HEADACHE

Headache disorders can be categorized into:

• Primary headaches, which are not associated with an underlying condition for
example migraine, tension-type headache, and cluster headache.
• Secondary headaches, which occur as a result of underlying local or systemic
pathology for example due to trauma, intracerebral infection, vascular disorders,
medication overuse, or neoplasm.

DIFFERENTIAL DIAGNOSIS
• Acute Angle Glaucoma
• Sinusitis
• Giant Cell Arteritis
• Size Occupying Lesion- could be a tumour or cyst
• Migraine Headache
• Cluster Headache
• Tension Headache
• Meningitis or Encephalitis
• Sub-Arachnoid Hemorrhage
• Cervical Spondylosis
• Alcohol – Hangover
• Pre-menstrual Syndrome
• Drugs

SOCRATES
S- SIDE
O- ONSET
C -CHARACTER
R – RADIATION
A – ASSOCIATED
T – TRAUMA
E- EXABERATING AND RELIEVING FACTORS
S- SEVERITY

For chronic headaches, please don’t forget to ask about the effect of
headaches on the daily life and mood of the patient.

Red Flags
• Acute Angle Closure Glaucoma
o Any vision problems or halos?
• Giant Cell Arteritis
o Any scalp tenderness or history of Polymyalgia Rheumatica?
• Size Occupying Lesion
o Any morning headaches or nausea?
• Sub-Arachnoid Hemorrhage
o Is this the worst headache of your life?
• Meningitis
o Any fever or neck stiffness?
ACUTE ANGLE-CLOSURE GLAUCOMA

Signs and Symptoms

• Headache
• Eye pain
• Blurry vision
• Severe nausea and vomiting

Examinations and Investigations

• Vitals - Unremarkable
• Tonometry – Raised pressure
• Routine Bloods - Unremarkable

Management
• Address ICE
• Name Diagnosis
• Explain Diagnosis
• Admit Patient
• General Treatment – Analgesia and Anti-emetic
• Urgent Ophthalmology Referral
• Start Emergency Treatment
o Pilocarpine 4% in brown eyes and Pilocarpine 2% in blue eyes
o Tab Acetazolamide 500mg orally if possible, otherwise IV
medication
 Common Scenarios

You are F2 in A&E.

Tina aged, 50 presented to the hospital with redness in her eye.
Take history, assess the patient, and discuss the management with
the patient.

Concerns
• Will I lose my vision come back? Prognosis is good if
treatment is started early
• Do I have a brain tumour? No.
• Do I need a CT Brain? No.

SINUSITIS
Signs and symptoms
• History of cold or flu
• Purulent discharge
• Pain worsens on leaving forward
• Tenderness of affected sinus and triggering of headache
 Management
• Address ICE
• Name and Explain Diagnosis
• General Treatment – Paracetamol and Nasal Saline
• Specific treatment :
o Decongestant nasal sprays or drops to unblock the nose
(decongestants should not be taken by children under 6)
o Steroid nasal sprays or drops – to reduce the swelling in the sinuses
o Antihistamines – if an allergy is causing your symptoms
• Lifestyle modification
o - General advice
o getting plenty of rest
o drinking plenty of fluids
o avoiding allergic triggers and not smoking
o cleaning your nose with a saltwater solution to ease congestion
• Only prescribe antibiotics if it has not resolved within 2-3 weeks and there’s
purulent discharge present or the patient is at risk of complications
• Surgery for sinusitis
o For chronic sinusitis - functional endoscopic sinus surgery (FESS).
o FESS is carried out under general anaesthetic (where you're asleep).
o The surgeon can widen your sinuses by either removing some of the
blocked tissue or inflating a tiny balloon in the blocked sinuses, then
removing it
• Safety netting
• Follow up.

GIANT CELL ARTERITIS

SIGNS AND SYMPTOMS

• Scalp tenderness especially
• Jaw claudication and jaw tenderness
• PMH: Signs and symptoms or Diagnosis of Polymyalgia Rheumatica is an
important hint
• Diplopiaia or Vision loss on the affected side
• Chronic Headache on one side
 INVESTIGATIONS AND EXAMINATION
o Blood CP - raised WBCs
o ESR
o General Physical Exam -scalp tenderness on the affected side
o Neurological exam- Unremarkable

MANAGEMENT WITH EYE INVOLVEMENT

• Address ICE
• Name and Explain Diagnosis
• Symptomatic treatment – pain relief and anti-emetic
• Urgent ophthalmologist referral
• High dose IV steroids – prednisolone
• Urgent Doppler Ultrasound of the temporal artery- target sign
• Temporal artery biopsy under local anaesthesia- signs of chronic infiltration
• Urgent Rheumatology referral
• Start PPI and Bisphosphonates for prophylaxis against steroid-induced
gastritis and bone wasting
• Low dose aspirin
• Immunosuppressants for steroid weaning therapy once the condition has
improved

MANAGEMENT WITHOUT EYE INVOLVEMENT

o Low dose steroids

o Ophthalmology referral within 48 hours
o Temporal artery doppler ultrasound
o Rheumatology referral

o Safeguarding against vision loss is extremely important

o Safeguarding for steroids side effects and PMR
o Followup
o Information Pamphlet
 ESSENTIAL HEADACHES
• CLUSTER
• MIGRAINES
• TENSION

CLUSTER HEADACHES
SIGNS AND SYMPTOMS
o Typical presentation
o Begins quickly and without warning
o Pain is very severe - a sharp, burning, or piercing sensation on one side of
the head.
o Often felt around the eye, temple, and sometimes face. It tends to affect the
same side for each attack.
o People often feel restless and agitated during an attack
o Cluster headaches usually happen every day, in bouts lasting several weeks
or months at a time (typically 4 to 12 weeks), before they subside.
o A symptom-free period (remission) will often follow, which sometimes lasts
months or years before the headaches start again.
o People tend to get cluster headaches at the same time each day. For
example, they often wake up with a headache within a couple of hours of
going to sleep.
o They'll often get cluster headaches every year for many years and they may
be lifelong. They tend to happen at similar times of the year, commonly in
the spring and autumn.
MANAGEMENT
o Address ICE
o Name and Explain Diagnosis
o Explain the role of headache diary – Date, time, duration, triggering and
relieving factors
o Symptomatic treatment – pain relief and anti-emetic
o Specific treatment- 3 main treatments are available to relieve pain when taken
soon after a cluster headache starts.
o Over-the-counter painkillers, such as paracetamol, are not effective
for cluster headaches because they're too slow to take effect.
o sumatriptan injections –up to twice a day
 o sumatriptan or zolmitriptan nasal spray – which can be used if the
patient does not want to have injections
o oxygen therapy –pure oxygen through a face mask
o These treatments usually relieve the pain of a cluster headache within
15 to 30 minutes.
SUPPORT -The Organisation for the Understanding of Cluster Headache
(OUCH UK) has more information about the medicines used to treat cluster
headaches.
PREVENTION
o Avoiding the triggers of cluster headaches can help prevent them.
o Avoid strong-smelling chemicals, such as perfume, paint, or petrol, which
can often trigger an attack.
o Becoming overheated during exercise can also bring on a cluster headache
attack in some people, so it's best not to exercise during a bout.
o Smoking has also been linked to an increased risk of getting cluster
headaches, so you should consider giving up smoking (if you smoke)
o Verapamil is the main treatment for preventing cluster headaches. It's taken
as a tablet several times a day.

MIGRAINE
A migraine is usually a moderate or severe headache felt as a throbbing pain on 1 side of
the head.

SIGNS AND SYMPTOMS

o Pulsating pain
o Severe enough to prevent you from carrying out daily activities
o Made worse by physical activity or moving about
o Accompanied by feeling and being sick
o Accompanied by sensitivity to light and noise

There are several types of migraine, including:

o migraine with aura – where there are specific warning signs just before the migraine
begins, such as seeing flashing lights
o migraine without aura – the most common type, where the migraine happens without
the specific warning signs
o migraine aura without headache, also known as silent migraine – where an aura or
other migraine symptoms are experienced, but a headache does not develop

MANAGEMENT
 MANAGEMENT
o Address ICE
o Name and Explain Diagnosis
o Explain the role of headache diary – Date, time, duration, triggering and
relieving factors
o Lifestyle modifications
o Symptomatic treatment
o Painkillers – including over-the-counter medicines
like paracetamol and ibuprofen
o Triptans –reverse the changes in the brain that may cause migraines
o Anti-emetics –to help relieve nausea
o Sleeping or lying in a darkened room can also help.
o TMS involves holding a small electrical device to your head that delivers
magnetic pulses through your skin. Studies have shown that using it at the
start of a migraine can reduce its severity. It can also be used in combination
with the medicines mentioned above without interfering with them.TMS is
not a cure for migraines and does not work for everyone.
o Safeguarding
o Help and Support
o Several organisations offer advice and support for people with
migraines, including The Migraine Trust.
o Neurology referral if
o a diagnosis is unclear
o you experience migraines for 15 days or more a month (chronic
migraine)
o treatment is not helping to control your symptoms

o Followup

Important Note: Try not to use the maximum dosage of painkillers on a

regular or frequent basis as this could make it harder to treat headaches
over time. Migraines are associated with a small increased risk of ischaemic
strokes, and a very small increased risk of mental health problems. The risk
of having an ischaemic stroke is increased by using
the combined contraceptive pill. Medical professionals generally advise
women who experience migraine with aura not to use the combined
contraceptive pill.
 SAFEGUARDING

You should call 999 for an ambulance immediately if you or someone you're with
experiences paralysis or weakness in 1 or both arms or 1 side of the face, slurred or
garbled speech, a sudden agonizing headache resulting in a severe pain unlike
anything experienced before headache along with a high temperature (fever), stiff
neck, mental confusion, seizures, double vision, and a rash. These symptoms may
be a sign of a more serious condition, such as a stroke or meningitis, and should be
assessed by a doctor as soon as possible.

HEADACHE DIARY
Keeping a migraine diary can help you identify possible triggers and monitor how
well any medicine you're taking is working.
In your migraine diary, try to record:
• the date of the attack
• the time of day the attack began
• any warning signs
• your symptoms (including the presence or absence of aura)
• what medicine do you take
• when the attack ended
 MENINGITIS

Meningitis is an infection of the protective membranes that surround the

brain and spinal cord (meninges).
Most common in babies, young children, teenagers, and young adults.

SIGNS AND SYMPTOMS

• a high temperature
(fever)
• nausea
• a headache
• a rash that does not fade
when a glass is rolled
over it (but a rash will
not always develop)
• a stiff neck
• a dislike of bright lights
• drowsiness or
unresponsiveness
• seizures (fits)

SPREAD
Meningitis is usually caused by a bacterial or viral infection. Bacterial meningitis is
rarer but more serious than viral meningitis. Infections that cause meningitis can be
spread through:
• sneezing
• coughing
• kissing

INVESTIGATIONS AND EXAMINATION

• Vitals – Raised Temperature
• Neurological exam - unremarkable
• Blood CP - raised
• CRP -raised
 MANAGEMENT
• Address ICE
• Name and Explain Diagnosis
• Admit patient
• Isolate and inform Infectious disease
• Symptomatic relief with paracetamol for fever and headache
• Lumbar Puncture with CSF cytology and CSF culture
• CT Scan Brain without contrast
• IV Antibiotics
• IV Fluids
• IV Steroids for brain swelling
• Neurology referral

If acutely ill, Start Sepsis 6.

• High flow Oxygen
• IV Antibiotics
• IV fluids
• Blood Cultures
• Serum Lactate to monitor
• Catheterization for I/O charting
Vaccinations against meningitis
Vaccinations offer some protection against certain causes of meningitis.
These include the:
• meningitis B vaccine – offered to babies aged 8 weeks, followed by a second
dose at 16 weeks and a booster at 1 year
• 6-in-1 vaccine – offered to babies at 8, 12, and 16 weeks of age
• pneumococcal vaccine – offered to babies born before 1 January 2020 at 8
and 16 weeks and 1 year of age; babies born on or after 1 January 2020 have
2 doses at 12 weeks and 1 year
• Hib/MenC vaccine – offered to babies at 1 year of age
• MMR vaccine – offered to babies at 1 year and a second dose at 3 years and
4 months
• meningitis ACWY vaccine – offered to teenagers, sixth formers, and
"fresher" students going to university for the first time

PREVENTING THE SPREAD OF INFECTION

• The risk of someone with meningitis spreading the infection to
others is generally low.
• But if someone is thought to be at high risk of infection, they may be
given a dose of antibiotics as a precautionary measure.
• This may include anyone who's been in prolonged close contact
with someone who developed meningitis, such as:
o people living in the same house
o pupils sharing a dormitory
o university students sharing a hall of residence
 o a boyfriend or girlfriend
• People who have only had brief contact with someone who
developed meningitis will not usually need to take antibiotics

SUBARACHNOID HAEMORHHAGE
It is an uncommon type of stroke caused by bleeding on the surface of the brain.

SIGNS AND SYMPTOMS

• a sudden severe headache unlike anything you’ve experienced before-

thunderclap headache
• a stiff neck
• feeling and being sick
• sensitivity to light
• blurred or double vision
• stroke-like symptoms – such as slurred speech and weakness on one side of
the body
• loss of consciousness or convulsions
•
A subarachnoid haemorrhage is a medical emergency.
 CAUSES
Often caused by a burst blood vessel in the brain (a ruptured brain aneurysm).
It's not known exactly why brain aneurysms develop in some people. But certain risk
factors have been identified, including:
• smoking
• high blood pressure
• excessive alcohol consumption

COMPLICATIONS
Serious short-term complications can include
• rebleeding at the site of an aneurysm
• cerebral vasospasm
• hydrocephalus

Long-term complications include:

• epilepsy – where a person has repeated seizures (fits)
• problems with certain mental functions, such as memory, planning, and
concentration
• changes in mood, such as depression

INVESTIGATIONS AND EXAMINATIONS

• A CT scan Brain without contrast is used to check for signs of a brain
haemorrhage.
• Lumbar puncture.
• Neurological exam – localizing signs

MANAGEMENT
• Address ICE
• Name and Explain Diagnosis
• CT Brain without contrast
• Urgent Neurosurgery referral – Specialist Neurosciences Unit
• Symptomatic relief with paracetamol. Avoid sedating patients because GCS
needs to be monitored
• Hypertensive therapy
• Neurosurgeon will decide if conservative or surgical management
 • Neurosurgeon might start on Nimodipine for cerebral vasospasm,
anticonvulsants to prevent seizures, and antiemetic for nausea
• Surgical management could be coiling and clipping
• Transfer to an intensive care unit (ICU) if required
• Physiotherapy to help with any functional loss

SURGERY AND PROCEDURES

If scans show that the subarachnoid haemorrhage was caused by a brain aneurysm,
a procedure to repair the affected blood vessel and prevent the aneurysm from
bursting again may be recommended. This can be carried out using one of 2 main
techniques. Both are carried out under general anaesthetic.

Coiling

A thin tube called a catheter is inserted into an artery in your leg or groin. The tube
is guided through the network of blood vessels into your head and the aneurysm.
Tiny platinum coils are then passed through the tube and into the aneurysm. Once
the aneurysm is full of coils, blood cannot enter it. This means the aneurysm is
sealed off from the main artery, preventing it from growing or rupturing again.

Clipping

A cut is made in your scalp (or sometimes just above your eyebrow) and a small
flap of bone is removed so the surgeon can access your brain. This type of
operation is known as a craniotomy. When the aneurysm is located, a tiny metal
clip is fitted around the base of the aneurysm to seal it shut. After the bone flap
has been replaced, the scalp is stitched together. Over time, the blood vessel lining
will heal along where the clip is placed, permanently sealing the aneurysm and
preventing it from growing or rupturing again.

Coiling versus clipping

Whether clipping or coiling is used depends on things such as the size, location,
and shape of the aneurysm. Coiling is often the preferred technique because it has
a lower risk of short-term complications such as seizures than clipping, although
the long-term benefits over clipping are uncertain.
 CERVICAL SPONDYLOSIS
Cervical spondylosis causes neck pain and headaches – often in the over 50s. Ageing causes wear
and tear to muscles and bones. This is called cervical spondylosis.

SIGNS AND SYMPTOMS

o neck and shoulder pain or stiffness – that

comes and goes
o headaches that often start at the back of
the neck

INVESTIGATIONS
• X-ray C-Spine – signs of wear and tear

MANAGEMENT
• Address ICE
• Name and Explain Diagnosis
• Lifestyle modifications such as adjusting sleep routine, improving posture
• Symptomatic Relief with OTC painkillers
• Physiotherapy referral
• Neurosurgery referral for
o a nerve is being pinched by a slipped disc or bone (cervical
radiculopathy)
o a problem with your spinal cord (cervical myelopathy)
• Safeguarding for Cervical Myelopathy
o pain that's getting much worse
o lack of coordination – for example, trouble with tasks like buttoning a
shirt
o heaviness or weakness in your arms or legs
o pins and needles in an arm as well as pain
o problems walking
o loss of bladder or bowel control
 HANGOVER

SIGNS AND SYMPTOMS

• Splitting headaches
• Nausea and vomiting
• Dizziness
• Dehydration - causes many of the symptoms of a hangover.
• Obvious history of excessive alcohol intake

MANAGEMENT OF HANGOVER
• Address ICE
• Name and Explain Diagnosis
• Lifestyle modifications such as adjusting drinking habits and reducing intake
• Symptomatic Relief with OTC painkillers, antiemetics, and antacids
• Help with quitting if the patient agrees – medications such as acamprosate,
disulfiram, naltrexone
• Social support as Alcoholics Anonymous, CBT, Family therapy, and a
drinking diary
• Safeguarding
• Follow up if required

There are no cures for a hangover, but there are things you can do to
avoid one and, if you do have one, ease the discomfort.
- Symptomatic
• Rehydrate before going to sleep after a drinking session.
• Painkillers can help with headaches and muscle cramps.
 • Sugary foods make the patient feel less trembly
• an antacid may be needed to settle dyspepsia
• drinking bland liquids that are
• gentle on your digestive system, such as water, soda water and
• isotonic drinks.

-To avoid a hangover:

• Do not drink more than you know your body can cope with. If you're not
sure how much that is, be careful.
• Do not drink on an empty stomach. Before you start drinking, have a meal
that includes carbohydrates (such as pasta or rice) or fats. The food will help
to slow down your body's absorption of alcohol.
• Do not drink dark-colored drinks if you've found you're sensitive to them.
They contain natural chemicals called congeners, which irritate blood vessels
and tissue in the brain and can make a hangover worse.
• Drink water or non-fizzy soft drinks in between each alcoholic drink. Fizzy
drinks speed up the absorption of alcohol into your body.
• Drink a pint or so of water before you go to sleep. Keep a glass of water by
your bed to sip if you wake up during the night.
• Drinking more alcohol, or "hair of the dog", does not help.
• Drinking in the morning is a risky habit, and you may simply be delaying the
appearance of symptoms until the extra alcohol wears off.
• If you've been drinking heavily, please wait at least 48 hours before drinking
any more alcohol (even if you don't have a hangover), to give your body
time to recover.

- Advice for regular drinkers

• To keep the health risks from alcohol to a low level, if you drink most
weeks:
• do not drink more than 14 units a week regularly
• spread your drinking over 3 or more days if you regularly drink as much as
14 units a week
• if you want to cut down, try to have several alcohol-free days each week