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
- Medication
- 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
- Until more definitive treatments can be used, the goal is to ↓ICP and avert secondary injury
- 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)