First Ever Headache Disorders You Must Not MissI have included in first ever headache the emergency headaches, and those who have the first headache of an episodic headache disorder (except we don't know yet that this is going to become an episodic headache disorder). The first ever headache disorders not to miss are:
If missed you can have a serious outcome which was potentially avoidable with proper diagnosis and treatment, or you have someone left in persistent pain when there is actually a treatment available. Types of First Ever HeadacheHere's how I normally think about an acute headache.Before you start, you should remember that First Ever Headache divides neatly into the following 5 categories, and each category has a slightly different range of potential diagnoses:
STEP 1 - take the history From your patient's history, you can quickly decide which category you are dealing with, and the likely potential diagnoses. More on each below, please bear with me. STEP 2 - Clinical and Neurological Examination You perform a relevant clinical examination, including the Vital Signs and a Neuro Exam. STEP 3 - You make a clinical diagnosis Make sure you always write down a diagnosis, or differential diagnosis. This process focusses your mind into making a decision. STEP 4 - Start Emergency Treatment You initiate best emergency treatment, including analgesics. Codeine-based treatments are OK in severe, acute headaches,due to serious diseases such as subarachnoid haemorrhage. If you suspect migraine, you should avoid codeine at all costs, as codeine can be addictive for migraine sufferers. Migraine usually responds best to NSAIDS and Anti-emetics. Antibiotics must be administered in suspected meningitis - benzylpenicillin should have been given by pre-hospital clinicians. Cefotaxime is usually first line treatment for suspected bacterial meningitis. Steroids are necessary in temporal arteritis. STEP 5 - Plan your Investigations You plan investigations if necessary, remembering that the usual tests are from this list: CT Brain Scan, Erythrocyte Sedimentation Rate, ECG, Lumbar Puncture. MRI Brain Scan, CT Venogram, MR Angiography or MR Myelogram and Temporal Artery Biopsy are more specialised and not necessary in every case. STEP 6 - You make a final diagnosis You plan your definitive treatment, stopping unnecessary medication and trying to avoid prolonged use of opiate/codeine containing medicines if migraine is your diagnosis. Thunderclap HeadacheThis group of first ever headaches is a mix of very serious disease, like Subarachnoid Haemorrhage, and non-life threatening disease like Orgasm Headache. There are about 40 Thunderclap Headache presentations per 100,000 people each year. So a General Practitioner, like those here in Northern Ireland where I work, with a list of 2500 patients may see one case each year. If this headache is ever encountered is is quite justifiable to send straight to hospital for investigation. In my own practice about 1 in 12 will have a serious cause after baseline investigations.The main error encountered is not to realise that a thunderclap headache has occurred. Someone's presentation to their doctor may be delayed, or confusion or speech disturbance may have developed. If you recognise thunderclap headache - you have a medical emergency until you know that baseline investigations (CT Brain Scan and Lumbar Puncture) are normal. Your examination should include an assessment for meningism (caused by meningitis, subarachnoid haemorrhage or raised intracranial pressure), Horners Syndrome (carotid dissection), and evidence of accelerated hypertension. Pregnancy may not be obvious, so be aware of this please. Read more about Thunderclap Headache here, including the Reversible Cerebral Vasoconstriction Syndrome.
Headache and FeverThe presence of fever helps sort out first ever headache presentation.If you do not check the temperature, it may not be obvious that you have someone with fever! I always say that vital signs should be measured in a first headache presentation. There is a huge difference between a first ever headache for someone whose vital signs read: BP 124/86; Pulse 68/min regular; Respiratory Rate 12/min regular and T 36C; and someone who has a first headache and BP 240/122; P 110/min, RR 22/min, & Temp 38.8C!! This category should include the majority of cases who develop bacterial meningitis, viral meningitis or other infections of the nervous system. Subarachnoid haemorrhage cases can also develop fever. Most cases of headache and fever that present to hospital are due to systemic illness headache - a headache associated with a non-neurological febrile illness. However, meningitis is so serious that it always should be considered until it is obvious that there is an alternative, more plausible, diagnosis. Headache with Focal NeurologyThese are people who present with a first ever headache associated with some sort of "focal symptom". The chief complaint however, remains the headache i.e. they are more concerned about the headache and mention the other focal symptom as a secondary problem or in passing.Almost always these headaches are migraine with aura. Brain tumours in theory could be included here. However, usually in brain tumors the focal symptoms dominate the headache. Only about 2% of brain tumours present with isolated and persistent headache without the development of focal neurology. By a focal symptom a neurologist means visual disturbance, altered sensation, weakness, memory problem, seizures or confusion. New Onset Persisting HeadacheThere is a classification by the International Headache Society called "New Daily Persistent Headache" - but this has to be present for 3 months before meeting that criteria.In Emergency Departments and General Practice Surgeries, and even my own out-patients and ward consultations, there are lots of people with new onset headache who would fulfil this classification except that they have not been waiting for 3 months to be seen! I call these new onset persisting headache, and the search for secondary disease has to be made. The onset of headache is recalled by the patient, and they have lasted more than 3 days. The potential diagnoses include:
Primary Headache - The first episode of a recurring headache disorderHaving thought of the preceding diagnoses, you are left with those first ever headache which are in fact first presentations of a primary headache disorder. In a recurring headache disorder, there has to be a first time. In most cases a migraine is easy to diagnose, and they have usually sought advice as they are surprised at the intensity of the pain and lack of response to painkillers taken once the headache is firmly established.One cautionary note - just because a headache responds to a triptan, does not mean it is a migraine - there are cases of subarachnoid haemorrhage and meningitis where the initial headache did settle with a triptan drug, before the actual diagnosis became apparent. Strictly speaking you cannot be diagnosed with migraine until you have had at least 5 episodes. Most migraine episodes resolve completely within 24 hours, or up to 72 hours. So a new, persisting headache would not be typical of migraine. Sometimes you have no alternative explanation after an exhaustive search, but note that migraine should be diagnosed with caution as underlying disorders should be excluded. Back to top of page
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