Secondary headaches

• Giant cell arteritis is a sight-threatening vasculitis characterised by inflammation of median and large sized arteries. It is rarely seen before the age of 50 and is more common in white women.
• Giant cell arteritis is strongly linked with polymyalgia rheumatica - causes pain and stiffness in the neck, shoulders and hips
• Giant cell arteritis presentation:

  • Unilateral headache - severe and typically around the temples
  • Scalp/temporal tenderness
  • Jaw claudication - fatigue with chewing
  • Systemic symptoms - weight loss, fatigue and fever
  • Blurred or double vision
  • Reduced or absent pulsation of the temporal artery
• Diagnosis of giant cell arteritis when three of the following are met:

  • Age at disease onset  ≥ 50 years
  • New headache
  • Temporal artery abnormality
  • Elevated ESR (>50mm/hr)
  • Temporal artery biopsy showing granulomas
• Any patient with visual symptoms relating to suspected GCA require an urgent ophthalmic assessment with slit-lamp examination the same day. The characteristic finding is anterior ischaemic optic neuritis - which is seen as a pale, swollen optic disc
• Management of GCA:

  • Acute visual loss is usually treated with IV glucocorticoid therapy
  • Without visual symptoms - 40-60mg oral prednisolone per day
  • Steroids weaned slowly over 1-2 years
• Differential diagnosis of a headache with vomiting:

  • Meningitis
  • Stroke
  • Subarachnoid haemorrhage
  • Subdural/epidural haematoma
  • Carbon monoxide poisoning
  • Migraine
• Headache red flags:

  • Thunderclap - suggestive of SAH
  • Associated with postural change
  • Vomiting
  • Visual changes and jaw claudication in over 50s - suggestive of giant cell arteritis
  • Acute confusion/neurological deficit
  • New type of headache/change in character
• Cushings triad is a late sign of raised intracranial pressure = Widened pulse pressure, bradycardia and deep/irregular breathing
• 1st line investigation of headache with red flags is a CT without contrast

  Lumbar puncture is done if CT is negative but SAH, abscess, meningitis or encephalitis is suspected
• Clinical exam for suspected secondary headache:

  • Blood pressure and pulse
  • Palpate temporal arteries
  • Examine spine/neck muscles
  • Cranial nerve exam
  • Upper and lower neurology exam
  • Fundoscopy
• Idiopathic intracranial hypertension will have a negative CT head but raised opening pressure on a lumbar puncture. Most common in female, obese, 20-30 year olds
• Hypertensive encephalopathy is a syndrome in which altered mental status, headache, vision changes or seizures accompany elevated blood pressure. ICP is aggressively lowered with Labetalol.
• Emergency headaches:

  • Meningitis - headache accompanied by stiff neck and fever
  • Epidural haematoma
  • Subdural haematoma
  • Subarachnoid haemorrhage
  • Hypertensive encephalopathy
  • Giant cell arteritis
  • Acute angle-closure glaucoma
  • Features of raised ICP