Background
Secondary
- Have underlying cause
- Meds. overuse, arteritis, ↑ICP, infection
Clinical
High risk (investigate further)
- Sudden-onset headache (max intensity in 1 min)
- Worsening headache with fever
- New-onset neurological deficit
- New-onset cognitive dysfunction
- Change in personality
- ↓ level of consciousness
- Recent (3 months) head trauma
- Headache triggered by cough, valsalva
- Headache triggered by exercise
- Orthostatic (Δ with posture)
- Symptoms of giant cell arteritis
- Symptoms/signs of acute narrow-angle glaucoma
- Substantial Δ in the characteristics of headache
Consider referral
- Compromised immunity
- Hx malignancy
- Vomiting without other obvious cause
Remember
- Subarachnoid
- Meningitis
- ↑ICP (E.g SOL - papilloedema)
- Venous thrombosis (papilloedema)
- Glaucoma - headache, blurred vision, vomiting, dusky cornea (recent halos), semi dilated pupil (constricted in cluster)
- Cluster bouts
- Temporal arteritis - jaw claudication, new headache, myalgia, ±tender temporal art, ↑ESR, ±PMR ("roll" out of bed)
- Optic neuritis - retro-orbital pain with eye movement
| Feature | Tension headache | Migraine (±aura) | Cluster headache |
|---|---|---|---|
| Pain location | Bilateral | Unilateral or bilateral | Unilateral (around/above the eye and side of the head/face) |
| Pain quality | Pressing / tightening (non-pulsating) | Pulsating (throbbing or in young people aged 12–17 years) | Variable (can be sharp, boring, burning, throbbing or tightening) |
| Pain intensity | Mild or moderate | Moderate or severe | Severe or very severe |
| Effect on activities | Not aggravated by routine activities | Aggravated by, or causes avoidance of, activities of daily living | Restlessness/agitation |
| Other symptoms | None | Unusual sensitivity to light and/or sound or nausea and/or vomiting. Aura symptoms can occur with or without headache and: - are fully reversible - develop over at least 5 minutes - last 5−60 minutes. Typical aura symptoms include visual symptoms such as flickering lights, spots or lines and/or partial loss of vision; sensory symptoms such as numbness ±paraesthesia, ±speech disturbance. |
Same side as headache: - red and/or watery eye - nasal congestion ±catarrah - swollen eyelid - forehead / facial sweating - constricted pupil ±drooping eyelid. |
| Duration | 30 minutes–continuous | 4–72 hours in adults, 1–72 hours in young people aged 12–17 years | 15–180 minutes |
| 1. Headache pain can be felt in the head, face or neck. 2. Chronic migraine and chronic tension-type headache commonly overlap. If there are any features of migraine, diagnose chronic migraine. | |||
Ottawa SAH rule
The ottawa SAH rule has a 100% sensitivity (but low specificity) for SAH (more on SAH). A patient with headache does not require investigations for SAH if then do not have any of:
- age ≥40 years
- neck pain or stiffness
- witnessed loss of consciousness
- onset during exertion
- thunderclap h'ache [instantly peaking]
- limited neck flexion on examination