CLINICAL MANAGEMENT GUIDELINE

Headache disorder

ICD10: Headache [R51]

Treatment: General evaluation

Headache is one of the most common medical complaints in primary clinics. However, physicians should have a higher sensitivity toward life-threatening clinical presentations.

Red flags presentations:

  • Sudden severe headache.

    thunderclap like pain. within sec to min.

  • Association of fever and systemic involvement.

    Rash. Petichie.

  • Associated w/ meningism

    Nausea/vomiting. photophobia Nuchal rigidity, Kernig's sign, Brudzinski's signs.

  • Altered LOC status.

  • Seziure or focal nuro deficite; cerbral, cerebellar, or cranial n, or autonomic abnormality; horner syndrome

  • Ophthalmic involvement; visual deficit, papilledema, orbital mov. deficit.

  • Association of ⇧ BP; diastolic > 120 mmHg.

  • New onset of headache in elderly

  • Associated with pregnancy; pre-eclampsia/eclampsia

  • Associated with Cocaine, methamphetamine, IV drug abuse.

  • Iatrogenic to anticoagulant DOACs, adrenergic drugs,

  • Risk of CO exposure.


Differential diagnosis: (1), (2), (3), (4), (5), (6), (7), (8), (9), (10), (11), (12), (13)

RiskFrqPresentationDDxInvestigate
Common• Mild-moderate. • Bilateral. • Pressure-like, dull, band-like. • frontal, temporal, sternocleidomastoid, and trapezius muscle tenderness • Stress-related.Tention Headache; Episodic; more than 10 episodes, lasting 30 min-7 days, Chronic; more than 180 days/yr, lasting hrs to days.to exclude other causes.
Common; ♀️>♂️, youngTypical: 1st: Prodrome (77%); 1-2 days before the episode. > Yawning, mood change, change bowel habit, neck stiffness. 2nd: Aura (25%); visual, auditory, sensory, or motor disturbance. 3ed: headache; Uni(60%)>Bi-lateral (40%), throbbing/pulses(50%), last 4-72 hrs, nausea/vomiting (<30%), photo/phono-phobia, Pt seeks a quiet environment. 4th: postdrome; pain resolution and feel exhausted.Migraine; typical: triggered by emotional (80%), hormonal in ♀️ (>60%), Caffeine, BMI>30,to exclude other causes.
Common• Associated w/ positional sinuses pain/tenderness, congestion, discharge. • May associate w/ Upper Resp. infection or allergic rhinitis.2ry to Acute sinusitisMainly clinical.
Common; children• Associated w/ pain, irritability, hearing loss, vomiting, fever, tympanic bulging. • May associate w/ Upper Resp. infection.2ry to Acute otitis M.Mainly clinical.
Common• Antihistamines, caffeine, pseudoephedrine, opiates, corticosteroids Meds withdrawal -
Common• pain related to drinking, eating. Dental related -
Uncommon; ♀️<<♂️, young• Severe, stabbing, unilateral orbital/temporal pain. • associated w/ ipsilateral lacrimation, redness, miosis, ptosis, rhinorrhea, nasal congestion, facial sweating. • repetitive attacks >5 per day, last 15 min to 3 hrs as clusters in certain weeks before remission(at least 2 clusters/yr). Cluster headache to exclude other causes.
Uncommon• Recurrent, severe, uni- > bi-lateral, short electric-like shocks, the pain worsen by the end of the episode. within the distribution of trigeminal n. • last <2 min. • trigger by touching, or using the innervated muscles by trigeminal n. • Lacrimation, vasodilatation, sweating, runny nose ipsilateral to the affected trigeminal n.Trigeminal neuralgiamainly clinical.
🚩Rare; Pt >40y• Severe thunderclap-like headache (worst headache in life). • associated w/ meningismus symptoms and signs, loss of consciousness, retinal Hemorrhage (🚩), cerebral or cerebellar deficits. • triggered by ⇧ BP, antithrombotics. •Subarachnoid hemorrhage• Head CT • LP, if CT is -ve. •head MRI or CT Angio, if previous was inconclusive.
🚩Rare; >50y• Sever, temporal pain/tenderness, may reach frontal or occipital. • Associated w/low-grade fever, unexplained fatigue (polymyalgia rheumatica), Wt loss, jaw claudication, visual disturbance (🚩),Giant cell arteritis• High ESR, CRP, PLT count. • Temporal artery doppler. • Biopsy for histopathology. • CT/MRI Angio for other major arteries (if applicable).
🚩Rare; ♀️>♂️, young, obese• Headache. • Associated w/ signs of ⇧ ICP and meningismus; nausea/vomiting, visual deficit/papilledema/diplopia (XI CN palsy). • may be induced by medications.Benign intracranial hypertension (pseudotumor cerebri)• Head MRI to exclude. • LP with high opening pressure > 250 mm.
🚩Rare• Wt loss, focal motor/sensory deficit, headache while sleeping, worsen with Valsalva/exertion.Brain tumor• brain CT or MRI +/- contrast.
🚩Rare• Headche at the 3ed trimester, limp edema, visual deficit, seziure. BP> 140/90 mmHg.Pre-eclampsia/ echlampsia• Protenuria >1g/ mL • Abnoromal LFT
🚩Uncommon• associated w/ fever, meningism, ⇧ ICP, seizure, focal neural deficit, photophobia, rash (systemic), altered mental status, septic shock.Meningitis• CT brain w/out contrast • LP analysis.
🚩-• Risk of exposure; fire, gas heater/stove. • morning headache, dizziness, ataxia, confusion, nausea/vomiting.Carbon monoxide toxicity• Carboxyhemoglobin level • high CO oximetry.
🚩• unilateral eye pain, vision deficit.Acute angle-closure glaucoma• tonometry

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