Some things don't need an introduction... a headache is a headache.
Primary vs Secondary Headache
Ask yourself:
Is the headache being caused by an underlying problem, like an infection or a bleed?
- No: This is a primary headache e.g. migraine, tension type or trigeminal neuralgia
- Yes: This is a secondary headache e.g. meningitis (secondary to bacterial infection) or raised intracranial pressure (secondary to an intracranial haemorrhage or an intracranial tumour).
We’re going to go through some different types of headache here, except for migraine which is a topic of its own.
Causes
- Tension type headache
- Cluster headaches
- Migraine
- Trigeminal neuralgia
- Meningitis/Encephalitis
- Intracranial haemorrhages (subdural, subarachnoid, extradural etc)
- Hormonal headaches
- Giant cell arteritis
- Sinusitis
- Cervical Spondylosis
- Trigeminal Autonomic Cephalgia’s – TACs
- Glaucoma
- Pre-eclampsia
Red Flags
- Headache associated with vomiting
- Maximal at onset
- Thunderclap headache: Sudden onset, severely painful headache
- Wakes someone from sleep
- Worse with pressure or position e.g. coughing/sneezing/straining or leaning forward
- Occipital headaches
- Focal neurological deficits
- History of head injury/trauma
- Visual changes
Tension-Type Headache
These are your very common, standard frontal type headaches.
Clinical Features:
- Pressure/tight band around the head
- Bilateral
- Can be associated with many things including
- Dehydration
- Stress
- Hypertension
- Refractive errors
Management
- Headache diary
- Reassurance and conservative relaxation methods
- Simple analgesics e.g. aspirin/paracetamol/NSAIDs. Opioids are not recommended for treating tension-type headaches
- Acupuncture: NICE recommend considering an acupuncture course, lasting up to 10 sessions over 5-8 weeks for prophylaxis of chronic tension-type headaches
Trigeminal Neuralgia
Pathophysiology
Thought to be due to a dilated (ectatic) blood vessel which puts pressure on the trigeminal nerve.
Clinical Features
- Electric shock-like pains which are very short lived (seconds to minutes usually) in the distribution of the trigeminal nerve. Patients tend to experience several attacks throughout a day.
- Usually unilateral but can be bilateral
- Can be triggered by touching the face, shaving, cold wind on the face, brushing teeth – can be triggered by things touching the face
Management
- Carbamezapine – if this is unsuitable or contraindicated, expert specialist advice can be consulted.
Medication Overuse Headache
Clinical Features
- In patients presenting with chronic, dull headaches, consider medication overuse headaches, particularly if patients have been using the following drugs for at least 3 months:
- >15 days/month: Paracetamol, Aspirin, NSAIDs
- >10 days/month: Triptans, Opioids, Ergots, Combined Analgesics
Management
- Withdrawal of the analgesic agent is the treatment for this
- NICE advise stopping the agent abruptly for at least a month
- Patients who are on strong opioids may require specialist intervention or inpatient care to help withdraw from medication.
Trigeminal Autonomic Cephalgias – TACs
These are a type of primary headache where you tend to get unilateral pain which can be in the distribution of the trigeminal nerve, alongside ipsilateral autonomic symptoms such as watering of the eyes/nose/drooping eyelid. There are a few types, but we're going to cover three here:
- Cluster Headache
- Paroxysmal Hemicrania
- Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing headache (SUNCT)
Cluster Headache
Clinical Features
- Excruciating unilateral pain
- Around/above the eye
- Unilateral on the head or face
- Tends to affect men
- Associated with ipsilateral autonomic symptoms
- Conjunctival injection
- Lacrimation
- Nasal congestion
- Rhinorrhoea
- Miosis
- Ptsosis
- Swollen eyelid
- Sweating
- Forehead swelling
- Short attacks e.g. half an hour to an hour and a half. However, they occur in clusters so patients can have many attacks in a day over a period of weeks/months, with periods of remission where they don't have symptoms
- Patients are usually agitated/restless and tend to want to move around rather than lie down. Differs to migraine as in migraine, patients tend to want to sleep/lie down.
Management
Acute Attack
- 100% oxygen ≥12L/min via non-rebreather
- Subcutaneous/nasal triptan e.g. sumatriptan or zolmitriptan respectively
Prophylaxis
- Verapamil – if this does not work, specialist advice should be sought.
Paroxysmal Hemicrania
Clinical Features
- Tends to affect women
- Extremely painful, similar to cluster headaches. The episodes are much shorter however, lasting around 10-30 minutes, but they occur more often.
- Respond to indomethacin, a type of NSAID
Short-Lasting Unilateral Neuralgiform Headache with Conjunctival Injection and Tearing (SUNCT)
Clinical Features
- These are extremely short bursts of severe headache that last from a few seconds to a couple of minutes.
- Unilateral stabbing or burning pain around the eye
References
https://s3.amazonaws.com/rdcms-iasp/files/production/public/Content/ContentFolders/Publications2/PainClinicalUpdates/Archives/PCU_20-3_web_RevApr2012.pdf
https://www.nice.org.uk/guidance/cg173/chapter/1-Recommendations
