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Approach to Headache – Evidence Reviewed
Approach to Headache 2018-01-30T16:36:29+08:00

Differential diagnosis

  • Inflammatory
    • Giant cell arteritis
    • Optic neuritis
  • Vascular
    • Subarachnoid haemorrhage
    • Subdural haemorrhage
    • Epidural haematoma
    • Cerebral vein thrombosis
  • Infectious
    • Meningitis
    • Septic carvenous sinus thrombosis
    • Brain abscess
  • Headache syndromes
    • Migraine
    • Tension headache
    • Cluster headache
    • Analgesia misuse headache
    • Cervical headache
  • Raised intracranial pressure
    • Brain tumour
    • Benign intracranial hypertension
    • Hydrocephalus
  • Obstructive sleep apnoea
  • Hyperviscosity
    • Polycythaemia
    • Acute leukaemia
    • Chronic lymphocytic leukaemia
    • Waldenström’s macroglobulinaemia
  • Low pressure headache
  • Hypertension
  • Pre-eclampsia
  • Traumatic
  • Psychogenic

History

  • Headache
    • How did it start?
    • Where is the headache?
    • Is it on one side of the head or both?
    • Did it start suddenly?
    • Was it most painful at the start, or does it gradually get more painful?
    • What does the pain feel like?
    • Have you noticed any other symptoms with the headache?
      • Any nausea or vomiting?
    • Does anything make it better?
    • Does anything make it worse?
    • How bad is the pain on a scale of 1 – 10?
    • If recurrent: how often do you get the headaches?
    • Have you ever had this before?
  • Inflammatory
    • Do you have any fever?
    • Have you noticed any blurred vision?
    • Do you get pain in your jaw when you eat?
    • Does your head hurt if you brush your hair?
    • Have you ever noticed that colours are not as vibrant or bright as before?
  • Raised ICP
    • Is the headache worse when you cough?
    • Is it worse in the morning?
    • Is it worse when you squat?
    • Do you have nausea or vomiting with the headache?

Investigation

  • Computed tomography to rule out ICH
  • Magnetic resonance imaging of the brain and venography to rule out space-occupying lesion
  • BIH: papilloedema
  • Lumbar puncture: raised opening pressure in BIH, meningitis
  • Radioisotope cisternography for low pressure headache

Management

  • Meningitis
    • Ceftriaxone 2g BD, acyclovir IV 5mg/kg 8H
    • Ampicillin if elderly
    • Streptococcus pneumoniae or TB meningitis: dexamethasone 0.15mg/kg 6H
  • Migraine
    • Acute: NSAIDS with tryptans
    • Prophylaxis: propranolol or topiramate
      • When to start depends on patient factors and quality of life
    • Avoid OCP in patients with migraine and aura
  • Cluster headache
    • Acute: oxygen, tryptans
    • Prophylaxis: verapamil
  • Benign intracranial hypertension
    • Weight loss
    • Stop OCP
    • Stop smoking
    • Acetazolamide
    • Lumbar puncture (therapeutic)
    • Optic nerve fenestration

This Is A Custom Widget

This Sliding Bar can be switched on or off in theme options, and can take any widget you throw at it or even fill it with your custom HTML Code. Its perfect for grabbing the attention of your viewers. Choose between 1, 2, 3 or 4 columns, set the background color, widget divider color, activate transparency, a top border or fully disable it on desktop and mobile.

This Is A Custom Widget

This Sliding Bar can be switched on or off in theme options, and can take any widget you throw at it or even fill it with your custom HTML Code. Its perfect for grabbing the attention of your viewers. Choose between 1, 2, 3 or 4 columns, set the background color, widget divider color, activate transparency, a top border or fully disable it on desktop and mobile.