HEADACHE
Headache is caused by traction, displacement, inflammation, vascular
spasm or distension of the pain sensitive structures in the head or neck.
Headaches that are new in onset and clearly different from any the patient
has experienced previously are commonly a symptom of serious illness and
therefore demand prompt evaluation. The precipitating factors, associated
symptoms and clinical findings on examination, together with the results of
appropriate investigations, can provide a guide to the cause of the
headache.
CAUSES
Acute onset
· Subarachnoid haemorrhage and other cerebrovascular diseases
· Infections e.g. malaria, typhoid fever, viral infections
· Meningitis or encephalitis
· Ocular disorders (glaucoma, acute iritis, refractive errors)
· Post-seizures
· Post-lumbar puncture
· Hypertensive encephalopathy
· Giant cell temporal arteritis
Subacute onset
· Lesions of the middle ear(otitis media, mastoiditis)
· Intracranial mass (tumour, subdural haematoma, abscess)
· Benign intracranial hypertensión
· Trigeminal neuralgia
· Postherpetic neuralgia
· Severe Hypertension
· Atypical facial pain
· Medication overuse
· Post trauma
· Giant cell temporal arteritis
Chronic
· Migraine
· Cluster headache
· Tension headache
· Cervical spine disease
· Sinusitis
· Dental disease
· Psychogenic causes
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SYMPTOMS
· Visual e.g. photophobia, flashes of light, floaters
· Aura e.g. visual, auditory, gustatory
· Accompanying features e.g. nausea, vomiting,
· Site of pain e.g. occipital, ocular, unilateral, bilateral
· Characteristics e.g. pulsating, throbbing, sharp, dull
· Relieving or exacerbating factors e.g. cough, coitus, lying flat
SIGNS
· Local tenderness
· Fever
· Neck stiffness
· Positive Kernigs
· Drowsiness
· Excessive lacrimation
· Conjunctival redness
· Papilloedema
INVESTIGATIONS
· FBC
· ESR
· Skull X-ray
· Cervical X-ray
· X-ray of the paranasal sinuses
· CT scan head if warranted
· Lumbar puncture if warranted
TREATMENT
Treatment objectives
· To relieve pain
· To identify and treat underlying cause
· To prevent complications relating to the underlying cause
· To improve quality of life
Non-pharmacological treatment
· Relaxation techniques
· Stress avoidance
· Psychotherapy
· Identification and elimination of trigger factors
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DISORDERS OF THE CENTRAL NERVOUS SYSTEM
Pharmacological treatment
(Evidence rating: B)
· Paracetamol, oral,
Adults
500 mg - 1 g 6-8 hourly
Children
6-12 years; 250-500 mg 6-8hourly
1-5 years; 120-250 mg 6-8hourly
3 months-1 year; 60-120 mg 6-8hourly
Or
Diclofenac, oral,
Adults
25-50 mg 8 hourly
Or
Ibuprofen, oral,
Adults
200-400 mg 12 hourly
Prophylaxis for chronic headaches
· Propranolol, oral,
40-80 mg daily (for migraine)
Or
Amitriptyline, oral,
10-25 mg nocte
Or
Carbamazepine, oral,
200 mg daily (for neurogenic pain)
REFER
Refer headaches not responding to treatment and those that are
unexplained to a specialist
