Headache

Probability diagnosis

Acute:

• respiratory infection

Chronic:

• tension-type headache

• combination headache

• migraine

• transformed migraine

Serious disorders not to be missed

Cardiovascular:

• subarachnoid haemorrhage

• intracranial haemorrhage

• carotid or vertebral artery dissection

• temporal arteritis

• cerebral venous thrombosis

Neoplasia:

• cerebral tumour

• pituitary tumour

Infection:

• meningitis (esp. fungal)

• encephalitis

• intracranial abscess

Haematoma: extradural/subdural

Glaucoma

Benign intracranial hypertension

Pitfalls (often missed)

Cervical spondylosis/dysfunction

Dental disorders

Refractive errors of eye

Sinusitis

Ophthalmic herpes zoster (pre-eruption)

Exertional headache

Hypoglycaemia

Post-traumatic headache (e.g. post-concussion)

Post-spinal procedure (e.g. epidural, lumbar puncture)

Sleep apnoea

Rarities:

• Paget disease

• post-sexual intercourse

• cluster headache

• Cushing syndrome

• Conn syndrome

• Addison disease

• dysautonomic cephalgia

Masquerades checklist

Depression

Diabetes

Drugs (see list)

Anaemia

Thyroid disorder and other endocrine (as above)

Spinal dysfunction (cerviogenic)

UTI

Is the patient trying to tell me something?

Quite likely if there is an underlying psychogenic disorder.

Key history

A full description of the pain including a pain analysis should be obtained, especially associated symptoms. It is useful to get the patient to prepare a diary with a grid plotting the relative pain intensity with time of day. Family history, psychosocial history and drug history.

Key examination

• Use the basic tools of trade: thermometer, sphygmomanometer, pen torch, diagnostic set with ophthalmoscope and stethoscope

• Inspect the head, temporal arteries and eyes

• Areas to palpate include the temporal arteries, the facial and neck muscles, the cervical spine and sinusitis, teeth and TMJs

• Look for signs of meningeal irritation and papilloedema

• A mental state examination is advisable

• Perform a basic neurological examination

Key investigations

Consider:

• FBE

• ESR/CRP

• selective radiography (e.g. skull X-ray, sinus X-ray, CT scan or MRI scan).

Diagnostic tips

• Hypertension is an uncommon cause of headache.

• ‘Combination headaches’, which can last for days, have a mix of components such as tension, depression, vascular headache and drug dependence.

• A patient >55 years presenting with unaccustomed headache probably has an organic cause.

• Drugs that may cause headache: alcohol, analgesics (rebound), caffeine, antihypertensives (several), COCP, corticosteroids, NSAIDs (esp. indomethacin), vasodilators esp. nitrates, sildenafil.