INTERNAL MEDICINE

Headaches
Prepared by Ben.Ombura

Headaches are a very common presentation with a large number of

differential diagnoses.
DDx
• Tension headaches
• Migraines
• Cluster headaches
• Secondary headaches
• Sinusitis
• Giant cell arteritis
• Glaucoma
• Intracranial haemorrhage
• Subarachnoid haemorrhage
• Analgesic headache
• Hormonal headache
• Cervical spondylosis
• Carbon monoxide poisoning
• Trigeminal neuralgia
• Raised ICP
• Brain tumours
• Meningitis
• Encephalitis

Red Flags
It is important to consider red flags for serious conditions (such as raised
ICP and intracranial haemorrhage) when taking a history and managing a
patient with a headache.
The NICE Clinical Knowledge Summaries on headache. Have a good
summary of how to assess a headache. This is not an exhaustive list but
includes key symptoms to look
out for:
• Fever, photophobia or neck stiffness (meningitis or encephalitis)
• New neurological symptoms (haemorrhage, malignancy or stroke)
• Dizziness (stroke)
• Visual disturbance (giant cell arteritis or glaucoma)
• Sudden onset occipital headache (subarachnoid haemorrhage)
• Worse on coughing or straining (raised ICP)
• Postural, worse on standing, lying or bending over (raised ICP)
• Severe enough to wake the patient from sleep
• Vomiting (raised ICP or CO poisoning)
• Hx of trauma (intracranial haemorrhage)
• Pregnancy (pre-eclampsia)

Fundoscopy examination to look for papilloedema is an important part

of assessment of a headache. Papilloedema indicates raised ICP, which
may be due to a brain tumour, benign intracranial hypertension or an
intracranial bleed.

TOM TIP: Practice asking red flag questions so you can demonstrate in
an exam that you are thinking about serious causes.
This will score extra points in exams and help you document well when
you start seeing patients.

Tension Headaches
Tension headaches are very common. Classically they produce a mild
ache across the forehead and in a band-like pattern around the head.
This may be due to muscle ache in the frontalis, temporalis and
occipitalis muscles.
Tension headaches comes on and resolve gradually and don't produce
visual changes.
Associations
• Stress
• Depression
• Alcohol
• Skipping meals
• Dehydration
Treatment
• Reassurance
• Basic analgesia
• Relaxation techniques
• Hot towels to local area

Secondary Headaches
Secondary headaches give a similar presentation to a tension headache
but with a clear cause.
They produce a non-specific headache secondary to:
• Underlying medical conditions such as infection, obstructive sleep
apnoea or pre-eclampsia
• Alcohol
• Head injury
• CO poisoning

Sinusitis
Sinusitis causes a headache associated with inflammation in the
ethmoidal, maxillary, frontal or sphenoidal sinuses.
This usually produces facial pain behind the nose, forehead and eyes.
There is often tenderness over the effected sinus, which
helps to establish the diagnosis.
Sinusitis usually resolves within 2-3 weeks. Most sinusitis is viral.
Nasal irrigation with saline can be helpful.
Prolonged symptoms can be treated with steroid nasal spray. Antibiotics
are occasionally required.

Analgesic Headache
An analgesic headache is a headache caused by long term analgesia use.
It gives similar non-specific features to a tension
headache.
They are secondary to continuous or excessive use of analgesia.
Withdrawal of the analgesia is important in treating the headache,
although this can be challenging in patients with long term pain and
those that believe the analgesia is necessary to treat the headache.

Hormonal Headache
Hormonal headaches are related to oestrogen. They produce a generic,
non-specific, tension-like headache. They tend to be related to low
oestrogen:
• Two days before and the first three days of the menstrual period
• Around the menopause
• Pregnancy. It is worse in the first few weeks and improves in the last 6
months. Headaches in the second half of pregnancy should prompt
investigations for pre-eclampsia.
The oral contraceptive pill can improve hormonal headaches.

Cervical Spondylosis
Cervical spondylosis is a common condition caused by degenerative
changes in the cervical spine. It causes neck pain, usually made worse by
movement. It often presents with headaches.
It is important to exclude other causes of neck pain such as
inflammation, malignancy and infection. It is also important to exclude
spinal cord or nerve root lesions.

Trigeminal Neuralgia
The trigeminal nerve is made up of three branches:
• Ophthalmic (V1)
• Maxillary (V2)
• Mandibular (V3)
Trigeminal neuralgia can affect any combination of the branches. The
cause is unclear but it is thought to be caused by
compression of the nerve. 90% of cases are unilateral, 10% are bilateral.
Around 5 to 10% of people with multiple sclerosis have trigeminal
neuralgia.
It presents with intense facial pain that comes on spontaneously and last
anywhere between a few seconds to hours.
It is often described as an electricity-like shooting pain. Attacks often
worsen in severity over time.
There are a number of possible triggers for the pain in patients with
trigeminal neuralgia.
These include things like cold weather, spicy food, caffeine and citrus
fruits.

Treatment
NICE recommend carbamazepine as first line for trigeminal neuralgia.
Surgery to decompress or intentionally damage trigeminal nerve is an
option.

Migraines
Migraines are a complex neurological condition that cause headache and
other associated symptoms. They occur in “attacks" that often follow a
typical pattern.
There are several types of migraine:
• Migraine without aura
• Migraine with aura
• Silent migraine (migraine with aura but without a headache)
• Hemiplegic migraine
The pathophysiology: There is no simple explanation for why migraines
occur and it may be a combination of structural, functional, chemical,
vascular and inflammatory factors.
Typical Headache Symptoms
Headaches last between 4 and 72 hours. Typical features are:
• Moderate to severe intensity
• Pounding or throbbing in nature
• Usually unilateral but can be bilateral
• Discomfort with lights (photophobia)
• Discomfort with loud noises (phonophobia)
• With or without aura
• Nausea and vomiting

Aura
Aura is the term used to describe the visual changes associated with
migraines. There can be multiple different types of
aura:
• Sparks in vision
• Blurred vision
• Lines across vision
• Loss of different visual fields

Hemiplegic Migraine
Hemiplegic migraines can mimic stroke. It is essential to act fast and
exclude a stroke in patients presenting with symptoms of hemiplegic
migraine.
Symptoms of a hemiplegic migraine can vary significantly. They can
include:
• Typical migraine symptoms
• Sudden or gradual onset
• Hemiplegia (unilateral weakness of the limbs)
• Ataxia
• Changes in consciousness

Triggers
Migraines can have specific triggers that are individual to the person.
Often it is not possible to identify triggers. Potential triggers are:
• Stress
• Bright lights
• Strong smells
• Certain foods (e.g. chocolate, cheese and caffeine)
• Dehydration
• Menstruation
• Abnormal sleep patterns
• Trauma

Five Stages
The course of a migraine can be described in 5 stages. These stages are
not typical of everyone and will vary between patients. Some patients
may only experience one or two of the stages.

The prodromal stage can involve several days of subtle symptoms such
as yawning, fatigue or mood change prior to the onset of the migraine.
• Premonitory or prodromal stage (can begin 3 days before the
headache)
• Aura (lasting up to 60 minutes)
• Headache stage (lasts 4 to 72 hours)
• Resolution stage (the headache can fade away or be relieved
completely by vomiting or sleeping)
• Postdromal or recovery phase

Acute Management
Patients can develop their own patterns for helping to relieve their
symptoms.
Often patients will go to a dark quiet room and sleep.
Options for medical management are:
• Paracetamol
• Triptans (e.g. sumatriptan 50mg as the migraine starts)
• NSAIDs (e.g ibuprofen or naproxen)
• Antiemetics if vomiting occurs (e.g. metoclopramide)
Triptans
Triptans are used to abort migraines when they start to develop. They
are 5HT receptors agonists (serotonin receptor
agonists).
They have various mechanisms of action and it is not clear which
mechanisms are responsible for their effects on
migraines. They act on:
• Smooth muscle in arteries to cause vasoconstriction
• Peripheral pain receptors to inhibit activation of pain receptors
• Reduce neuronal activity in the central nervous system
Migraine Prophylaxis
Keeping a headache diary can be helpful in identifying the triggers.
Avoiding triggers can reduce the frequency of the
migraine. A headache diary is also useful in demonstrating the response
to treatment.
Certain medications can be used long term to reduce the frequency and
severity of attacks:
• Propranolol
• Topiramate (this is teratogenic and can cause a cleft lip and palate, so
patients should not get pregnant)
• Amitriptyline
Acupuncture is an option recommended by NICE recommend for the
treatment of migraines. It is reported to be as
effective as prophylactic medications.
Supplementation with vitamin B2 (riboflavin) may reduce frequency and
severity.
In migraine specifically triggered around menstruation prophylaxis with
NSAIDS (e.g. mefanamic acid) or triptans
(frovatriptan or zolmitriptan) can be used around menstruation as a
preventative measure.
Migraines tend to get better over time and people often go in to
remission from their symptoms.

Cluster Headaches
Cluster headaches cause severe and unbearable unilateral headaches,
usually around the eye. They are called cluster headaches as they come
in clusters of attacks and then disappear for a while.
For example, a patient may suffer 3 to 4 attacks a day for weeks or
months followed by a pain free period lasting 1 to 2 years. Attacks last
between 15 minutes and 3 hours.
They can be triggered by things like alcohol, strong smells and exercise.
A typical patient with cluster headaches in your exams is a 30 to 50 year
old male smoker.

Symptoms
Cluster headaches are often described as one of the most severe and
intolerable pains in the world. They are sometimes
referred to as “suicide headaches" due to the severity of the pain.
Symptoms are typically all unilateral:
• Red, swollen and watering eye
• Pupil constriction (miosis)
• Eyelid drooping (ptosis)
• Nasal discharge
• Facial sweating

Treatment options
Acute management:
• Triptans (e.g. sumatriptan 6mg injected subcutaneously)
• High flow 100% oxygen for 15 to 20 minutes 4-14l/min (can be given
at home)

Prophylaxis options:
• Verapamil
• Lithium
• Prednisolone (a short course for 2 to 3 weeks can be used to break the
cycle during clusters)

“In union of demystifying medical knowledge and concepts we foster

oneness”
Good luck friend