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The commonest cause of headache presenting in general practice is respiratory infection. Common causes of chronic recurrent headache are tension, so-called transformed migraine and combination (mixed) headaches. Migraine is not as common as in specialist practice.
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Red flag pointers for headache
sudden onset
severe and debilitating pain
fever
vomiting
disturbed consciousness
maximum in morning
worse with bending, coughing or sneezing
neurological (inc. visual) symptoms and signs
‘new’ in elderly esp >50 yr
young obese female
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Headache: diagnostic strategy model
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Probability diagnosis
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Acute:
Chronic:
tension-type headache
combination headache
migraine
transformed migraine
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Serious disorders not to be missed
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Pitfalls (often missed)
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Cervical spondylosis/dysfunction
Dental disorders
Refractive errors of eye
Sinusitis
Ophthalmic herpes zoster (pre-eruption)
Exertional headache
Hypoglycaemia
Post-traumatic headache (e.g. post-concussion)
Post-spinal procedure (e.g. epidural, lumbar puncture)
Sleep apnoea
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Tension-type headache
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Tension or muscle contraction headaches are typically a symmetrical tightness. They can be episodic or chronic. They tend to last for hours and recur each day. They are often associated with cervical dysfunction and stress or tension, although the patient may be unaware of such tension (see Fig. H3).
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Careful patient education.
Counselling and reassurance.
Advise stress reduction, relaxation therapy and yoga or meditation classes. Provide mindfulness therapy or CBT.
Medication—mild analgesics such as aspirin or paracetamol. Avoid tranquillisers and antidepressants if possible but consider these drugs if symptoms warrant medication (e.g. amitriptyline 10–75 mg (o) nocte increasing to 150 mg if nec.).
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Migraine, or the ‘sick headache’, is derived from the Greek word meaning ‘pain involving half the head’. It affects at least 1 person in 10, ratio ♀:♂ ∼2:1, and peaks between 20–50 yrs. There are various types of migraine with classic migraine (headache, vomiting and aura) and common migraine (without the aura) being the best known.
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Patient education—explanation and reassurance about the benign nature of migraine
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Counselling and advice
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Avoid known trigger factors, e.g. physical or emotional stress, lack of sleep, bright lights.
Diet: keep a diary—consider elimination of chocolate, cheese, red wine, walnuts, tuna, Vegemite, spinach and liver.
Practise a healthy lifestyle, relaxation programs, meditation techniques and biofeedback training.
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Treatment of the acute attack
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Start treatment at earliest impending sign.
Rest in a quiet, darkened, cool room.
Cold packs on the forehead or neck.
Avoid moving around too much.
Do not read or watch television.
Avoid drinking coffee, tea or orange juice.
For patients who find relief from simply ‘sleeping off’ an attack, consider prescribing temazepam 10 mg or diazepam 10 mg in addition to the following measures.
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First signs of attack:
1st line: soluble aspirin, e.g. Dispirin Direct 2–3 tabs or paracetamol/codeine co 2 tabs (o) + metoclopramide 10 mg (o) if nausea a feature or
consider NSAIDs (e.g. ibuprofen, diclofenac rapid)
2nd line: a triptan agent—sumatriptan 100 mg (o) or 6 mg (SCI) or nasal spray 10–20 mg per nostril or
zolmitriphan 2.5–5 mg (o) repeat in 2 h if nec. or
naratriptan 2.5 mg (o) repeat in 2–4 h if nec.
rizatriptan 10 mg wafer, repeat in > 2 hrs if nec.
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Practice tip for severe classic migraine: IV metoclopromide or chlorpromazine + 1 L IV N saline in 30 mins + oral soluble aspirin or paracetamol
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Prophylaxis (for >2 attacks per mth)
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propranolol 40 mg (o) bd increasing up to 240 mg/d if nec. or
pizotifen 0.5 mg (o) nocte increasing to 3 mg if nec.
hormone manipulation, e.g. OCP for menstrual migraine
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Consider an antidepressant alone or in combination. Reserve methysergide for unresponsive severe migraine.
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This term describes the progressive increase in frequency of migraine attacks until the headache recurs daily. The typical migraine features become modified so that the pattern resembles tension headache but with the unilateral focus of migraine. Overuse of analgesics is implicated. A trial of a triptan agent is worthwhile and naproxen for drug withdrawal headache.
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Occurs in paroxysmal clusters of unilateral headache, which typically occur nightly, usually early a.m. A hallmark is the pronounced cyclical nature of the attacks. Occurs typically in males (6:1 ratio). Another feature is ptosis, lacrimation and rhinorrhoea on the side of the pain.
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Acute attack:
consider 100% oxygen 10 L/min for 15 mins by face mask (usually good response)
sumatriptan 6 mg SCI (or 20 mg intranasal) or
avoid alcohol during cluster
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Prophylaxis (once a cluster starts)—consider the following:
methysergide 2 mg (o) tds
prednisolone 50 mg/d for 10 d then reduce
pizotifen
indomethacin trial (helps confirm diagnosis)
sodium valproate
verapamil SR 160 mg (o) /d ↑ 320 mg
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Cervical dysfunction/spondylosis
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Headache from neck disorders, often referred to as occipital neuralgia, is far more common than realised and is very rewarding to treat by physical therapy, including mobilisation and manipulation and exercises in particular.
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Combined (also known as mixed) headaches are common and often diagnosed as psychogenic headache or atypical migraine. They have a combination of various degrees of:
tension and/or depression
cervical dysfunction
vasospasm (migraine)
drugs (e.g. analgesics—rebound, caffeine)
some cases may be transformed migraine
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The headache, which has many of the features of tension headache, tends to be constant, being present throughout every waking moment. It can last for weeks or months.
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Treatment includes insight therapy, reassurance that the patient does not have a cerebral tumour, and lifestyle modification. Wean the patient off analgesics. The most effective medication is amitriptyline or other antidepressant. Consider physical treatment for a cervical component.
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Temporal arteritis (TA), a subset of giant cell arteritis, is also known as cranial arteritis. There is usually a persistent unilateral throbbing headache in the temporal region and scalp sensitivity with localised thickening, with or without loss of pulsation of the temporal artery. Usually >50 yrs; the mean age is 70 yrs.
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Diagnosis is by biopsy and histological examination of the superficial temporal artery. The ESR is usually markedly elevated. The CRP is usually elevated.
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Initial medication is prednisolone 40–60 mg (o) daily, initially for 2–4 wks then gradual reduction (max. 10%) wk intervals. Dose reduction and progress is monitored by the clinical state and ESR levels. Add aspirin.
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Contrary to popular belief, sinusitis is a relatively uncommon source of headache.
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Subarachnoid haemorrhage (SAH)
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Sudden onset headache (moderate—to—intense severity)
Occipital location
Localised at first, then generalised
Pain and stiffness of the neck follows
Vomiting and loss of consciousness often follow
Kernig's sign +ve
About 40% die before treatment
CT scanning is the investigation of choice
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Refer urgently to major neurosurgical unit.
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Hypertension headache
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Tends to occur only in severe hypertension, such as malignant hypertension or hypertensive encephalopathy. The headache is typically occipital, throbbing and worse on waking in the morning.
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Benign intracranial hypertension (pseudotumour cerebri)
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This is a rare but important sinister headache condition which typically occurs in young obese women. Key features are headache, visual blurring and obscurations, nausea, papilloedema. The CT and MRI scans are normal but lumbar puncture, which relieves the headache, reveals increased CSF pressure and normal CSF analysis.
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It is sometimes linked to drugs, including tetracyclines (most common), nitrofurantoin, oral contraceptive pill and vitamin A preparations.
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Pharmacological treatment in children
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Tension headache and migraine:
paracetamol 20 mg/kg (o) statim then 15 mg/kg 4–6 hrly (max 90 mg/kg) or
ibuprofen 5–10 mg/kg (o) statim, up to 40 mg/kg/day (not <6 mths)