Neurology >
Secondary Headaches

“Headaches caused by an underlying condition”

  • Temporal Arteritis
    • Also called giant cell arteritis. The temporal artery is inflamed (vasculitis)
  • Subarachnoid Haemorrhage
    • A life-threatening type of stroke caused by bleeding into subarachnoid space
  • Raised ICP
    • Elevation of pressure within the cranium
  • Glaucoma
    • A common eye condition where the optic nerve becomes damaged due to an increase in intraocular pressure
  • Sinusitis
    • Also known as rhinosinusitis. Inflammation of mucous membranes that line the sinuses
Risk Factors
  • Temporal Arteritis
    • Age (55+)
    • Women
    • Family history
  • Subarachnoid Haemorrhage
    • Previous Aneurismic SAH
    • Smoking
    • High blood pressure
    • Alcohol
  • Raised ICP
    • Female
    • Obese
    • High blood pressure
  • Glaucoma
    • High blood pressure
    • Family history
  • Sinusitis
    • Asthma
    • CF,
    • Nasal passage abnormality
    • Hay fever
Aetiology
  • Temporal Arteritis
    • Cause thought to be autoimmune
  • Subarachnoid Haemorrhage
    • Can be traumatic or non-traumatic
  • Raised ICP
    • Can be caused by: primary/metastatic tumours, head injury, haemorrhage, infection, hydrocephalus, status epilepticus
  • Glaucoma
    • Cause not always known.
    • Can be steroid use, sever diabetic retinopathy or trauma
  • Sinusitis
    • Precipitated by an earlier URTI
Pathophysiology
  • Temporal Arteritis
    • The lining of arteries become inflamed → narrows lumen → reduction in blood reaching tissues
  • Subarachnoid Haemorrhage
    • Berry aneurism rupture
    • Arterio-venous malformation
  • Raised ICP
    • The volume inside the cranium is fixed, so any increase in the contents can lead to a raised ICP
  • Glaucoma
    • Increased intraocular pressure due to reduced outflow of aqueous humor.
    • Damages optic nerve
  • Sinusitis
    • Obstruction of sinus drainage pathways, ciliary impairment→ stasis of secretions → proliferation of various pathogens → sinusitis
Clinical Presentation
  • Temporal Arteritis
    • Unilateral
    • Throbbing pain
    • Scalp tenderness
    • Jaw claudication
    • Visual involvement
  • Subarachnoid Haemorrhage
    • Thunderclap headache (like being hit in the back of the head with a brick)
    • Vomiting
    • Seizures
    • Coma
    • Neck stiffness
    • Kernig’s sign
    • Eye bleeds and changes
  • Raised ICP
    • Headache that’s worse on coughing, leaning forwards and in mornings
    • Vomiting
    • ↓GCS
    • Pupil changes and ↓acuity
    • ↓HR ↑BP
  • Glaucoma
    • Pain around one eye
    • Swollen red eye
    • Visual blurring and halos
  • Sinusitis
    • Dull, constant facial pain
    • Pain worse on leaning head forward
    • Rhinorrhoea
    • 1-2 weeks
Investigations
  • Temporal Arteritis
    • Bloods: ↑ESR ↑CRP ↑Platelets ↑ALP ↓Hb
    • Temporal artery biopsy or FDG-PET scan
  • Subarachnoid Haemorrhage
    • CT scan
    • Lumbar puncture (only if no ↑ICP )
  • Raised ICP
    • Bloods: U&E, FBC, glucose, serum osmolality, clotting, blood culture
    • CXR, head CT, LP (if safe)
  • Glaucoma
    • Vision tests
    • Measure intraocular pressure (tonometer)
  • Sinusitis
    • CT can confirm but rarely used
Management
  • Temporal Arteritis
    • Prednisolone (PO) or Methylprednisolone (IV) if evolving vision loss.
    • Reduce dose when symptoms resolve
  • Subarachnoid Haemorrhage
    • Medication
      • Nimodopine – CCB, relaxes narrowed blood vessels to reduce secondary cerebral ischaemia
      • Pain relief – morphine/co-codamol
    • Surgery (if caused by burst aneurism)
      • Repair affected vessel via coiling or clipping to prevent rebleeding
  • Raised ICP
    • Until more definitive treatments can be used, the goal is to ↓ICP and avert secondary injury
      • Elevate bed head
      • Hyperventilate to ↓PaCO2 → vasoconstriction
      • Osmotic agent e.g. Mannitol
    • Aim to make a diagnosis and treat the cause or exacerbating factors
      • Focal causes e.g. haematoma – craniotomy or burr hole
      • Tumour – debulking surgery, radiotherapy, chemotherapy, steroids
  • Glaucoma
    • Eye drops – prostaglandin analogues e.g. latanoprost increase outflow
    • Laser treatment – trabeculoplasty
    • Surgery – trabeculectomy
  • Sinusitis
    • Hydrate
    • Rest
    • Painkillers
    • Avoid allergic triggers and smoking
    • Nasal spray – decongesting or steroids
    • Antihistamine
    • Antibiotics if needed
    • Surgery – FESS
Complications
  • Temporal Arteritis
    • Loss of vision
  • Subarachnoid Haemorrhage
    • Rebleeding, Secondary cerebral ischaemia, hydrocephalus
  • Raised ICP
    • Coma, stroke, herniation syndromes
  • Glaucoma
    • Blindness
  • Sinusitis
    • Brain abscess, meningititis, eye infection
Quick Revision Sheet

Access an overview table of the Primary and Secondary headaches here (pdf)

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