HEADACHE

MIRITI M.D
ECCCO
MASTER OF CLINICAL MEDICINE: ACCIDENTS AND EMERGENCY (MKU)
BSCM (MKU)
MED 1-4 (SSU-UKRAINE)
KMTC LECTURE SERIES
3RD APRIL 2023
 Introduction

• Headache is a common presenting complaint in both primary

and secondary care.
• It is the seventh most common presenting complaint in
primary care and is one of the top three neurological causes of
acute presentations to hospital.
• A comprehensive and structured approach to assessment is
vital to establishing the correct diagnosis. 
Aetiology

• Headaches can be categorised into primary or secondary headaches.

• Primary headaches are those with no identified pathology, such as
migraine or tension-type headache. These are by far the most common
types of headaches.
• Secondary headaches are those which are secondary to organic
pathology.
• Most headaches seen in clinical practice are primary headache.
However, a small minority of patients will have secondary headache.
It is important to be able to identify red flags suggestive of organic
pathology.
Primary headache

• The commonest primary headaches are tension-type

headache and migraine.
• Less common primary headaches are the trigeminal autonomic
cephalalgias, a family of four disorders which includes cluster
headache. 
 TENSION TYPE HEADACHE MIGRAINE CLUSTER HEADACHE

ASSOCIATED FEATURES No nausea/vomiting No more One or more of: nausea, Restlessness

than one of photophobia or vomiting, photophobia, or No aggravation by physical
phonophobia phonophobia activity
Ipsilateral to pain, there may
be:
Conjunctival injection
Lacrimation
Nasal congestion
Rhinorrhoea
Ptosis/miosis
Medication-overuse headache

• Medication-overuse headache is a common problem and causes a high

level of morbidity in patients with primary headache conditions. This
should be suspected in the history if a patient has headaches for more
than 15 days per month (i.e. a frequency equal to or greater than every
other day).
• The trigger (as is in the name) is medication overuse. Triptans, opioids,
and combination analgesics (e.g. co-codamol) are likely to cause faster
onset (they need to be taken on 10 or more days per month), in
comparison to simple analgesics (e.g. paracetamol), which can trigger
medication overuse headache if taken on 15 days or more per month
 Secondary headache
• Secondary headaches are those caused by organic pathology.
• There are four evidence-based indicators for a secondary headache.
Thunderclap (Sudden Onset) Headache
Associated Focal Neurological Deficit
Associated Systemic features
Patients over the age of 50
 Thunderclap (Sudden Onset) Headache
• Headache with onset which reaches maximal
intensity within a minute to five minutes of onset
(depending on who has provided the definition). This is
the most likely headache phenotype to have a secondary
precipitant.
• This presentation is an indicator of a potential acute
vascular pathology, one of the most serious of which is a 
subarachnoid haemorrhage. Other potential differential
diagnoses include meningitis and hypotensive pathology.
Associated focal neurological deficit
Neurological deficits may include unilateral limb weakness, cranial nerve
abnormalities, or sensory deficits. Neuroanatomically, this suggests there may be
a lesion that is altering the way that individual nerves, spinal, or intracerebral tracts
are functioning.
Associated systemic features
Systemic features may include fever, weight loss, night sweats, in conjunction with
recent-onset and progressive headache.
It is important to exclude temporal arteritis (a term used interchangeably with giant
cell arteritis), a pathology that can cause permanent visual loss if untreated. Other
differentials diagnoses include malignancy (e.g. central nervous system lymphoma)
or chronic infections (e.g. cerebral toxoplasmosis).
Patients over the age over 50
Headaches in patients over the age of 50 can herald specific pathology such as 
temporal arteritis
 Assessment of headache
• Acutely unwell patients with headache should undergo a rapid ABCDE assessment. Patients
with secondary headache (e.g. subarachnoid headache) may deteriorate and become rapidly
unresponsive. 
• Assessment of headache should involve a comprehensive history. (SOCRATES)
• Following the history, a neurological examination (including cranial nerves, upper limb, 
lower limb and fundoscopy) should be undertaken to elicit any abnormal neurological
features suggestive of organic pathology.
• Other important examination steps include:
Basic observations (vital signs): including blood pressure
Palpation of facial structures: palpation over the temporal arteries, TMJ, sites of trauma and
sinuses may reveal an extracranial cause of headache
Orbits: eye protrusion or periorbital swelling may suggest orbital/retro-orbital pathology
 Investigations
• Outside of an emergency setting, the chance of finding serious
secondary pathology with imaging in an isolated headache with no
abnormal neurology on examination is similar to people without a
headache.5 6
• Therefore, imaging such patients provides no clinical benefit, only
exposing them to unnecessary radiation, and risking
uncovering incidental findings that lead to further harm due to over
investigation.
• However, if a patient does present with a headache in association
with abnormal neurology, imaging is indicated. This is especially
important if a patient has presented with a thunderclap headache, as
this may be a symptom of a subarachnoid haemorrhage. CT scan
appropriate first line.
KEY POINTS
• Most headaches are primary headaches such as migraine or tension-type headache
• Tension-type headache is a non-disabling, bilateral headache that is pressing in
nature and lasts 30 minutes to 7 days
• The key differentiator for migraine is the disabling nature of attacks (i.e. inability
to perform activities of daily living), associated with nausea, vomiting, and photo or
phonophobia
• Cluster headache is rare but recognisable due to the excruciating pain of the attacks
• Medication overuse headache can occur with the use of analgesia on as little as 10
days per month
• Secondary headache indicators are thunderclap headache, associated systemic
features, focal neurology, and age over 50
• Patients presenting with secondary headache indicators should have a CT scan