Login

Headache Assessment

 

Assessment:

 

Key questions to ask in headache history:


Examination:

  • Check Vital signs (BP +/- pulse, RR, temp, SaO2) and BMI

  • Perform a head and neck examination:
    • 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.
      • The carotid arteries for bruits
         
  • 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:

  • 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:

  • 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.
    • Other signs and symptoms:
      • Worse on waking
      • Aggravated by physical exercise
      • Nausea and other gastrointestinal symptoms
      • Restlessness, anxiety, irritability, or poor concentration

 

  • 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

 

  • 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.

 

  • 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.

 

  • Obstructive sleep apnoea – consider this if the patient wakes with a headache


  • Alcohol consumption


  • Bruxism


  • Refractive error


  • Dehydration


  • Sinusitis

 

 

Supporting Information

 

For professionals:

 

For patients:

 

References:

 

  1. https://www.ebmedicine.net/store.php?paction=showProdSeg&sid=135
  2. 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.