Headache Assessment
Assessment:
Key questions to ask in headache history:
Examination:
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Check Vital signs (BP +/- pulse, RR, temp, SaO2) and BMI
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Perform a head and neck examination:
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Assess:
- Neck movements for discomfort
- The temporomandibular joints and jaw opening for TMJ dysfunction
- For sinus tenderness
- The temporal arteries for GCA – look for tender, thickened, hardened or reduced/absent pulses.
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The carotid arteries for bruits
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Assess:
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Perform a brief neurological examination:
- See 3 minute neuro exam by Dr Giles Elrington (National Migraine Centre) to help exclude serious causes of headache
Red Flags:
(think SNOOP pneumonic!)2
Investigations:
Note: avoid unnecessary imaging
- A detailed history and basic neurological examination are usually enough to differentiate between benign and serious causes.
- The risk of finding pathology in patients with a headache and a normal neurological exam is similar to those without a headache.
Consider investigations:
- Bloods – CRP/ESR if patient over 50 years with a new headache.
- Optician assessment
- If suspected brain tumour or metastases – request urgent MRI (or CT with contrast if MRI contraindicated) via 2ww Brain referral.
Secondary Causes of Headache:
Serious secondary causes of headaches:1
Primary Headaches:
Key points:
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Be aware a patient may have 2 or more co-existing types of headaches
- Migraine is commonly underdiagnosed – any patient with recurrent headaches with nausea has migraine
Other causes of headaches:
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Medication overuse headache (MOH):
- Common and under-diagnosed.
- Caused by regular headache medication used for 3 months or more, in a patient with a pre-existing headache disorder.
- Headache presents 15 days or more per month.
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Other signs and symptoms:
- Worse on waking
- Aggravated by physical exercise
- Nausea and other gastrointestinal symptoms
- Restlessness, anxiety, irritability, or poor concentration
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Iatrogenic causes:
- SSRIs – use and cessation
- Vasodilators: hydralazine, minoxidil, dihydropyridine calcium channel-blockers, nitrates
- Indometacin
- Trimethoprim
- COCP
- Steroids
- Phosphodiesterase type 5 inhibitors, e.g. sildenafil
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Caffeine withdrawal headache:
- May occur within 24 hours of interrupting regular caffeine consumption in excess of 200 mg a day for more than 2 weeks.
- 200 mg caffeine is approximately: 4 cups of instant coffee, 2 espressos, 4 cans of coke, 6 to 7 cups of tea.
- It may take 7 days to remit in the absence of further consumption.
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Headache attributed to fasting:
- a diffuse non-pulsating headache.
- usually mild to moderate.
- caused by fasting for at least 8 hours and relieved after eating.
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Obstructive sleep apnoea – consider this if the patient wakes with a headache
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Alcohol consumption
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Bruxism
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Refractive error
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Dehydration
- Sinusitis
Supporting Information
For professionals:
- Headache Management System – for Clinicians
- British Association for the Study of Headache – Guidelines for All Healthcare Professionals in the Diagnosis and Management of Migraine, Tension-Type, Cluster and Medication-Overuse Headache
- NICE Clinical Knowledge Summaries (CKS) – Headache Assessment
For patients:
References:
- https://www.ebmedicine.net/store.php?paction=showProdSeg&sid=135
- https://practicalneurology.com/articles/2018-mar-apr/ruling-out-secondary-headache
Page Review Information
Review date – December 2023
Next review due – December 2026
Reviewing GP – Dr Madeleine Attridge
Other contributors: Dr Oliver Leach, Dr Simon Parkin.