patient N' None of
obvious pointer w -610.
associated neck recent weight current or with typica ly these?
stiffness, photo- loss, hip/ to acute sinus or recent other migrainous
phobia, altered shoulder girdle ear infection, infective illness, symptoms?
level of symptoms, dental problem, especially viral ,(see 2)
consciousness? superficial accelerated upper respiratory
Are there focal temporal hypertension, tract infection
CNS signs? lieadache, drug side
effect?
worse at night?
Visual
I
symptoms?
Yes Yes Yes Yes Yes Yes
Examine
Consider superficial
SUBARACHNOID temporal
HAEMORRHAGE arteries for
tenderness,
*
loss of
MENINGITIS! pulsation
ENCEPHALITIS
It may not be TEMPORAL
possible to ARTERITIS
d HEADACHE | MIGRAINE
distinguish SECONDARY TO
between these ACUTE INFECTIVE
in general ILLNESS
practice
Check ER
[Admit to hospital [ Treatment Detailed
discussion of
Treatment Refer to
Start prednisolone management Simple analgesic. column 2
60 mg/day and outside scope of Manage
refer for urgent algorithm. Use underlying
ttemporal simple analgesic infection as
arteriogram/ and appropriate appropriate
biopsy measures for
underlying
problem
