BRITISH MEDICAL JOURNAL VOLUME 288 28 APRIL 1984 1281 Br Med J (Clin Res Ed): first published as 10.1136/bmj.288.6426.1281 on 28 April 1984. Downloaded from Clinical Algorithms

Headache

MICHAEL JAMIESON

Headache, although a near universal experience, is a relatively (8) Headache due to overt cranial inflammation: uncommon reason for consultation in general practice. The consul- A Intracranial, tation rate for migraine, for example, is said to be 12 per 1000 B Extracranial (arteritis, cellulitis). consultations, and it is estimated that the average general practi- tioner will see 28 patients on account of headache yearly.' (9) Headache due to disease of ocular structures. Most headache is of the migrainous or tension type. Fry estimates (10) Headache due to disease of aural structures. that less than 1% of headaches presenting to a general practitioner reflect "major intracranial disease."2 Despite its predominantly (11) Headache due to disease of nasal and sinusal structures. benign nature, headache may, however, be the presenting feature of (12) Headache due to disease of dental structures. potentially serious conditions such as cerebral tumour, meningitis, giant cell arteritis, and glaucoma. Cervical spondylosis, chronic (13) Headache due to disease ofother cranial and neck structures. sinusitis, and refractory errors probably cause headache less often than is commonly supposed. (14) Cranial neuritides (trauma, new growth, inflammation). (15) Cranial neuralgias. Classification A useful classification is that of the National Institute of Neuro- Diagnosis logical Disease and Blindness 1962.3 This is summarised below. History-Try to discover why the patient is presenting now. In (1) Vascular headache of migraine type: many cases, particularly of acute onset headache, the reason will be A Classic migraine, clear. In a considerable proportion ofcases oflongstanding headache http://www.bmj.com/ B Common migraine, the consultation will have been precipitated by other factors. In C Cluster headache, particular, look for any underlying anxiety or depression. Attempt D Hemiplegic and ophthalmoplegic migraine, to elicit obvious pointers to specific causes (detailed in the classifica- E "Lower half" headache. tion and algorithm). From the history it is often not possible to differentiate serious from more benign causes. Features such as (2) Muscle contraction headache. intensity, response to head movement and to vasoactive drugs, and the presence of a tender cervical spine with diminished movement (3) Combined headache: vascular and muscle contraction. do not have discriminating value. There are, however, certain un- common alerting features, which again do not clearly discriminate on 2 October 2021 by guest. Protected copyright. (4) Headache of nasal vasomotor reaction. but which should give rise to suspicion ofin particular an expanding (5) Headache of delusional, conversional, or hypochondriacal intracranial lesion. These are: (a) sleep disturbance, (b) paroxysmal states. headache, (c) cough headache.4 (6) Non-migrainous vascular headaches: Examination-One cannot be dogmatic about the approach to A Systemic infections, examination in general practice. Nevertheless, it is reasonable to B Miscellaneous disorders. measure the blood pressure in all cases. In older patients examination of the superficial temporal arteries and of the intraocular tension (7) Traction headache: would be appropriate. Examination will, on the whole, be guided by A Primary or metastatic tumours of meninges, vessels, or the history. brain, B Haematomas, Investigations-There is no indication for routine investigation, C Abscesses, other than the erythrocyte sedimentation rate in the older patient. D Postlumbar puncture headache, E Pseudotumour cerebri. Royal College of General Practitioners/Office of Population Censuses and Surveys 1974. Morbidity statistics from general practice: second national study 1970-71. London: HMSO, 1974. Studies on Medical and Population Subjects No 26. 2 Fry J. Common diseases, their nature, incidence and care. 2nd ed. Lancaster: MTP Press Ltd, 1979. Department ofTherapeutics and Clinical Pharmacology, Aberdeen Royal Infirmary, Vinken PJ, Bruyn GW. Handbook of clinical neurology 5: headaches and cranial Aberdeen AB9 2ZB neuralgias. Amsterdam: North Holland Publishing Company, 1968. MICHAEL JAMIESON, MRCP, lecturer Raskin NH, Appenzeller 0. Headache. Philadelphia, WB Saunders, 1980. (Major problemss in internal medicine; vol 19.) Br Med J (Clin Res Ed): first published as 10.1136/bmj.288.6426.1281 on 28 April 1984. Downloaded from 1282 BRITISH MEDICAL JOURNAL VOLUME 288 28 APRIL 1984 |Your patient complains of

HEADACHE

Chronic or No recurrent Yes The most likely diagnoses are MIGRAINE TENSION HEADACHE

eNone of oistory Uneryng Hry of No Histo ry of N IIs there an N Are there these? like or pressure _ paroxysmal_ unilateral (less l )bvious pointer unusual or s ~~~~~headache: retro-orbital often bilateral), tto disease of alerting bilateral, unilateral pain throbbing | |EEARS, NOSE, features in frequent, with associated headaches in l SINUSES, EYES? history or on perhaps eye/nasal episodes; i FPOSTCONCUS- examination? constarnt? congestion? nausea; familyI I SION? (see text) history? FFOOD ALLERGY/ Yes ICE CREAM Yes Yes|| HEADACHE? DRUGS (including Are there l l nitrates, in- Reie hitr domethacin)? Yes Unelyn Horer' No premonitory visual, sensory,l l CERVICAL SPINE examination depression? affected side motor l l DISEASE? | symptoms? | L HYPOGLYCAEMIA? ~~~~~~~(uncommon) HYPERTENSION? Any evidence Yes of: Yes ANAEMIA? I Yoev LIS RENAL INSUFFICIENCY? a Consider: |Do these persist |No EXPANDING CEREBRAL the| ARTERIO- CLUSTER during/after INTRACRANIAL headache? l LESION SCLEROSIS?SCLEROSIS7TENSIO | | HEADACHEMIGRAINOUS|l HEART DISEASE? HEADACHE (tumour, DEPRESSION? 1NEURALGIA) haematoma, http://www.bmj.com/ . ....~~~~~...... abscess) Bear in mind: XCMLICATEDI GLAUCOMA ||(HEMIPLEGIC/| TEMPORAL |-§OPHTHALMO-| ARTERITIS : COMMON .3PLEGIC) CL-ASSIC l- (see 4) : MIGRAINF iMIGRAINE | MHGRAINE b-.-...... - _I1Vt ...... *-,.... , on 2 October 2021 by guest. Protected copyright. L.- s These may be Treatment Treatment Treatment Detailed relevant. If still no Positive obvious diagnosis, attitude, Acute attack (brief- Acute attack discussion of try simple patience, treatment seldom General measures (dark room, quiet) management of measures education beneficial). these and important Ergotamine. Drugs-simple analgesic conditions reassurance. (aspirin/paracetamol) ± antiemetic |Review later Avoid alcohol during (metoclopramide, outside the | Relaxation cluster antihistamine)-early scope of this methods Ergotamine-sublingual, by mouth, per rectum, intramuscular, inhaled algorithm Prophylaxis (during Drugs (simple cluster) Prophylaxls analgesia) ergotamine, Identify precipitants-stress, paracetamol etc methysergide menstruation, drugs (oral contraceptive, (dose and timing indomethacin), dazzling lights, exertion, Consider tailored to individual) fatigue, hunger, ? food sensitivity anxiolytic, anti- Consider local Refer if appropriate depressants, anaesthetic Drugs and formal Others: 100% 02 Clonidine, methydergide, pizotifen, psychotherapy methoxyfluorane diuretic (for premenstrual episodes). (acutely), lithium, Not ergotamine amitriptyline, propranolol, Consider anxiolytic, antidepressant indomethacin, Others: propranolol. prednisolone Consider neurological referral if (infrequently used) complicated migraine BRITISH MEDICAL JOURNAL VOLUME 288 28 APRIL 1984 1283 Br Med J (Clin Res Ed): first published as 10.1136/bmj.288.6426.1281 on 28 April 1984. Downloaded from Headache

Recent onset Yes The most likely diagnoses are: FIRST MIGRAINE HEADACHE SECONDARY TO ACUTE INFECTIVE ILLNESS

Is there No 0o Is there an Is a No N' Older patient, N there w Young patient -610. None of associated neck recent weight obvious pointer current or with typica ly these? stiffness, photo- loss, hip/ to acute sinus or recent other migrainous phobia, altered shoulder girdle ear infection, infective illness, symptoms? level of symptoms, dental problem, especially viral ,(see 2) consciousness? superficial accelerated upper respiratory Are there focal temporal hypertension, tract infection CNS signs? lieadache, drug side worse at night? effect? I Visual symptoms?

Yes Yes Yes Yes Yes Yes

Examine Consider superficial SUBARACHNOID temporal HAEMORRHAGE arteries for tenderness, loss of * MENINGITIS! pulsation ENCEPHALITIS

It may not be TEMPORAL http://www.bmj.com/ possible to ARTERITIS d HEADACHE | MIGRAINE distinguish SECONDARY TO between these ACUTE INFECTIVE in general ILLNESS practice Check ER on 2 October 2021 by guest. Protected copyright. [Admit to hospital [Treatment Detailed Treatment Refer to discussion of Start prednisolone management Simple analgesic. column 2 60 mg/day and outside scope of Manage refer for urgent algorithm. Use underlying ttemporal simple analgesic infection as arteriogram/ and appropriate appropriate biopsy measures for underlying problem