Headaches, are They All Created Equal?

Clayton Tobin is a BCAS paramedic who also works for us in northern BC. To help his fellow Iridia paramedics out, he put together a summary on assessing and diagnosing headaches. For the benefit of other paramedics and first-aid attendants who read the blog, we decided to share an abridged version of it here.

Industrial Paramedics are in a unique situation where we are assessing patients in remote locations.  A common presenting complaint for these patients is of a headache.  Fortunately, most headaches are benign, but a small percentage of them can be serious. They are cannot-miss headaches, though they may initially have only mild symptoms.

HeadachesThere are two main classifications of headache: primary and secondary. Primary headaches are defined as existing independently from any other medical condition, and account for 90% of all headaches that present for medical assessment.  They’re usually migraines, tension headaches, and cluster headaches. Although they can be severe and debilitating, they are benign. Patients with primary headaches will almost always have a history of similar headaches. If the headache is different from their “normal” headaches or they are having a new onset of a primary headache, you’ll have to consider the possibility of a secondary headache. A secondary headache is one that results from an underlying medical condition. That condition can be something as benign as sinusitis or muscle strain or it can be life threatening.

Carbon monoxide (CO) poisoning, meningitis and subarachnoid hemorrhage (SAH) (bleeding between the membranes that cover the brain) are among the most worrying of serious headaches. A good history is important in catching the CO poisoned patient. It is important to keep this possibility in the back of your mind when you are assessing the headache patient in an industrial setting.

Meningitis is an inflammation of the membranes that cover the central nervous system and is almost always associated with a headache and fever. A stiff neck, confusion and photophobia (light hurts the eyes) are common accompaniments. Patients suspected of meningitis will require assessment by a physician as they can get very sick quickly. Pay special attention to any headache patient with a fever.

SAH presents as a severe, “thunderclap” (sudden onset) headache. Patients will often say things like, “this is by far the worst headache of my life”. They come usually during physical exertion or other activity that increases pressure in the head. Two thirds of all SAH are caused by the rupturing of an aneurysm Loss of consciousness or buckling of the knees is not uncommon, and they can often develop neck stiffness, low back pain, bilateral leg pain or increased intracranial pressure leading to confusion or coma. Sentinel headaches will warn of SAH 30%-50% of the time. These warning headaches can present as more mild or benign ones and are often misdiagnosed. Patients will often ignore these headaches as over-the-counter analgesia can relieve the pain. Sentinel headaches are characterized by a sudden severe pain often brought on by bending, lifting or even coughing as increased blood pressure in the cerebral artery causes a small leak in the aneurysm. A full-blown SAH can occur a few hours to a few months after a sentinel headache (2 weeks is the median time span). A patient suspected of having a sentinel headache or SAH will need a diagnostic CT scan or lumbar puncture to determine if there is blood in their cerebral spinal fluid.

Because some causes of secondary headaches are catastrophic, a thorough assessment must be done for all headache patients. This includes a complete set of vital signs including blood pressure and especially a temperature and a neurological assessment. It is important to obtain a good history including the onset (sudden?), severity (“worst headache in my life”?) and quality (“different from normal headache”?) of the pain and its precipitating events. Palpate the face and head. The location of the pain (i.e. unilateral or bilateral) may also be useful. Note whether or not anything makes the pain worse (tenderness over the temples as in temporal arteritis) or better (lying down as in spontaneous intracranial hypotension). Is there a stiff neck? What are the associated symptoms?

Headaches are most often benign and can easily be dismissed, but a limited few of them are caused by a cannot-miss condition. In the setting of industry we often get the worker coming in who is just looking for a Tylenol. With a thorough assessment we can significantly reduce our chances of missing the rare, cannot-miss headaches.