Headache

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Grouping Headaches

There are numerous causes of a headache, and they can be grouped in various ways. The commonest causes of headache, both acute or chronic, include:

• Upper respiratory infection (acute).
• Tension headache.
• Migraine.
• Combination headache (combination of tension/depression, migraine, cervical dysfunction, and drugs).
• Cervical dysfunction (referred pain from the back bones in the upper neck).
• Cluster headache.
• Drugs (e.g. caffeine, alcohol, high blood pressure tablets, stopping analgesics).
• Depression.
• Sinusitis.

• Subarachnoid haemorrhage, intracerebral haemorrhage (acute, sudden).
• Extradural/Subdural haematomas.
• Temporal arteritis.
• Malignancies (brain tumours, other cancers eg. lung that have spread to the brain).
• Severe infections (meningitis).
• Benign intracranial hypertension.
• Glaucoma.

Of course the above will vary with the age of the patient. Children are more likely to suffer from respiratory infections, while older people of glaucoma, temporal arteritis, malignancies etc. Acute causes, such as subarachnoid haemorrhage, meningitis, and epidural and subdural haematomas (after trauma) can occur suddenly (especially subarachnoid haemorrhage) and require immediate management, but will not cause repeated episodes. On the other hand, headache due to other causes, e.g. tension headache, migraine, depression, cervical dysfunction will often recur and may lead to a chronic or recurrent headache. In addition, the chronic use of analgesics by patients may lead to a drug rebound headache (where the headache recurs when they discontinue the medications) which can also complicate matters.

The History of the Headache

The history is often sufficient to obtain an accurate diagnosis - it is especially useful in ruling out serious diagnoses, or making decision on judicious use of investigations (eg. CT). Firstly, questions about the headache itself - when it started, where it is felt, severity, character, associated features (vomiting, visual symptoms), precipitants etc. The following questions are important to rule out a serious diagnosis:

• Any history of trauma (subdural and epidural haematomas);
• Sudden onset (especially Subarachnoid haemorrhage - which is occipital);
• Any fever, rash, neck stiffness (meningitis, encephalitis);
• Vomiting and photophobia (light hurts the eyes) - meningitis, subaracnoid, migraine;
• Any scalp tenderness, shoulder/hip aches, jaw pain - temporal arteritis;
• Headache associated with vomiting in the morning or if worse with coughing may indicate raised intra-cranial pressure;
• Any visual blurring - glaucoma, benign intracranial hypertension;
• Any new headache in an elderly patient could be serious - malignancy, temporal arteritis, depression.

In addition - enquiries should be made of the patient's lifestyle, stress levels (for tension headache) as well as whether there is any family history of migraines.

Investigations

• CT scan head: A CT of the head will help exclude a space-occupying lesion like a tumour or abscess in the chronic setting, and in the acute setting will help with diagnosing sub-arachnoid haemorrhage, subdural haematoma, and infections.
• Cervical spine x-ray: The diagnosis of cervical dysfunction is usually clinical, though x-rays can help to diagnose any obvious malalignment or osteoarthritis.
• Sinus x-ray: If suspected sinusitis;
• Chest x-ray: If suspected brain malignancy (looking for a lung primary)
• MRI: This will provide more soft tissue detail than a CT scan - but it is more expensive.
• Lumbar puncture: Diagnosis of meningitis or if CT is normal but suspected subarachnoid haemorrhage.

Treatment

Appropriate treatment is dependent on obtaining an accurate diagnosis.

Treatment may vary from:

• Urgent neurosurgical referral and treatment for epidural or subdural haematomas, subarachnoid haemorrhage and brain tumours.
• Urgent IV antibiotics and supportive treatment for meningitis.
• Corticosteroids for temporal arteritis.
• Referral to an opthalmologist and intra-occular pressure lowering for glaucoma.
• Psychotherapy, anti-depressants, and possible psychiatrist referral for depression.

• Simple analgesics and relaxation therapies for tension headache;
• Simple analgesics, general measures, avoidance of precipitants, and specific medications and preventative medications for migraine.
• Physical rehabilitation for cervicogenic headache.