Headache Practice Station

Presenting Complaint: John presents with a 3-month history of headaches.

“I’ve been having really bad headaches for the past three months.”

HPC and symptoms (SOCRATES):

Site: Left-sided facial pain localised around the eye .

“It feels really bad on the left side of my face, especially around my left eye.”

Onset: Initially started suddenly 3 months ago, lasted a couple of weeks and resolved, but has now relapsed 2 days ago. 

“It came on 3 months ago all of a sudden, then got better by itself after some weeks. A couple of days ago it started again and it’s agony.”

Characteristics: Boring, sharp and constant pain.

“It is sharp and constant, like someone is drilling in my head.”

Radiation: Mainly around the left eye but spreads around the whole left side of face. 

“Initially around my left eye but it spread to all over my face.”

Associated Symptoms/Neurological System Review: You have not had any seizures or noticed any sensorimotor deficits. No aura preceding headaches, no fever or rashes. The pain is not positional. You often feel restless during an attack and have to walk around to help deal with the headache.

During the headache your left eye becomes red and with increased lacrimation and rhinorrhoea.

“My left eye becomes red and teary during the headache. Also my nose starts to run during the spell.” 

Time: Each episode lasts between an hour or two, and occurs 2-3 times per day. Notably, you usually tend to get a headache at the same time before bed, and you get headaches at night. This has been ongoing for the last 2 days, and before that there were 2 weeks of similar symptoms 3 months ago. 

“I have these terrible headaches everyday. They usually last for an hour or two, and usually occur at the same times each day, especially before bed and at night.”

Exacerbating/relieving factors: You feel like you get headaches after having an alcoholic drink before you go to bed. Paracetamol and ibuprofen are not very effective. 

“I tend to get the pain after drinking alcohol. Nothing I’ve taken so far helps with the pain.”

Severity: This is the worst headache in your life, at its peak it’s 10/10. The lack of sleep, due to the headache, is reducing your quality of life. 

“10/10 on the pain scale. I can’t sleep properly and it’s ruining my life.”

Systems Review:

• • B-Symptoms: No fever, lethargy, anorexia, weight loss and night sweats.
  • GI Symptoms: No changes in bowel and bladder habit and no nausea and vomiting.
  • Cardio Symptoms: No chest pain, palpitations and dizziness.
  • Respiratory Symptoms: You have no shortness of breath, cough or breathing difficulty.
  • Neuro Symptoms: No changes in vision, smell or taste. No sensorimotor deficit, ataxia or balance and coordination issues. No seizures or loss of consciousness

Past Medical History:

• No known hospital admissions or past surgeries.
• No previous known headaches and neurological disease.
• Well controlled extensor psoriasis on both of your elbows.

Drug History:

• Topical corticosteroids and vitamin D analogue for the psoriasis.
• No herbal supplements or alternative therapies.

Allergies:

• No known drug allergies.

Family History:

• Mother: Hypertension.
• Father: Hypertension.

Social History:

• Smoking: Non-smoker.
• Occupation: Marketing Consultant.
• Alcohol: 30 units per week.
• No travel history.
• Live at home with your family.
• Activities of Daily Living & Hobbies: Walking and yoga.

ICE:

• Ideas: “I’m thinking this is a really bad migraine.”
• Concerns: “I am worried that I will not be able to sleep properly because of the headaches, which are affecting my work.”
• Expectations:  “I’d like some medication and treatment as soon as possible.”

Observations:

• HR:  83 bpm
• BP: 124/79
• SpO2: 99%
• Temperature: 36.5℃
• Respiratory Rate: 20 breaths per min
• GCS: 15/15

NEWS score: 0

General inspection:

• Appears to be suffering from a headache currently 
• Visibly in pain

Head and neck examination:

• On examination of the face: There is evidence of left-sided lacrimation and conjunctival injection, with slight constriction in the left pupil.
• There is evidence of rhinorrhoea.
• Cranial nerves grossly intact.
• No lymphadenopathy in head and neck.
• No abnormalities detected when inspecting the throat.
• No sinus tenderness.
• No marked temporal tenderness or temporal artery thickening.

For completion: “Given more time I would perform a full upper and lower limb neurological exam as well as a general systems examination for completion.”

1.What is the most likely diagnosis and explain why?

• Cluster Headache - This is the most likely differential due to the constellation of symptoms including severe unilateral headache and periorbital pain with autonomic features such as lacrimation, conjunctival injection and rhinorrhoea. From the symptom chronology we can elicit the characteristic ‘cluster period’ of frequent episodic headaches, with long periods of remission in between. The patient also notably reports restlessness during attacks, a key differentiator from migraine, and a possible trigger in alcohol consumption, in keeping with a clinical diagnosis of cluster headache.

Other Possible but less likely diagnoses:

• Migraine - This headache typically presents as a severe throbbing unilateral pain. The headache is typically associated with symptoms of nausea, vomiting, photophobia and phonophobia. Patients typically report that lying down in a dark and quiet room helps manage the headache, which contrasts the restlessness in this history. The pattern of clusters and autonomic features point towards cluster headache.
• Tension headache - Tension headaches are episodic headaches that feel like a tight band around their head rather than unilateral. The headaches are described as bothersome but not disabling, so the severity in this case is more than would be expected from a tension headache. Typically no/minimal nausea and vomiting with tension, no focal neurology, no autonomic features.
• Trigeminal neuralgia - Facial pain syndrome in the distribution of branches of the trigeminal nerve. Typically triggered by brushing their teeth, eating and touching that area of the face. Episodes of pain are frequent, very brief (lasting from seconds up to 2 minutes) and cause intense pain around the maxillary and mandibular innervation areas of the face/jaw. The episodes in this case are too long to fit this diagnosis, and do not have the characteristic triggers.
• Giant cell arteritis (GCA) - This is a form of large vessel vasculitis typically seen in older patients. Patients may report a temporal headache with scalp tenderness, jaw claudication +/- stiffness in their neck and shoulder. Importantly they may report loss of vision and on fundoscopy show pallor in the optic disc. It is important to exclude this diagnosis as it can lead to irreversible blindness due to optic nerve ischaemia. On examination, they will have temporal tenderness and sometimes a thickened temporal artery. This patient is slightly younger than the usual demographic for GCA, reports no visual symptoms or jaw claudication, however as a minimum a CRP and/or ESR level should be taken, with consideration for further investigations/rheumatological consultation if there is clinical suspicion.
• Acute angle-closure glaucoma (AACG) - This is an ophthalmological emergency. Patients will present with sudden onset eye pain or headache around the eye, and often complain of nausea and vomiting, blurred vision, reduction in visual acuity and halos around lights. On inspection of their eye, there will be a red eye, corneal oedema and a fixed mid-dilated pupil. Also they will have raised intraocular pressure as well. In this case the episodic, intermittent pattern with a period of remission is not in keeping with AACG, which will not tend to resolve by itself, however urgent ophthalmology opinion should be sought if there is clinical suspicion.

2.What features or signs may suggest a secondary cause of headache rather than primary?

• Progressive nature of symptoms e.g. weight loss, personality change, gradual onset visual or sensori-motor symptoms may indicate a growing intracranial tumour.
• History of head or neck trauma e.g. road traffic accident, sport-related.
• New-onset neurological deficits such as focal weakness, sensory deficit, seizures.
• Signs and symptoms suggestive of infective aetiology, e.g. fever, rash, confusion or seizures. 
• Features of ENT disorders such as sinus pain and tenderness, nasal discharge and congestion, history of sinusitis.
• While visual changes can overlap with primary headache conditions e.g. migraine, they can also be present in other key secondary headache conditions e.g. GCA and angle-closure glaucoma, bitemporal hemianopia in pituitary tumours, homonymous hemianopia in stroke.
• Clear history of a causative substance/medication or its withdrawal.

3.What investigations are appropriate in this patient?

• Bloods: inflammatory markers i.e. WBC, CRP and ESR to exclude infection, temporal arteritis etc
• Imaging: MRI Head (to rule out secondary causes of headache)
• To consider:
  • Pituitary function tests
  • ECG - check for conduction abnormalities before starting verapamil for prophylaxis

4.Given the suspected diagnosis of a cluster headache, how do you manage this patient?

• Acute management of cluster headache primarily involves administration of high-flow oxygen and subcutaneous sumatriptan, or intranasal sumatriptan or zolmitriptan. Contraindications to triptan use include cardiovascular and cerebrovascular disease and risk factors such as uncontrolled, moderate or severe hypertension.
• Prophylactic treatment with verapamil, galcanezumab or topiramate, as well as trigger avoidance (alcohol cessation) are recommended for long-term prevention. Often a short tapering course of oral corticosteroid e.g. prednisolone is used to bridge the gap between acute treatment and preventative, which can take up to 2 weeks to take full effect.