Headache

Published on 10/04/2015 by admin

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Last modified 10/04/2015

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Headache

Headache is common. Almost everyone has a headache at some time in life. Headache accounts for 2% of general practice visits and 20% of neurological outpatients. Headaches are only very rarely sinister. However, it is important to recognize certain dangerous headaches, and the major types of safe but unpleasant headaches (Table 1).

Table 1 Types of headaches and estimate of incidence

image

History

The history is the most important diagnostic tool in patients with a headache; in most patients the physical examination is normal. The key points in the history are as follows:

image Length of history.
image Pattern – when and how often do they occur?
image Duration – how long does each headache last or is it there all the time?
image Progression – is it getting worse?
image Site – whereabouts in the head does it occur?
image Quality of the pain – what does it feel like?
image Associated symptoms – does anything else occur with the headache, e.g. flashing lights, numbness, sickness or a runny nose? Are there any other neurological symptoms suggesting focal neurological disease?
image Triggers – does anything seem to bring the headache on, particularly bending, coughing or straining?

The different features of the common but unpleasant and the rare but dangerous headaches are summarized in Figures 1 and 2.

image

Fig. 1 Dangerous headaches.

image

Fig. 2 ’Safe’ but unpleasant headaches.

Examination

General and neurological examination is normal in most patients with headache. Hypertension is usually an incidental finding; occasionally, headache can be attributed to severe hypertension. Points of particular significance in this clinical setting are fever, rash and neck stiffness in patients with recent-onset headaches, scalp tenderness in older patients and fundoscopy in all patients. It is especially useful to see retinal venous pulsation on fundoscopy as this indicates that the intracranial pressure is normal.

Dangerous headaches

These headaches are single episodes of headache that develop in seconds to weeks. All are uncommon.

Subarachnoid haemorrhage

These patients classically present with a sudden severe headache: ‘like being hit by a baseball bat’ (Fig. 1a). There may be associated loss of consciousness and focal neurological signs. The subarachnoid blood provokes neck stiffness. Currently up to 50% of patients who present with subarachnoid haemorrhage are misdiagnosed by the first doctor who sees them. A high threshold of suspicion is needed (p. 72).

Meningitis

Meningitis is characterized by progressive headache developing over hours or days (Fig. 1b). There is an associated fever and neck stiffness, and there may be a rash and impaired consciousness. As early treatment favours a good prognosis, a high threshold of suspicion is needed (p. 98).

Temporal arteritis (or giant cell arteritis)

This is a vasculitis that affects middle-sized arteries. It is dangerous because the arteritis can affect retinal vessels and cause blindness. It occurs in patients aged over 50 years and the incidence increases with age (1 in 100 000 aged over 50 years and 800 in 100 000 over 80 years). Women are affected twice as commonly as men.

The headache is insidious in onset and may be unilateral or more generalized, though it usually produces bitemporal pain (Fig. 1c). The scalp is often tender. A specific symptom is ‘jaw claudication’, the development of pain in the muscles of mastication on chewing. Twenty-five per cent of patients also have generalized joint and muscle aching typical of polymyalgia rheumatica.

The erythrocyte sedimentation rate (ESR) is elevated, usually strikingly (60–100), as are other serological inflammatory markers such as plasma viscosity and C-reactive protein. The diagnosis is confirmed by a biopsy of a temporal artery; however, this may be negative as the arteritic lesions are patchy. If the diagnosis is suspected, treatment with steroids should be started immediately, to which there is usually a brisk response. Treatment is monitored using the ESR and can usually be stopped within 2 years.

Raised intracranial pressure

The ‘classical’ headaches of raised intracranial pressure (ICP; p. 48) are generalized and made worse or brought on by manoeuvres that increase ICP such as coughing, bending or lying down (Fig. 1d

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