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Headaches can be summarised as any pain in the head (above the eye). The nature of headaches can vary depending on the underlying cause:
- The pain can be sharp, dull, throbbing etc.
- Can occur both (or one side) of the head, either spreading or stationary. Headaches are classed as ‘Primary’ or 'Secondary'.
Primary headache (most common)
Causes of the headache is at molecular level with no demonstrated underlying aetiology e.g. Migraines, Tension & Cluster Headaches.
| Tension Headache | Banding around the head; usually results from stress or mood. |
|---|---|
| Pain from Neck (Cervicogenic) Headache | Band from neck to the forehead (can have scalp tenderness); this can be unilateral or bilateral. Consider traumatic cause and treat accordingly. |
| Cluster Headache | Often a nightly pain in the eyes for a period of time and then stops for a few months. This headache usually affects males (more common with smoking males). |
| Migraine | Sensory disturbances (Aura) such as visual; can have nausea/vomiting. Can occur as unilateral. Pain usually appear as ‘throbbing’ in nature. |
Secondary headache
Causes of the headache has an underlying cause, which can be life-threatening if left untreated e.g. TBIs, tumours, or infection.
| Meningitis | Fever, photophobia, stiff neck, rash, limb pain, cold peripherals, and mottled skin. Accompanied with a headache. |
|---|---|
| Encephalitis | Fever and confusion (reduced GCS). |
| Subarachnoid Haemorrhage | Very sudden headache onset, described as “thunder-clap.’ This can include stiff neck. Consider traumatic cause |
| Head Injury | Considered in trauma patients, including falls, or mechanism of injury suggesting head &/or spinal injury. |
| Acute Febrile Illness | Fever with symptoms of underlying cause of infection (e.g. Respiratory infection, tonsillitis etc.) |
| Raised Intracranial Pressure | Can be traumatic or non-traumatic caused (e.g. Aneurysm, tumour, infection) appear as raising blood pressure, reduced pulse and worsening headache when sneezing/waking. |
| Medication OveruseHeadache | Caused by regular, long-term medication use to treat headaches, this results in a ‘rebound’ headache. |
| Dehydration | The homeostatic balance of fluid and electrolytes has been disrupted due to water being expelled faster than it can be replenished, causing the brain to temporarily contract, causing intense pain. |
Clinical Features
Green Flags
Exercise high degree of caution, looking for red / yellow flags.
Exercise high degree of caution, looking for red / yellow flags.
- Symptoms associated with Influenza
- Known headache with usual symptoms, and triggers
- Normal clinical signs (e.g. vital signs, history), with no stroke symptoms and walking normally.
Yellow Flags
Consider Ambulance &/or CSPSOC consultation.
Consider Ambulance &/or CSPSOC consultation.
- Taking anticoagulants or antiplatelets drugs
- Hypertensive during pregnancy
- History of intracranial bleeding
- Onset during sexual activities
- Family history of cerebral vascular abnormalities
- New onset headache in patients older than 50yo or less than 10yo
Red Flags
Ambulance &/or CSPSOC consultation.
Ambulance &/or CSPSOC consultation.
- Intense, exploding and rapid onset headache (also known as a thunderclap headache)
- Worsening headache from recent head trauma
- Headache with fever, rash and/or altered GCS
- Meningeal signs (photophobia, stiff neck, or vomiting)
- Persistent morning headache with nausea
- Focal neurological or stroke signs
- Worsening & progressive headache overtime, and/or severe persistent vomiting
- Headache from postural change
- Aura lasting >60min, different than previous Aura episode
- First time on oral contraceptives.
Management
A detailed history should be done in order for a full clinical picture and differential diagnosis.
Due to the complexity of headaches, the expectation is not to diagnose the headache cause, but rather identify clinical warning signs.
Treat every headache patient cautiously and thoroughly, instead of discharging them after administering analgesia.
Primary Survey:
- C-Spine consideration for trauma patients
- Conduct a thorough assessment of pain using SAMPLE, OPQRST inc. pain score
- Emphasis on Circulation & Disability assessments in the Primary Survey, including a stroke assessment
- Keep an eye out for red & yellow clinical warning flags.
- Perform full vital signs
- Offer reassurance & consider patient position.
Relief of Pain:
- Relief of Pain as per Clinical Practice Guideline, applying non-pharmacological interventions before pharmacological interventions.
- Record pain scores before & after intervention for effectiveness.
Reassess:
- Repeat Primary Survey
- Keep an eye out for red & yellow clinical warning flags.
- Exercise caution when discharging patients; provide advice and document thoroughl
- If the patient falls into the yellow or red clinical warning category, consult CSPSOC & document interactions thoroughly
References
- https://www.ambulance.qld.gov.au/docs/clinical/cpg/CPG_Headache.pdf
- https://clinical.stjohnwa.com.au/clinical-practice-guidelines/general/relief-of-pain
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4590146/
Page contributors:
 | Thanh Bui, AP60825 Event Medic, Emergency Medical Technician & Volunteer Development Officer
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