On this page
Referral and warning signs
When to refer
Refer URGENTLY to hospital (H) if any DANGER SIGNS are present. Refer for investigation if headache pattern changes significantly, becomes progressively worse, or doesn't respond to standard treatment.
Red flags
- Recent significant head trauma.
- High fever (suspect malaria, meningitis, other infections).
- Acute onset, severe ('thunderclap') headache (suspect subarachnoid hemorrhage).
- Chronic, worsening headache (suspect tumor, hypertension).
- Altered consciousness, confusion.
- Focal neurological symptoms or signs (e.g., one-sided weakness, numbness, speech difficulty, visual field defect).
- Seizures accompanying headache.
- Neck stiffness or photophobia (suspect meningitis/SAH).
- Papilledema on fundoscopy (raised intracranial pressure).
- New onset headache in patient >50 years.
- Headache associated with systemic illness (e.g., HIV, cancer).
Signs and symptoms
- Pain in the head (location, character, intensity, duration, frequency vary widely).
- Associated symptoms depend on cause (e.g., fever, neck stiffness, nausea, vomiting, photophobia, focal neurological deficits, visual changes, sinus congestion).
Risk factors
- Factors vary widely depending on type:
- Tension headache: Stress, fatigue, poor posture.
- Migraine: Genetic factors, hormonal changes, stress, certain foods, sensory stimuli.
- Sinusitis: Upper respiratory infection, allergies.
- Secondary headaches: Hypertension, head trauma, infections (malaria, meningitis), intracranial bleeding, brain tumor, dehydration, eye strain, dental problems, medication overuse.
Diagnosis
Clinical assessment
Diagnosis starts with a thorough history (Onset, Location, Duration, Character, Aggravating/Relieving factors, Associated symptoms, Timing, Severity - OLD CARTS) and physical examination (vital signs, neurological exam including fundoscopy, neck stiffness assessment, sinus tenderness). Identify location to narrow possibilities (see UCG notes). Crucially, identify DANGER SIGNS.
Investigations
- Often not needed for primary headaches (tension, migraine) with normal exam.
- Guided by suspected cause and presence of danger signs:
- - Malaria test (RDT/Microscopy): Essential in endemic areas if fever present.
- - Lumbar Puncture (LP): If meningitis or subarachnoid hemorrhage suspected (CT first if focal signs/papilledema).
- - CT Scan / MRI Brain: If tumor, bleed, stroke, or increased intracranial pressure suspected (presence of danger signs).
- - Blood Pressure check.
- - Sinus imaging if chronic sinusitis suspected.
- - Eye examination if eye strain or visual problems suspected.
Diagnostic criteria
Specific criteria exist for primary headache disorders (e.g., Migraine, Tension-type). Diagnosis of secondary headache relies on identifying the underlying cause. Key initial step is ruling out serious underlying pathology via recognition of danger signs.
Management
Non-pharmacological management
- Rest in a quiet, dark room.
- Stress management techniques.
- Adequate hydration.
- Regular sleep.
- Avoid known triggers (for migraine/tension headaches).
Pharmacological treatment
- Simple Analgesics (for mild-moderate pain): Paracetamol, Ibuprofen, Aspirin (follow standard dosing).
- Treat underlying cause: e.g., Antibiotics for sinusitis/meningitis, Antimalarials for malaria, Antihypertensives for severe hypertension.
- Specific treatments for Migraine (see NEU004).
- Follow pain ladder approach as appropriate.
Monitoring
Monitor response to treatment. Monitor for development of danger signs.
Complications
- Related to underlying cause if serious pathology missed (e.g., stroke, brain damage from meningitis/bleed/tumor).
- Medication overuse headache (from frequent analgesic use).
- Chronic daily headache.
- Reduced quality of life.
Prevention
- Depends on cause.
- Stress management, regular exercise, adequate sleep for tension headaches.
- Trigger avoidance, prophylactic medication for frequent migraines.
- Malaria prevention.
- Vaccination against meningitis pathogens.
- Blood pressure control.
- Head injury prevention.
Patient education
- Explain likely cause if identified (e.g., tension, migraine).
- Educate on appropriate use of analgesics to avoid medication overuse headache.
- Teach trigger identification and avoidance if relevant.
- CRITICAL: Educate on DANGER SIGNS requiring immediate medical attention.
- Advise on lifestyle measures (hydration, sleep, stress).
Uganda-specific notes
Malaria and meningitis are critical differential diagnoses for headache with fever. Always check BP, especially if headache is temporal or occipital. Consider HIV/TB related causes in relevant patients. Access to neuroimaging is limited.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 9, Section 9.1.3