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Headache

Medicine > Neurosciences

Differential diagnosis schema 🧠

Primary Headaches

  1. Migraine: Typically unilateral, pulsating, associated with nausea, photophobia, phonophobia.
  2. Tension-type headache: Bilateral, pressing/tightening quality, mild to moderate intensity, not aggravated by routine physical activity.
  3. Cluster headache: Severe unilateral pain, often around the eye, associated with autonomic symptoms (e.g., tearing, rhinorrhoea), occurring in clusters.

Secondary Headaches

  • Subarachnoid haemorrhage: Sudden onset, severe (‘thunderclap’), often described as the worst headache ever experienced, associated with neck stiffness and photophobia.
  • Meningitis: Generalised headache, associated with fever, neck stiffness, photophobia, altered mental status.
  • Giant cell arteritis: Unilateral or bilateral temporal headache in older adults, scalp tenderness, jaw claudication, visual disturbances.
  • Acute angle-closure glaucoma: Severe headache with eye pain, nausea, vomiting, and visual disturbances, often with a red eye.
  • Intracranial tumour: Progressive, often worse in the morning, associated with focal neurological deficits, seizures, or symptoms of increased intracranial pressure.
  • Medication-overuse headache: Chronic daily headache in the context of regular use of analgesics or triptans.
  • Sinusitis: Dull, constant pain over the affected sinus, often associated with nasal discharge, fever, and facial tenderness.

Key points in history 🥼

Onset and Duration

  • Sudden onset (thunderclap): Suggestive of subarachnoid haemorrhage.
  • Progressive worsening: Consider intracranial mass or raised intracranial pressure.
  • Intermittent episodes: May indicate migraine, cluster headache, or tension-type headache.

Location and Quality

  • Unilateral, pulsating: Typical of migraine.
  • Bilateral, band-like: Tension-type headache.
  • Around one eye: Cluster headache, acute angle-closure glaucoma.
  • Sharp, severe pain: Consider trigeminal neuralgia.
  • Occipital pain: Could indicate cervical spondylosis or vertebrobasilar insufficiency.

Associated Symptoms

  • Nausea, vomiting: Common in migraine, subarachnoid haemorrhage, and raised intracranial pressure.
  • Photophobia, phonophobia: Suggestive of migraine or meningitis.
  • Visual disturbances: Consider migraine aura, giant cell arteritis, or acute angle-closure glaucoma.
  • Neck stiffness: Meningitis, subarachnoid haemorrhage.
  • Fever: May indicate meningitis, sinusitis, or systemic infection.

Background

  • Past Medical History: Previous episodes of headaches (migraine, tension-type), history of trauma (subdural hematoma), history of cancer (intracranial metastases).
  • Drug History: Use of anticoagulants (risk of haemorrhage), analgesic overuse (medication-overuse headache), COCP (venous sinus thrombosis), recent change in medication.
  • Family history of migraines or other headaches.
  • Social History: Alcohol use (risk factor for cluster headaches), stress levels (may contribute to tension-type headaches).

Possible investigations 🌡️

Initial Investigations

  • Full blood count: To rule out infection or anaemia.
  • ESR/CRP: Elevated in giant cell arteritis.
  • CT head: To rule out haemorrhage, space-occupying lesions, or other structural abnormalities.
  • Lumbar puncture: To assess for meningitis, subarachnoid haemorrhage if CT is negative, and elevated intracranial pressure.

Further Investigations

  • MRI brain: Preferred for assessing brain tumours, demyelinating disease, or chronic headaches.
  • MRA or MRV: For assessing vascular causes such as aneurysms or venous sinus thrombosis.
  • Ophthalmology review: If suspecting acute angle-closure glaucoma or papilledema.
  • Temporal artery biopsy: Confirmatory test for giant cell arteritis.

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Neurosciences