2. Introduction
• Headache also known as cephalalgia, is the symptom
of pain anywhere in the region of the head or upper neck
• Headache is among the most common pain problems
encountered in family practice.
• The brain itself is not sensitive to pain, because it
lacks pain receptors. The pain originates from the tissues
and structures that surround the skull or the brain
• These include the extracranial arteries, middle meningeal
artery, large veins, venous sinuses, cranial and spinal
nerves, head and neck muscles, the meninges, falx
cerebri, parts of the brainstem, eyes, ears, teeth, lining of
the mouth and Pial arteries
3. Classification
1. Primary headaches (benign, recurrent, not caused by
underlying disease or structural problems.)
• Migraine
• Tension-type headache (most common)
• Cluster headache
2. Secondary headaches ( caused by underlying organic diseases
or following an injury)
3.cranial neuralgias, facial pain, and other headaches.
4. Primary headache
90% of all headaches are primary headaches
between 20 and 40 years old
The most common types of primary headaches are
migraines, tension-type headaches and cluster
headache
Other very rare types of primary headaches include--
• Hemicrania continua: continuous unilateral pain
with episodes of severe pain and a/w autonomic
symptoms. It can be relieved by the medication
indomethacin.
5. • Primary sex headache: dull, bilateral headache that
starts during sexual activity and becomes much worse
during orgasm. Treated by advising the person to stop
sex if they develop a headache. Medications such
as propranolol and diltiazem can also be helpful.
• Primary thunderclap headache:Sudden onset of severe
headache may occur in the absence of any known
provocation-DDx includes SAH, sentinel bleed of an
intracranial aneurysm, cervicocephalic arterial dissection
and cerebral venous thrombosis.
• Hypnic headache: moderate-severe headache that starts
a few hours after falling asleep and lasts 15–30 minutes.
The headache may recur several times during night.
Hypnic headaches are usually in older women. They may
be treated with lithium.
6. • Primary stabbing headache: recurrent episodes of
stabbing "ice pick pain" or "jabs and jolts" for 1 second to
several minutes without autonomic symptoms (tearing,
red eye, nasal congestion). These headaches can be
treated with indomethacin.
• Primary cough headache: generalised ,starts suddenly
and lasts for several minutes after coughing, sneezing or
straining –Rx-indomethacin
• Primary exertional headache: B/L,throbbing, pulsatile
pain which starts during or after exercising, lasting for 5
minutes to 24 hours. It can be treated with medications
such as indomethacin.
7. • New daily-persistent headache (NDPH)
-Headache that is daily and unremitting from very
soon after onset (within 3 days at most). Headache is
present daily, and is unremitting, for > 3 months
-The pain is typically bilateral, pressing or tightening in
quality and of mild to moderate intensity. There may
be photophobia, phonophobia or mild nausea.
10. Contd;
4. Headache associated with substance abuse or
withdrawal,excess use of medications used to treat
headache(rebound headache)
5. Headache associated with noncephalic infection (viral
infection,bacterial infection)
6. Headache associated with metabolic disorder (hypoxia,
hypercapnia, hypoglycemia, dialysis)
7. Headache or facial pain associated with disorder of
cranium, neck, eyes, ears, nose, sinuses, teeth or mouth
—cervicogenic headache
8. Headache attributed to psychiatric disorder
11. cranial neuralgias, facial pain, and other
headaches
• Cranial neuralgia describes inflammation of
one of the 12 cranial nerves coming from the
brain that control the muscles and carry
sensory signals (such as pain) to and from the
head and neck.
• most common example is trigeminal
neuralgia, which affects cranial nerve V (the
trigeminal nerve), the sensory nerve that
supplies the face and can cause intense facial
pain when irritated or inflamed.
12. Headache -Evaluation
• Evaluation focuses on determining whether a
secondary headache is present and checking
for symptoms that suggest a serious cause.
• If no cause or serious symptoms are
identified, evaluation focuses on diagnosing
primary headache disorders.
13. History
NEW OR OLD HEADACHE
• The first step to diagnosing a headache is to
determine if the headache is old or new
• Old headaches are usually primary headaches
and are not dangerous-- migraines, tension
headaches, cervicogenic headache etc
• New headaches are more likely to be
dangerous secondary headaches
14. History
AGE OF ONSET
• Primary headaches can occur at any age but most
often begin during childhood or between 20 and 50
years of age.
• Onset of headache after 50 years of age is a red
flag for consideration of a secondary headache
disorder such as temporal arteritis or a mass lesion.
15. History
SYMPTOMS
The patient should be asked to describe current symptoms as
well as symptoms experienced before , during and after
the headache
• Primary headache disorder such as cluster headache
(ipsilateral lacrimation and/or nasal congestion) or
migraine with aura (e.g., scotomata, photophobia,
phonophobia, nausea).
• Secondary headache disorder (diplopia, dimming of vision
in a single eye,stiff neck, disorientation, rash, fever, eye
pain, unilateral paresthesias, unilateral weakness, balance
change).
16. History
ONSET
Questions should be asked about the time and nature of
headache onset (e.g., gradual, sudden, subacute).
Headache of sudden and severe onset can be due to:
• SAH
• Vascular malformations(ruptured or unruptured)
• Acute ischemic Cerebrovascular disorder
• Posterior fossa mass lesions.
• Cluster headache
17. History
SEVERITY AND QUALITY OF PAIN
• Tension-type headache: Mild or moderate, pressing or
tightening pain.
• Cluster headache : Severe, stabbing pain
• Migraine headache: Moderate or severe, pulsating,
throbbing
18. History
FREQUENCY AND DURATION OF PAIN
• Migraine-duration of 4 hours to 3 days, periodic
occurrence; several per month to several per year
• Tension headache-duration of 30 minutes to several
hours,
• Cluster headache-duration of 30 minutes to 3 hours,
may happen multiple times in a day for months
19. History
LOCATION AND RADIATION OF PAIN
It is important to determine the location of a patient's pain and whether the pain
radiates to another area
• Cluster headaches are strictly unilateral.
• Tension-type headaches are usually band-like and bilateral.
• Migraines generally begin unilaterally but may progress to involve the entire
head.
• Pain along the distribution of the temporal artery may suggest temporal
arteritis, and pain along the distribution of the trigeminal nerve may be a sign
of trigeminal neuralgia
• Eye pain may suggest acute glaucoma.
20. History
CURRENT /PAST MEDICAL HISTORY
Check for other oraganic causes of headache
• Meningitis
• HIV
• CNS lymphoma
• Toxoplasmosis
• Cancer---Metastases
• Intracranial vascular disorder
• Acute viral syndrome or acute bacterial infection
• Hypertension
• Immunosuppresive disorders
• coagulopathy
21. History
MEDICATIONS/DRUG HISTORY
it is important to review any medication that a patient
is taking for its potential to cause headache.
• Prescription and over-the-counter medications
(especially caffeine-containing analgesics) have been
implicated as triggers for drug-rebound and
nonspecific headaches.
22. History
RECENT TRAUMA OR PROCEDURES
• Headache subsequent to trauma may signify a
postconcussive disorder, although ICH should always be
suspected.
• Migraine and cluster headaches may be triggered by
head trauma.
• Headache has also been associated with common
medical procedures (e.g. LP, rhinoscopy) and dental
procedures (e.g., tooth extraction).
23. History
TRIGGERS/AGGRAVATING /RELIEVING FACTORS
Miragine -The pain is generally made worse by physical activity
-triggers include: menstruation, loud noise,stress, heat, alcohol,
stress,OCP,dietary triggers such as MSG etc
FAMILY HISTORY
• migraine has strong family history
PSYCHOSOCIAL HISTORY
– Substance abuse
– Occupational and personal life
– Psychologic history
– Sleep history
24. History
MISCELLANEOUS
• If the patient routinely has headaches, it is
important to determine whether the current
episode is typical. Is this headache like the
ones you usually have?
• What time of day the headaches usually occur
25. Physical examination
General physical examination:
- Vitals (BP, temperature)
- Funduscopic examination (papilledema)
- CV assessment (assess risk of CVA)
- Palpation of the head and face (R/O sinusitis)
Full neurologic exam
• Mental status
• Level of consciousness
• Cranial nerve testing
• Motor strength testing
• Deep tendon reflexes
• Pathologic reflexes (e.g. Babinski’s sign)
• Sensation
• Cerebellar function
• Gait testing
• Signs of meningeal irritation (Kernig’s and Brudzinski’s signs).
26. Red Flags
These "red flag" symptoms means that a headache warrants further
investigation with neuroimaging and lab test
• Headache beginning after 50 years of age (temporal arteritis, mass lesion)
• Sudden onset of headache (SAH, hemorrhage into a mass lesion or
vascular malformation, mass lesion especially posterior fossa mass)
• Headaches increasing in frequency and severity (mass lesion, subdural
hematoma, medication overuse)
• New-onset headache in patient with risk factors for HIV infection or
cancer (brain abscess, meningitis, metastasis)
27. Red Flags
• Headache with signs of systemic illness (e.g. fever, stiff neck, rash
indicating meningitis)
• Focal neurologic signs (mass lesion, vascular malformation, stroke,
collagen vascular disease evaluation)
• Papilledema (mass lesion, pseudotumor cerebri, meningitis)
• Headache subsequent to head trauma (ICH, subdural hematoma,
epidural hematoma, post traumatic headache)
• Headache triggered by cough, exertion or while engaged in sexual
intercourse--Mass lesion, subarachnoid hemorrhage
28. Investigations
Laboratory
• Random use of laboratory testing in the evaluation of acute headache is
not warranted.
• CBC when systemic or intracranial infection is suspected
• ESR when temporal arteritis is a possibility.
Neuroimaging
• Neuroimaging is not usually warranted in patients with primary
headaches .
• CT scanning is recommended to identify acute hemorrhage.
• MRI is best for brain tumors and problems in the posterior fossa, or back
of the brain
MRI should be done if patients have any of the following:---Focal
neurologic deficit of subacute or uncertain onset,Age > 50 yr,weight
loss,cancer,HIV,diplopia or a change in established headache pattern
29. Investigations
• lumbar puncture and CSF analysis--if meningitis, subarachnoid
hemorrhage, encephalitis,idiopathic intracranial hypertension, is
being considered
• Tonometry should be done if findings suggest acute narrow-angle
glaucoma (eg, visual halos, nausea, corneal edema, shallow anterior
chamber).
30. Migraine
• Migraine is a primary headache disorder characterized
by recurrent headaches that are moderate to severe
• most often unilateral
• some cases associated with visual or sensory
symptoms—collectively known as an aura
• most common in women and has a strong genetic
component.
• Pain builds up over a period of 1-2 hours, progressing
posteriorly and becoming diffuse
• Headache lasts 4-72 hours, however in young children
frequently lasts less than 1 hour.
• Aggravates with movement or physical activity.
31. Migraine-causes
• The underlying causes of migraines are
unknown. However, they are believed to be related
to a mix of environmental and genetic factors
• Triggers-psychological stress,hormonal
(menarche,OCP,pregnancy,menstruation,menopause
etc),dietary (MSG,chocolate,wine,tyramine
etc),environmental(indoor air quality and lighting)
32. Migraine -Pathophysiology
• Neurovascular theory--- neuronal hyperexcitability in
cerebral cortex
• Cortical spreading depression theory by Leao - explain the
mechanism of migraine with aura - CSD is a well-defined wave
of neuronal excitation in the cortical gray matter that spreads
from its site of origin at the rate of 2-6 mm/min.This cellular
depolarization causes the primary cortical phenomenon or
aura phase; in turn, it activates trigeminal fibers, causing the
headache phase
• Vasoactive substances and neurotransmitters-----
Perivascular nerve activity also results in release of
substances such as 5-HT, substance P, neurokinin A, calcitonin
gene-related peptide, and nitric oxide, which interact with the
blood vessel wall to produce dilation, protein extravasation,
and sterile inflammation. This stimulates the
trigeminocervical complex
33. Migraine
Signs and symptoms
Typical symptoms of migraine include the following:
• Throbbing or pulsatile headache, with moderate to severe
pain that intensifies with movement or physical activity
• Unilateral and localized pain in the frontotemporal and ocular
area, but the pain may be felt anywhere around the head or
neck
• Nausea (80%) and vomiting (50%), anorexia , food
intolerance, and light-headedness
• Sensitivity to light and sound
• Other neurologic symptoms----Hemiparesis (this symptom
defines hemiplegic migraine),Aphasia,Confusion,Paresthesias
or numbness
34. There are four possible phases to a migraine---
• The prodrome, which occurs hours or days before the headache---
including
altered mood,irritability, depression or euphoria, fatigue, craving
for certain food, stiff muscles (especially in the neck), constipation
or diarrhea, and sensitivity to smells or noise
• The aura, which immediately precedes the headache, and
generally last less than 60 minutes---- Symptoms can be
visual(scintillating scotoma ),sensory(pins-and-needles
,numbness ,loss of position sense),speech or language
disturbances, motor (weakness)
• The pain phase, also known as headache phase
• The postdrome --the effects of migraine may persist for some days
after the main headache has ended;(impaired thinking,sore feeling
,GI symptoms,mood changes,weakness etc)
36. Diagnostic Criteria for Migraine without aura
A. At least five attacks fulfilling criteria B through D
B. Headache lasting 4 to 72 hours (untreated or unsuccessfully treated)
C. At least two of the following pain characteristics:
1. Unilateral location
2. Pulsating quality
3. Moderate or severe intensity
4. Aggravation by walking stairs or similar physical activity
D. During headache, at least one of the following:
1. Nausea and/or vomiting
2. Photophobia and phonophobia
E.Not attributed to another disorder
38. Diagnostic Criteria for Migraine with aura
A. At least two attacks fulfilling criteria B and C
B. One or more of the following fully reversible aura symptoms:
1. visual
2. sensory
3. speech and/or language
4. motor
5. brainstem
6. retinal
C. At least two of the following four characteristics:
1. at least one aura symptom spreads gradually over 5 minutes, and/or two or
more symptoms occur in succession
2. each individual aura symptom lasts 5-60 minutes
3. at least one aura symptom is unilateral
4. the aura is accompanied, or followed within 60 minutes, by headache
D. Not attributed to another disorder and transient ischaemic attack has been
excluded.
39. Migraine –differential diagnosis
Other conditions that can cause similar
symptoms to a migraine headache include
• temporal arteritis
• cluster headaches
• acute glaucoma
• meningitis
• subarachnoid hemorrhage
41. Migraine-Treatment
• Metoclopramide(IV or oral) (5HT3-receptor antagonist and a
dopamine antagonist,prokinetic antiemetic)---enhances the
analgesic effect with NSAIDS
• Prochlorperazine(iv or oral)-- dopamine antagonists ---antiemetic
and anticholinergic action
NOTE: -The use of abortive medications must be limited to 2-3 days
a week to prevent development of a rebound headache
phenomenon.
-5-HT 1B/1D agonists are contraindicated in individuals with
a history of cardiovascular and cerebrovascular disease
-ergotamine appears to have a much higher incidence of
nausea than triptans, but less headache recurrence.
42. Migraine-Treatment
Prophylactic Therapy
If attacks are frequent (more than 3–4 per month),
prophylaxis should be considered
• 1 st line-Beta blockers(atenolol 50-200 mg or propranolol 80-
320 mg daily,Tricyclic antidepressants(amitryptyline),valproic
acid(enhance GABAneurotransmission),Divalproex,Topiramate
• 2 nd line-methysergide,flunarazine(calcium chanel
blocker),MAOI’s(Phenelzine), gabapentin
• Botulinum toxin A--intractable, chronic migraine
• NSAID’S like naproxen
• transcutaneous electrical nerve stimulation (TENS) device
43. Migraine-Treatment
NOTE:Status Migrainosus(an attack lasting
longer than 72 hours)---treated with
intravenous valproate or dihydroergotamine
(intravenously/subcutaneously/intramuscularl
y) for a few days.
Menstrual Migraine---perimenstrual use of
preventive agents (eg, frovatriptan),
perimenstrual estrogen supplementation with
estradiol (0.5 mg orally twice a day, or a 1-mg
transdermal patch)
44. Tension-type headache
• A tension headache is generally a diffuse, mild to moderate
pain in your head that's often described as feeling like a tight
band around your head
• Most common type of primary headache
• More common in women than men
• Tension headaches are divided into two main categories —
episodic and chronic.
Episodic tension-type headaches are defined as tension-type
headaches occurring fewer than 15 days a month, whereas
chronic tension headaches occur 15 days or more a month for
at least 6 months
45. Diagnostic Criteria for Episodic Tension-Type
Headache
A. At least 10 previous headache episodes fulfilling criteria B through D;
number of days with such headaches: less than 180 days per year
B. Headache lasting from 30 minutes to 7 days
C. At least two of the following pain characteristics:
1. Pressing or tightening quality
2. Mild or moderate intensity
3. Bilateral location
4. No aggravation by walking stairs or similar routine physical activity
D. Both of the following:
1. No nausea or vomiting
2. Photophobia and phonophobia are absent, or one but not the other is
present.
46. Tension-type headache
Signs and symptoms
• Dull, aching head pain(usually occurs in occipital and frontal
regions and then spreads to entire head)
• Sensation of tightness or pressure across your forehead or on
the sides and back of your head
• Tenderness on your scalp, neck and shoulder muscles
Other features are---
• The pain is usually mild or moderate, but it can also be
intense.
• Usually not associated with nausea,vomiting, visual
disturbances,photophobia and phonophobia(seen in rare
cases)
• Not aggravated by physical activity
• The pain is usually less severe in the early part of the day,
becoming more troublesome as the day goes on.
47. Tension-type headache
Cause
Tension headaches are caused by muscle contractions
in the head and neck regions.
Various precipitating factors may cause tension-type
headaches in susceptible individuals:
• Stress: usually occurs in the afternoon after long
stressful work hours or after an exam
• Sleep deprivation
• Uncomfortable stressful position and/or bad posture
• Irregular meal time (hunger)
• Eyestrain
• Other triggers---alcohol,smoking,cold
temperature,caffeine ,dehydration etc
48. Tension-type headache
Treatment
• Reassurance
• Avoiding triggers
• stress management techniques---regular exercise,
deep breathing techniques,biofeedback,cognitive behavioral therapy.
• Other nonmedicinal approaches---
yoga,massage,heat,ice,accupuncture(esp for chronic tension headache)
,physiotherapy(for musculoskeletal symptoms)
• Drug therapy
acute management-analgesics like
acetaminophen,aspirin,ibuprofen,naproxen etc
note: -Avoid codeine-containing preparations and other opioids
-The first-line treatment for chronic tension type headache
is amitriptyline, whereas mirtazapine and venlafaxine are second-line
treatment options.
prophylaxis—TCAs(amitriptyline),SSRIs,supplements such as riboflavin
49. Cluster headache
• Cluster headache is a rare neurological
disorder characterized by recurrent,
severe headaches on one side of the head, typically
around the eye
• men are more commonly affected than women
• Cluster headaches typically start before the age of 30
• Onset is nocturnal in about 50% of patients
50. Cluster headache
Cause
• The cause of cluster headache is unknown,but
in some cases show genetic association and
smoking as causes,another theory links to the
hypothalamus which activates the trigeminal
nerve
• The season is the most common trigger for
cluster headaches, which often occur in the
spring or autumn.
51. Cluster headache
Signs and symptoms
• Cluster headache is always unilateral, or one-sided
• The pain of a cluster headache is generally very intense and
severe and is often described as having a burning or piercing
quality
• The pain is retroorbital/periorbital. It may radiate to the
forehead, temple, nose, cheek, or upper gum on the affected
side.
• the pain of a cluster headache lasts a short time, generally 30
to 90 minutes. It may, however, last from 15 minutes to three
hours
• Most sufferers get one to three headaches per day during a
cluster period . They occur very regularly, generally at the
same time each day, hence called "alarm clock headaches
52. Cluster headache
Signs and symptoms-cont
• Cluster headache attack is accompanied by at least one of the
following autonomic symptoms: drooping eyelid, pupil
constriction, redness of the conjunctiva, tearing, runny nose,
and less commonly, facial blushing, swelling, or sweating
• Restlessness ,photophobia,phonophobia(U/L) may occur
during a CH
• Cluster headaches are typically not associated with nausea or
vomiting.
• cluster headaches occurring in two or more cluster periods,
lasting from 7 to 365 days with a pain-free remission of one
month or longer between the headache attacks, may be
classified as episodic. If headache attacks occur for more than
a year without pain-free remission of at least one month, the
condition is classified as chronic
53. Diagnostic Criteria for Cluster Headache
A. At least five attacks fulfilling criteria B through D
B. Severe unilateral orbital, supraorbital and/or temporal pain lasting 15 to
180 minutes
C. Headache associated with at least one of the following signs on the pain
side:
1. Conjunctival injection
2. Lacrimation
3. Nasal congestion
4. Rhinorrhea
5. Forehead and facial sweating
6. Miosis
7. Ptosis
8. Eyelid edema
D. Frequency of attacks: one attack every other day to eight attacks per
day
54. Cluster headache
Treatment
Acute CH
• 100% oxygen at 10–12 L/min for 15–20 min
• sumatriptan- Subcutaneous(6 mg) or intranasal
Preventive treatment
• verapamil(160-960mg/day),methysergide(1-2mg tds)
,prednisolone(60-80mg/day tapering over 21
days),topiramate,lithium(400-800mg/day)(chronic cases)
etc
Neurostimulation therapy -- deep brain
stimulation or occipital nerve stimulation
Note:analgesics have no role in treating CH
55. HeadacheHeadache
typetype
MigrainesMigraines Tension-typeTension-type ClusterCluster
LocationLocation
60-70 % unilateral Bilateral Unilateral, peri/retro-
orbital
durationduration 4-72 hrs >30 min (typically last 4-6
hrs),constant
15 min to 3 hrs,repetitive
qualityquality Throbbing, pulsating, Band-like pressure Boring, piercing
Severity andSeverity and
onsetonset
Moderate to severe,gradual
onset
Dull ache may wax/wane,
usually mild or moderate, but
it can also be intense.
Excruciating pain,rapid
onset
PatientPatient
appearanceappearance
Resting in quite dark
room,young female
Remains active or prefers to
rest
Remains active,prefers hot
showers,male,smoker
AssociatedAssociated
featuresfeatures
N/V, photo/phono/,
scotoma, neurologic deficits
Generally none Ipsilateral conjunctival
injection, lacrimation,
nasal congestion,
rhinorrhea, miosis, facial
sweating
TreatmentTreatment Acute – Analgesics,NSAIDs,acetamino Acute –
56.
57. Temporal arteritis
• Giant-cell arteritis (GCA or temporal arteritis or cranial
arteritis) or Horton disease is an inflammatory disease
of blood vessels most commonly involving large and
medium arteries of the head,
• The mean age of onset is >55 years
• SSx:-A persistent ,severe,U/L,throbbing headache with
fever,weight loss,jaw claudication,visual disturbances and
proximal myalgias ,may be accompanied by scalp tenderness.
• Dx: -physical exam-Palpation of the head reveals
prominent temporal arteries with or without
pulsation,the temporal area may be tender ,decreased pulses
may be found throughout the body,evidence of ischemia may
be noted on fundal exam
-lab:raised ALP,ESR,CRP,
-confirmed by temporal artery biopsy,USG
59. Trigeminal neuralgia
• TN( tic douloureux)is a neuropathic chronic pain disorder affecting
the trigeminal nerve ( fifth cranial nerve)
• TN symptoms usually appear in individuals over 50 years old
• Women>men
• Cause:-most cases are due to compression of trigeminal nerve root
by abberant loop of artery or vein- focal trigeminal nerve
demyelination
• other causes are- pontine infarct ,arteriovenous
malformation,MS,tomors such as acoustic neuroma,chronic
meningeal inflammation etc
signs and symptoms:-
• sudden,usually unilateral,severe,brief,stabbing,lancinating,recurring
pain in the distribution of one or more branches of the 5 th cranial
nerve
60. • Each individual attack usually lasts from a few seconds to
several minutes or hours
• Pain may be initiated by stimulation of trigger points
Treatment
• carbamazepine is the first line treatment
• second line medications include
baclofen, lamotrigine, oxcarbazepine, phenytoin, gabapenti
n and pregabalin.
• Percutaneous procedures (eg, percutaneous retrogasserian
glycerol rhizotomy)
• Surgery (eg, microvascular decompression)
• Radiation therapy (ie, gamma knife surgery)
