IM
Secondary Headaches
- Intracranial disease: (meningitis, brain hemorrhage, brain tumor)
- Eye diseases: (vision problems are the commonest)
- Sinusitis
- Temporal arteritis: (inflammation of the temporal artery)
- Head trauma
- Systemic diseases: (HTN)
FM
Urgent Considerations
Meningitis
- Presents with fever, headache, stiff neck.
- Patients may develop meningococcal sepsis, presenting with hypotension, altered mental state, and purpuric or petechial rash.
- Patients should have a lumbar puncture (LP) within 1 hour of arrival at hospital, provided it is safe to do so, and commence antibiotic treatment immediately afterwards.
- If high suspicion, antibiotics should be administered empirically before LP.
- If LP is delayed for CT, blood cultures should be obtained and broad-spectrum antibiotics given before CT.
Subarachnoid Haemorrhage (SAH)
- About 1% of all patients presenting to the emergency department with headaches have SAH.
- It may present with a ‘thunderclap’ headache (sudden onset of severe headache, seen in 12% of SAH).
Sudden onset, worst headache of life
- Immediate CT
Hypertensive Encephalopathy
- Elevated BP, mean arterial pressure >150 to 200 mmHg
- Immediate CT
- BP should be quickly lowered by 20% to 25% (labetalol, nicardipine).
Giant Cell Arteritis
- Patient >50 years, with their first severe headache
- Erythrocyte sedimentation rate is checked
- Immediate treatment with corticosteroids is required to prevent blindness if diagnosis is suspected.
Acute Angle-Closure Glaucoma
- Headache in older person (>50 years)
- Decreased visual acuity, nausea/vomiting, eye pain, mid-dilated fixed pupil
- Intra-ocular pressure should be reduced (pilocarpine, timolol, acetazolamide)
- Ophthalmology consultation.
Raised Intracranial Pressure
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Untreated may lead to permanent sight loss, permanent neurological deficit, and death.
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Constant, severe headache. May be aggravated by coughing, straining, or bending.
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One third of patients report a headache that is worse on waking.
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Patients also experience visual symptoms including blurred or double vision, and transient losses of vision.
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Examine fundi for papilloedema.
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Urgent neuroimaging looking for mass lesion, followed by lumbar puncture if safe.
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Effect of pain on activity
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Relationship with food
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Response to any previous treatment
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Any recent change in vision
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Association with recent trauma
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State of general health
Temporal Arteritis
Temporal arteritis (giant cell arteritis) is where the arteries, particularly those at the side of the head (the temples), become inflamed (vasculitis). It’s serious and needs urgent treatment.
- Commonly affects elderly female.
- The ESR is markedly elevated.
Symptoms
- Fatigue.
- Fever.
- Jaw pain that may become worse after chewing.
- Tenderness at the scalp or temples.
- Vision problems, such as double vision, blurry vision, or transient (brief) vision loss; if this is not treated, it could be followed by permanent, irreversible vision loss.
Treatment
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The mainstay of therapy for temporal arteritis is glucocorticoids, such as oral prednisone in high dose.
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Patients sometimes need to take glucocorticoids for up to two years.
Thunderclap Headaches
Sudden-onset headache pain, with peak intensity occurring within several minutes.
Causes:
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Subarachnoid hemorrhage,
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Hypertensive emergencies,
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Vertebral artery dissections, and
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Acute angle–closure glaucoma.
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Known systemic illnesses that predispose to secondary headaches (cancer, HIV).
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Altered mental status
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History of trauma
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History of malignancy
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Pregnancy.
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Neck stiffness
Rare/Serious
- Cough Headache – secondary.
- Brain AVM (arteriovenous malformation).
- Brain aneurysm.
