Headache

Differential diagnosis

  • Meningism – fever, neck stiffness, rash
  • Raised ICP / SOL – postural, vomiting, drowsiness, personality change
  • SAH – sudden occipital
  • Temporal arteritis – jaw claudication, temporal artery tenderness
  • Tension – mild, frontal pressure
  • Medication overuse – analgesics more than twice per week
  • Migraine – unilateral, throbbing, aura, nausea, photophobia, triggers, FH
  • Cluster – rare, severe unilateral periorbital pain, lasts up to 3 hours, cluster of episodes in 3 months
  • Eye strain – optician review

 

Data gathering

  • Red flags
    • See above
  • Others
    • Change from previous headache
    • Analgesia use
    • Stress
    • Timings
    • Optician
  • Examine
    • BP, temperature
    • CN
    • Fundoscopy
    • Temporal arteries

 

Clinical management

  • Investigations
    • No specific investigations needed but consider baseline bloods
  •  Treatment
    • Tension headache
      • Lifestyle
        • Exercise, fluids, CBT
      • Medications
        • Aspirin/paracetamol/ibuprofen
        • Amitriptyline 10-150mg/day (if not tolerated, try Nortriptyline)
          • only use medications < twice per week
    • Medication overuse headache
      • Stop causative analgesia (esp opiates)
        • Headache may get worse for days-weeks before improvement
    • Migraine
  • Safety-net / Follow-up
    • Refer
      • If therapy fails or uncertain diagnosis