Approach to Headache
Who hasn’t had one?
Pain sensitive struc. in skull
Skin, muscles, periosteum Eye, ear, paranasal sinuses Venous sinuses & veins Dura at base of skull Arteries in dura & pia arachnoid Nerves- V, IX, X, C1-3
Causes of headache Spasm/trauma/inflammation of muscles Distention of cranial arteries Traction of intracranial veins/sinuses Compression/traction/inflammation of
nerves Meningeal irritation Increased intracranial pressure Diseases of eye/ear/paranasal sinuses
History Onset Progression Frequency Duration Location Character Severity
Aura Eye/ear/nose symp. Precipitating factors Relieving factors Effective treatment Other medical
problems
Focused general examination
Vital signs Extracranial structures- muscles,
arteries, paranasal sinuses Evidence of meningeal irritation Neck flexion Kernig sign Brudzinski sign
Focused neurological exam. Consciousness, coherence, orientation Pupils- symmetry, reactivity Ocular motility, visual fields, optic fundi Facial sensation & symmetry Muscle tone, strength, DTR Response to painful stimuli Plantar response Gait & coordination
Warning signs New or different headache Progressive headache New headache after 50 Headache of maximum severity at onset Headache precipitated by Valsalva
maneuver Associated seizures Associated focal neurological deficit Associated fever, HT, myalgia,
scalp tenderness
Investigations, if required
CT scan or MRICSF examination
Angiography
Tension headache
Usually bilateral Over temple, cranium or back of neck Described as tightness or pressure Gradual onset & progression Worsens over the day Asso. with depression or anxiety Relieved with NSAIDs, TCA, anxiolytics
Migraine Periodic, hemicranial, throbbing pain More in young females Associated with nausea/vomiting Aura +/- Family history +ve in 60% May have neurologic symptoms/signs Treatment- NSAIDs &/or Triptans,
opioids Prophylaxis- Propranolol, Amitriptyline,
SSRI, Verapamil
Cluster headache More in young men Episodic, onset when asleep Bouts lasting 4-8 weeks Unilateral, periorbital, constant,
nonthrobbing Asso. with lacrimation, rhinorrhoea etc. Treatment- 100% oxygen, Triptans Prophylaxis- Lithium carbonate, Verapamil,
Valproate, Topiramate
Giant cell arteritis
Elderly Headache, with systemic symptoms Tenderness over temporal artery &
scalp May cause loss of vision ESR raised Treatment- steroids
Trigeminal neuralgia More in women Episodes of unilateral sudden
lancinating facial pain Limited to distribution of Vth cranial n. Suspect multiple sclerosis in young Treatment- Oxcarbazepine,
Carbamazepine, Gabapentin Surgical exploration/ gamma
radiosurgery help in intractable cases
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