Thread by @GatesPhysio

🤕🤦‍♂️Headache Thread🤦‍♀️🤕

I will try to cover common DDx in 1ry & 2ry Headache, Red Flag/screening Qs, resources/links etc

I may add to it over time so consider bookmarking / sharing if useful.

Aimed towards MSK clinicians, FCP/ACPs, Primary Care non-medics for now

The International Classification of Headaches separate Headaches into 3 main catagories:

1) The primary headaches
2) The secondary headaches
3) Neuropathies & Facial Pains

ichd-3.org

Primary Headaches- One not corrilated with an underlying condition.

E.g. Migraine, Tension-type and Cluster

NICE CKS cks.nice.org.uk/topics/headach…

NICE Dx Poster Below nice.org.uk/guidance/cg150…

Tension-Type Headache (TTH)

Common - 30-78% of us will get one.

Episodic (Infrequent / Frequent) or Chronic
+/- pericranial tenderness

More here
ichd-3.org/2-tension-type…
&
via @PainSci painscience.com/tutorials/head…

Migraine without Aura

Can overlap other headache conditions Dx criteria below

ichd-3.org/1-migraine/1-1…

Migraine is usually characterized by moderate to severe pulsating pain, often on one side of the head, which can be accompanied by nausea, vomiting, and sensitivity to light and sound.

NICE CKS Migraine cks.nice.org.uk/topics/migrain…

Migraine with Aura

Aura with the absence of headache makes it difficult to R/o other causes e.g. TIA

If 1st time >40 & hemianompia etc.

Cluster Headaches (an example of a Trigeminal autonomic cephalalgia)

These are characterized by severe pain on one side of the head, often around the eye, with autonomic symptoms such as tearing, nasal congestion, and eyelid drooping.

there are others but beyond my scope!

- >5 attacks, 1 every other day - 8 /day
- Severe pain 15-180mins
ipsilateral to the headache:
– conjunctival injection
– nasal congestion
– eyelid oedema
– facial sweating
– horners
Not better accounted for by another ICHD-3 diagnosis.ichd-3.org/3-trigeminal-a…

To recap so far, this is an infographic from the Pharmacuitical Journal which covers Migraine, Tension type Headache and Cluster Headache

pharmaceutical-journal.com/article/infogr…

Ok so now lets talk about secondary headaches, these are headaches which are caused by another condition and are a symptom.

In MSK, we likely mostly come accross cervicogenic headaches, @ClementsCharl96 did a thread on this already so check that out

Head or neck injuries understandabley can cause referred pain as well as the symptom of headache and overlap with things like migraine.

Dx for example post-concussion syndrome,
ichd-3.org/5-headache-att…

cks.nice.org.uk/topics/head-in…

Those working in sport I expect will be more familiar with Sport-related concussion (SRC) but obviously any kind of concusion or trauma can cause and be associated to headache. Visual summary for overlap of symptoms.

bjsm.bmj.com/content/53/4/2…

Next 2ry Headache classfication we have vascular issues
- Stroke/TIA
-Intracranial Haemorage (e.g. subarac)
-GCA
-Cervical Carotid/Vertebral Artery
-etc (aka some others that sound really complex!)

ichd-3.org/6-headache-att…

OK so Stroke/TIA ( by that I mean cerebral ischimic event)

People may report very severe headache that comes on within seconds or minutes.

Depending on area may have other specific defecits.

Think 'FAST'
stroke.org.uk/what-is-stroke…

GCA:

See PMR - hear headache - think GCA

@ClementsCharl96

@TaylorAlanJ clin pearl- tele consult -ask the pt to gently press /stroke between the eye brow and hair line (temporal artery), inflammation artery --> acutely tender to pressure or palpation

While we are on vascular pathologies, these will often impact the cranial nerves.

@TaylorAlanJ @NathanHutting @RogerKerry1 are the guys for the job with this and see their pages for more info pubmed.ncbi.nlm.nih.gov/34182898/

Again another common 'physio' Q would be '5D3N1A'
Needs to include Headache as well as sensible vascular profile questions
ichd-3.org/6-headache-att…

So with our CAD/VBI again @RogerKerry1 and @TaylorAlanJ could do whole threads on this so please see their resources for further info but key Ax:
Vascular profile, unusual pain, Site occipital for vertebrobasillar system, FHx- young cvd/stroke/DVT

Worth checking their BP in clinic :

Worth looking for horners syndrome- mneumonic and infograph via @MattDelBrocco

OK so I'm going a little out of order so i'll circle back. Ill be here all day if we go through ALL of these so take a look depending on caseload:

ichd-3.org/8-headache-att…
ichd-3.org/9-headache-att…
ichd-3.org/10-headache-at…
ichd-3.org/11-headache-or…
ichd-3.org/12-headache-at…

And lastly there is the 'orofacial' stuff

Lovely visual summary from @bmj_latest
bmj.com/content/361/bm…

ichd-3.org/13-painful-cra…

RIGHT, assesment. We about to 'drop it like its hot' 'fo shizzle'. If you dont get the reference now, you soon will. 'snnoopppppppppp'

SNNOOP10 ⛳️
pubmed.ncbi.nlm.nih.gov/30587518/

Key Qs to ask in Primary Headache:
What is the impact on daily life?
How many days/month is this happening?
How many days do you take symptomatic medications?
Any vision or unilateral sensory symptoms?

Other key shares by @neiljlangridge

Red flags:

& @fi_firstchoice share from @PhysioFirstC InTouch

Some tips within this thread on headache teaching

@DrLucyDouglas
'most part patients will have figured out if dehydration, sleep deprivation, chocolate/ tomatoes/cheese etc were the culprit ... Endlessly focusing on those things can feel like gaslighting

Will circle back to NICE CKS guidelines for Ax and more detail on Ax perhaps another day.

While it is on my mind- remember this fab paper on Safetynetting exactly this kind of stuff

Back to cranial nerves - why/when we should Ax them (hint- headache)

To recap red flags see these below

I think the fact there are X10 Ps is confusing but easy enough to print in clinic for quick checklist.

HT @emmalchan for Paeds

A few key cranial nerve resources

@TaylorAlanJ

@alexludai below / + other images @OGdukeneurosurg

@TaylorAlanJ @alexludai @OGdukeneurosurg Further cranial nerve resources
From @julia_tabrah

@TaylorAlanJ @alexludai @OGdukeneurosurg @julia_tabrah Cranial nerve music video





Hope everyone loves the ear worm "so call me maybe"

Cranial nerve name and function mnumonics

Via instagram.com/ezmedlear

Others include:
On old Olympus's towering top, a Finn and German viewed some hops

Oh, Oh, Oh To Touch And Feel Very Good Velvet AH

AI (#ChatGPT) generated Cranial Nerve rap

Dizziness in headache/acute vertigo?

bmj.com/content/366/bm… @BJSM_BMJ @bmj_latest (2019)

semanticscholar.org/paper/TiTrATE%…

@GeraldMDMD