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)