Headache on the CCFP exam

Approach

• Ask how fast it peaked. A thunderclap headache is at its worst almost at once.
• Ask what set it off. Lifting, straining, coughing or sex is an unusual trigger, and a red flag.
• Ask about fever, a stiff neck, new weakness, numbness, poor balance, and being woken from sleep by the pain.
• Ask if it is new, or getting worse fast. Ask about cancer and a weak immune system. A first headache after 50 is a red flag.
• Examine for fever, a stiff neck, and a swollen optic disc (papilledema). Look for focal signs: weakness or numbness on one side.
• Skip checks that do not fit. Jaw, sinus and neck muscle findings cannot explain a thunderclap headache. A temporal artery check means nothing at 16.
• Typical migraine, a normal exam and no red flags: no computed tomography (CT), magnetic resonance imaging (MRI) or sinus imaging. Explain the diagnosis instead.

Approach

• Suspected meningitis: take blood cultures and give intravenous (IV) antibiotics at once. Do not hold them for the LP or a scan.
• Scan before the LP if there is papilledema, a seizure, a focal sign or a drop in alertness.
• Suspected giant cell arteritis: check the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Start steroids the same day, then arrange a temporal artery biopsy.
• Vision loss in giant cell arteritis is an emergency. Send the patient in now.
• Suspected bleed around the brain: CT head now, in emergency. If the CT is normal, a lumbar puncture is next.
• Suspected tumour: image the brain. Clues are a headache that keeps getting worse, waking from sleep, papilledema, focal signs or past cancer.
• Pain that eases with a painkiller or a triptan proves nothing. A bleed or meningitis can ease too.

Approach

• Ask about every painkiller, bought or prescribed, and how many days a month each one is taken.
• Ask for a headache diary. It shows how often attacks come and how often drugs are used.
• Painkillers taken too often can cause near-daily headache by themselves. This is medication overuse headache. The day limits are in the table.
• Do not use opioids for migraine. They work poorly and bring dependence and more headache. Tramadol is an opioid.
• Do not start a butalbital mix first. Butalbital is a barbiturate, with the same risks.
• For attacks, use an anti-inflammatory painkiller (NSAID) or a triptan, within the day limits.
• Help with regular meals, enough sleep, stress, relaxation and pacing. These can cut the need for drugs.

Approach

• CT finds most bleeds when done soon after onset. The longer the wait, the more it can miss.
• If the CT is normal and the story still fits, a lumbar puncture is next, the same day.
• In the fluid, look for red cells that do not clear, and xanthochromia: a yellow colour from broken-down blood.
• Do not repeat the CT later. Blood clears from around the brain over time, so a later CT misses more.
• Do not book an outpatient MRI. A small warning bleed can be followed by a bigger one within days.
• ESR and CRP cannot find blood. They do not help here.
• Blood or xanthochromia in the fluid: urgent imaging of the brain's blood vessels, and a neurosurgeon.

Approach

• First line for an attack: an NSAID or a triptan.
• Before sumatriptan, ask about heart disease, stroke or mini-stroke, poor blood flow to the legs or gut, and uncontrolled high blood pressure. Each rules it out.
• No sumatriptan for hemiplegic or basilar migraine, or within 24 hours of another triptan or ergot. Not with severe liver disease, or within 2 weeks of a monoamine oxidase (MAO) inhibitor, a type of antidepressant.
• Sumatriptan tablets: if the headache returns, repeat after 2 hours, up to 200 mg in 24 hours. If the first dose did nothing, do not repeat it for that attack.
• No opioids. They work poorly and can make nausea and vomiting worse.
• Then review the plan: a diary, the day limits on each drug, sleep, meals and stress.
• Attacks still frequent despite these steps: think about a medicine to prevent attacks. Refer if the diagnosis is unclear, red flags appear, or prevention fails.