Headache – how not to miss the bad ones

Headache. Still one of those areas that causes concern. Not because we make a mess of it, but more because we often don’t know what we should be considering, so we don’t miss the bad ones. How do we learn this material? Like all other things, I believe in simplicity to make this happen.

To me, it’s a migraine, a subarachnoid haemorrhage (SAH) or i’ts all those other things. The goal is to have a way to remember so as not to miss those other things.

Here are examples of patients I had recently and then a simple mnemonic to help you get all the bad ones.

CASE 1

A 24 year woman presents with blurred vision in the left eye for about a minute and then a headache over that left eye. On closer questioning, the patient has no past medical history and has been well. Today there was an episode of seeing strange regular patterns and flashing lights in that eye, then the vision became blurred and then she became better.

Neurological examination was normal and the fundoscopic exam was normal. The patient was in sinus rhythm, with two heart sounds.

In summary, the patient had ‘fortification spectra’ and ‘photopsia’ and then a headache, with a normal examination. This was a…migraine. Pretty straightforward.

CASE 2

A 46 year old woman with a past medical history of hypertension, was sitting on the edge of her bed after a long walk and had a SUDDEN, SEVERE headache and now had a GCS of 14-15. No need for anything else. With that story we all think SAH. In fact the CT demonstrated a subarachnoid bleed. The patients GCS then dropped and she was intubated.

These are fairly straightforward cases and ones that we get immediately. The ones that concern me are the ones that are not so easy. In the past I have covered SAH on www.resustv.com and sudden headache in weightlifters in the resus blog in ‘https://resus.com.au/headache-how-not-to-miss-the-bad-ones/. Now I wanted to find a simple way to help us remember the possible headache causes, in a similar way to the ‘sic kid’ mnemonic on ww.resustv.com.

Here is my simple way of remembering all the important headaches causes not to miss:  ‘HEAD TIE’ (just visualise a tie around someone’s head squeezing it and causing a headache)

H – Haemorrhage, intracranial and subarachnoid

E – Eclampsia – remember it can occur post-partum

A – Arterial causes – temporal arteritis and dissections

D – DVT of the brain or otherwise known as cavernous sinus thrombosis

T – Tumour and other space occupying lesions

I – Infection – meningitis, encephalitis

E – Eye disorders such as glaucoma

I will be covering all of these in detail at the EM CORE as I will be giving the talks in neurology. This is a favourite topic of mine and one that takes some time to discuss. Enough that here you are aware of the potential causes and have a simple way to remember them.

In the meantime, remember ‘HEAD TIE’.