2. To learn about the major types of
headaches
To understand the difference between
primary and secondary headaches
Be familiar with the ‘RED FLAGS’
To understand when and how to
investigate headache
2
4. Sensory stimuli from head are conveyed to
CNS via-
Trigeminal nerves- for structures above the
tentorium in the anterior and middle fossae
of the skull
C1, C2, C3 – for structures in the posterior
fossa and inferior surface of tentorium
4
5. Broadly headaches are divided primarily into
2 main types by Headache classification
committee of International Headache Society:
PRIMARY HEADACHES - Those in which
headache and its associated features are
disease in themselves
SECONDARY HEADACHES – Those that are
caused exogenously
5
6. The Primary Headaches
1. Migraine
2. Tension-type headache
3. Cluster headache and other trigeminal
autonomic cephalgias
4.Other primary headaches:-
a. Primary stabbing headache
b. Primary cough headache
c. Primary exertional headache
6
7. d. Primary headache associated with
sexual activity – Pre orgasmic
- Orgasmic
e.Hypnic headache
f. Primary thunderclap headache
g. Hemicrania continua
h. New daily persistant headache
7
9. The Secondary Headaches
Headache attributed to –
1. Head and/or neck trauma
2. Cranial or cervical vascular disorder
3. Non-vascular intracranial disorder
4. Substance or its withdrawal
5. Infection
6. Disorder of homeostasis
9
10. 7. Disorder of cranium, neck, eyes, ears,
nose, sinuses, teeth, mouth, or other facial or
cranial structures.
8. Psychiatric disorders
Cranial neuralgias, central and primary
facial pain and other headaches
10
13. RED FLAGS
1. Head or neck injury
2. New onset or new type or worsening
pattern of existing headache
3. New level of pain(e.g. worst ever)
4. Abrupt or split-second onset
5. Triggered by valsalva manouvre/cough
6. Triggered by exertion
7. Triggered by sexual activity
8. Headache during pregnancy/peurperium
13
14. 9. Age>50 yrs
10. Neurological signs/symptoms
11. Systemic illness
a. Fever
b. Nuchal rigidity
c. Weight loss
d. Scalp artery tenderness
12. Secondary risk factors
a. Cancer
b. Immunocompromised host
c. Recent travel
14
15. YELLOW FLAGS
1. Wakes patient from sleep at night
2. New onset side – locked headache
3. Postural headaches
15
16. RED FLAGS
Head or neck
injury
CONSIDERATIONS
Hemorrhage
Epidural
Subdural
Subarachnoid
Intraparenchymal
Dissection
Carotid arteries
Vertebral arteries
16
17. New onset or new
type or worsening
pattern of existing
headache
New level of pain
(e.g. “worst ever”)
Mass lesion
Subdural hematoma
Medication overuse
Meningoencephaliti
s
Subarachnoid
hemorrhage
17
18. Abrupt or split-second
onset
Intraparenchymal
hemorrhage
Bleed into a mass or AVM
Dissection
Cerebral venous thrombosis
Pituitary apoplexy
Spontaneous intracranial
hypotension
Reversible cerebral
vasoconstriction syndrome
Acute hypertensive crisis
Mass lesion esp.post fossa
Primary thunderclap
headache
18
19. Triggered by
Valsalva manouver
or cough
Triggered by
exertion
Chiari malformation
Mass lesion
Subarachnoid
hemorrhage
Dissection
Angina equivalent
Pheochromocytoma
19
20. Triggered by sexual
activity( Pre-
orgasmic,orgasmic)
Headache during
pregnancy or
puerperium
Subarachnoid
hemorrhage
Dissection
Cortical
venous/cranial
sinus thrombosis
Pituitary apoplexy
20
26. Affects 15% of the general population
Female > Males
Family History present in 70%
Pathophysiology: vascular vs neurologic
Precipitants: caffeine, chocolate, alcohol,
cheese, BCP/HRT, menses, stress
26
27. Diagnostic criteria:
1. 5 attacks in 6 months
2. Headaches lasting 4-72 h with >/= 2:
- unilateral
- pulsatile
- moderate to severe in intensity
- aggravated by activity
3. Associated with >/= 1:
- nausea/vomiting
- photophobia/phonophobia
27
33. Most common type, typically brought on by
stress, lasting 30 min to 7 d
Diagnostic Criteria >/= 2:
◦ Pressing/tightening, non-pulsating
◦ Mild-moderate
◦ Bilateral
◦ Not worsened by ADLs
◦ Photo or phonophobia (not coincident)
◦ Not associated with N/V
Treatment: reassurance, NSAIDS
33
34. Diagnostic criteria:-
A. At least 5 attacks fulfilling B-D;
B. Severe or very severe unilateral orbital, supraorbital,
and/or temporal pain lasting 15-180 min if untreated;
C. Headache is accompanied by at least 1 of the following:
1. I/L conj. Injection/lacrimation
2. I/L nasal congestion/rhinorrhoea
3. I/L forehaed and facial swelling
4. I/L eyelid edema
5. I/L miosis and/or ptosis
6. A sense of restlessness/agitation
D. Attacks have frequency from 1 every other day to 8/day
34
38. PRIMARY STABBING HEADACHE
Pain confined to head, rarely facial.
Stabbing pain lasting 1 to many sec and occuring as a single stab
or series of stabs
Recurring at intervals of hours to days
PRIMARY COUGH HEADACHE
B/L headache of sudden onset, lasting minutes, precipitated by
coughing
Prevented by avoiding coughing
Diagnosed only after structural lesions, such as posterior fossa
tumour, have been excluded by neuroimaging
38
39. HYPNIC HEADACHE
Headache of moderate to severe nature that
typically occur few hrs after going to sleep
Last from 15–30 mins
Typically generalised although may be
unilateral and can be throbbing
Falling back to sleep only to be awoken by
further attack few hrs later with upto 3
repetitions of this pattern over night
39
41. PRIMARY THUNDERCLAP
HEADACHE(TCH)
Defined as severe headache reaching maximal
intensity within seconds to a minute
Thunderclap headache is a NEUROLOGICAL
EMERGENCY
Numerous etiologies ranging from benign to
life-threatening have been reported most
notable being aneurysmal subarachnoid
hemorrhage
41
58. It is important to differentiate between Primary
and Secondary Headaches
“HISTORY” is the most important diagnostic tool
in evaluation of headache
Early recognition of RED FLAGS in a case of
headache is invaluable
Not all cases of headache require neuroimaging,
judicious use of investigations must be done
weighing their benefits and harms…
58