Headache

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Key points ⚡
Succinct notes to superpower your revision
Headache\: common presenting complaint in primary and secondary care, vital to assess thoroughly to establish correct
diagnosis.
Primary headaches\: no identi
Secondary headaches\: caused by organic pathology; important to identify red
Tension-type headache\: bilateral, pressing/tightening, mild/moderate severity, no nausea/vomiting, lasts 30 minutes to 7
days.
Migraine\: unilateral or bilateral, pulsating/throbbing, moderate/severe, associated with nausea/vomiting, lasts 4-72 hours.
Cluster headache\: always unilateral, excruciating/stabbing, very severe, associated with restlessness, ipsilateral
conjunctival injection, lacrimation, nasal congestion, lasts 15 minutes to 3 hours.
Medication-overuse headache\: common problem, headaches >15 days/month, triggered by overuse of triptans, opioids,
combination or simple analgesics.
Secondary headache indicators\: sudden onset (thunderclap headache), associated focal neurological de
systemic features (fever, weight loss), age >50 years.
Thunderclap headache\: reaches maximal intensity within 1-5 minutes, indicates potential acute vascular pathology, e.g.,
subarachnoid haemorrhage.
Systemic features\: fever, weight loss, night sweats, suggestive of temporal arteritis, malignancy, chronic infections.
Assessment\: comprehensive history, neurological examination, basic observations (vital signs), palpation of facial
structures, assessment of orbits.
Investigations\: imaging indicated in abnormal neurology or thunderclap headache, CT scan
subarachnoid haemorrhage.
BASH guidelines\: national headache management system for real-time use during consultations.
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A comprehensive topic overview

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.
This article will cover primary and secondary headaches, as well as diagnostic features and investigations.

Aetiology

Headaches can be categorised into primary or secondary headaches.
Primary headaches are those with no identi
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

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.
Table 1. The features of migraine, tension-type headache, and cluster headache according to the international classi
of headache disorders.
1
T ension-type
headache
Site Bilateral
Pressing/tighteni
Character
ng
Mild or moderate
Severity
Not disabling
Migraine
Unilateral (often
bilateral)
Pulsating/throbbing
Moderate or severe
Disabling (i.e.
interferes with the
ability to perform
routine activity)
Cluster
headache
Always
unilateral
Excruciating,
stabbing,
burning
Very severe
Associated
features
No
nausea/vomiting
No more than one
of photophobia or
phonophobia
One or more of\:
nausea, vomiting,
photophobia, or
phonophobia
Restlessness
No aggravation
by physical
activity
Ipsilateral to
pain, there may
be\:
Conjunctival
injection
Lacrimation
Nasal
congestion
Rhinorrhoea
Ptosis/miosis
Attacks last 15
minutes to 3
hours
Attacks last hours to
days
Timing
Attacks last 30
minutes to 7 days
(usually 4-72 hours)
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).
2
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.
2Secondary headache
Secondary headaches are those caused by organic pathology.
There are four evidence-based indicators for a secondary headache.
Thunderclap (sudden onset) headache
Headache with onset which reaches maximal intensity within a minute to
provided the de
This presentation is an indicator of a potential acute vascular pathology, one of the most serious of which is a subarachnoid
haemorrhage. Other potential di
Associated focal neurological de
Neurological de
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 di
lymphoma) or chronic infections (e.g. cerebral toxoplasmosis).
Patients over the age over 50
Headaches in patients over the age of 50 can herald specitemporal arteritis.
3 4

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. For more information, see the Geeky Medics guide to
headache history taking.
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
British Association for the Study of Headache (BASH)
The national headache management system provides information for clinicians and patients on the assessment and
management of headache. It is designed to be used in real-time during consultations. The system is derived from the
2019 British Association for the Study of Headache (BASH) guidelines.

Investigations

Outside of an emergency setting, the chance of
with no abnormal neurology on examination is similar to people without a headache.
5 6Therefore, imaging such patients provides no clinical bene
uncovering incidental
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. A CT scan would be the imaging modality most appropriate
2

References

Headache Classi
Headache Disorders, 3rd edition. C e p h a l a l g i a 2018;38(1)\:1-211.
British Association for the Study of Headache. B A S H G u i d e l i n e s 2 0 1 9 . Available from\: [LINK]
Locker TE, Thompson C, Rylance J, et al. The utility of clinical features in patients presenting with nontraumatic headache\:
an investigation of adult patients attending an emergency department. H e a d a c h e 2006;46(6)\:954-61.
Ramirez-Lassepas M, Espinosa CE, Cicero JJ, et al. Predictors of intracranial pathologic
emergency care because of headache. A r c h N e u r o l 1997;54(12)\:1506-9.
Kurth T, Buring JE, Rist PM. Headache, migraine and risk of brain tumors in women\: prospective cohort study. J H e a d a c h e
P a i n 2015;16(1)\:501.
Morris Z, Whiteley WN, Longstreth WT, et al. Incidental
and meta-analysis. B M J 2009;339\:b3016.

Reviewer

Dr Stuart Weatherby
Consultant Neurologist
University Hospitals Plymouth NHS Trust

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Contents

Introduction
Aetiology
Primary headacheSecondary headache
Assessment of headache
Investigations
Source\: geekymedics.com