Last bit of headaches this month with guidance on management of various primary headaches, including medication overuse headache. Also more on domperidone, psoriasis, respiratory and heart rates to worry about and a link to a new colic summary I’ve put under the Primary Care Guidelines tab. Do leave comments below.
More musings from Dr Waterfield this month – this time on paracetamol for immunisation discomfort. Also the 7 important features of a headache y0u must ask about, a link to a very good paediatric emergency medicine site, NICE quality standards in depression, molluscum contagiosum and more musings from me, this time on paediatric phlebotomy. Do leave comments below.
- worsening headache with fever
- sudden-onset headache reaching maximum intensity within 5 minutes
- new-onset neurological deficit
- new-onset cognitive dysfunction
- change in personality
- impaired level of consciousness
- recent (typically within the past 3 months) head trauma
- headache triggered by cough, valsalva (trying to breathe out with nose and mouth blocked) or sneeze
- headache triggered by exercise
- orthostatic headache (headache that changes with posture)
- symptoms suggestive of giant cell arteritis
- symptoms and signs of acute narrow-angle glaucoma
- a substantial change in the characteristics of their headache.
- compromised immunity, caused, for example, by HIV or immunosuppressive drugs
- age under 20 years and a history of malignancy
- a history of malignancy known to metastasise to the brain
- vomiting without other obvious cause.
- frequency, duration and severity of headaches
- any associated symptoms
- all prescribed and over the counter medications taken to relieve headaches
- possible precipitants
- relationship of headaches to menstruation.
|Headache feature||Tension-type headache||Migraine (with or without aura)||Cluster headache|
|Pain location1||Bilateral||Unilateral or bilateral||Unilateral (around the eye, above the eye and along the side of the
|Pain quality||Pressing/tightening (non-pulsating)||Pulsating (throbbing or banging in young people aged 12–17 years)||Variable (can be sharp, boring, burning, throbbing or tightening)|
|Pain intensity||Mild or moderate||Moderate or severe||Severe or very severe|
|Effect on activities||Not aggravated by routine activities of daily living||Aggravated by, or causes avoidance of, routine activities of daily living||Restlessness or agitation|
|Other symptoms||None||Unusual sensitivity to light and/or sound or nausea and/or vomiting
Symptoms can occur with or without headache and:
Typical aura symptoms include visual symptoms such as flickering lights,
spots or lines and/or partial loss of vision; sensory symptoms such as
numbness and/or pins and needles; and/or speech disturbance.
|On the same side as the headache:
|Duration of headache||30 minutes–continuous||4–72 hours in adults
1–72 hours in young people aged 12–17 years
|Frequency of headache||< 15 days per month||≥ 15 days per month for more than 3 months||< 15 days per month||≥ 15 days per month for more than 3 months||1 every other day to 8 per day3, with remission4 >
|1 every other day to 8 per day3,
with a continuous remission4 <1 month
|Chronic tension-type headache5||Episodic migraine (with or without aura)||Chronic migraine6 (with or without aura)||Episodic cluster headache||Chronic cluster headache|
|1 Headache pain can be felt in the head, face or neck.
2 See recommendations 1.2.2, 1.2.3 and 1.2.4 for further information on diagnosis of migraine with aura.
3 The frequency of recurrent headaches during a cluster headache bout.
4 The pain-free period between cluster headache bouts.
5 Chronic migraine and chronic tension-type headache commonly overlap. If there are any features of migraine, diagnose chronic migraine.
6 NICE has developed technology appraisal guidance on Botulinum toxin type A for the prevention of headaches in adults with chronic migraine
(headaches on at least 15 days per month of which at least 8 days are with migraine).