Medical causes of headache

Headache - Epidemiology

Most frequent presenting symptom - outpatient clinic

1-2.5% of emergency visits

>95% of population experience atleast one episode during

lifetime

-Primary care physicians to speciality doctors

one of the top ten complaints in any speciality

Longest list of differential diagnosis in medicine

Underestimating headache to over investigating headache

remains a concern….
Classification of headache
International Classification Of Headache Disorders
ICHD (revised in 2004 )

1.Primary
2.Secondary

The primary headaches( no identifiable cause)

1.Migraine
2.Tension-type headache
3.Cluster headache and other
4.Trigeminal-autonomic cephalalgias
5.Other primary headache disorders
Other primary headache disorders

Primary stabbing headache

Primary cough headache
Primary exertional headache
Primary headache associated with sexual
activity
Primary thunderclap headache
Hemicrania continua
New daily persistent headache
Diagnostic criteria for migraine
At least 5 attack f ulfilling criteria
Headache attacks lasting 4-72 hours (untreated or
unsuccessfully treated)

Headache has at least two of the following characteristics:

unilateral location
pulsating quality
moderate or severe pain intensity
aggravation by routine physical activity (eg,
walking or climbing stairs)
During headache at least one of the following:
nausea and/or vomiting
photophobia and phonophobia
Not attributed to another disorder
Treatment Acute ergotamine, sumatriptan
Prophylaxis verapamil, propanalol
Tension headache

1.Episodic
2.Chronic

Episodic 1.Frequent
2.Infrequent

Bilateral, non throbbing

Non pulsatile
Band like
Treatment Acetaminophen, relaxation
therapy
Cluster headache

1.Common in males 7 : 1 ratio

2.Occurs in specific time period of a day,
daily, specific month of year
3.Associated with lacrimation, conjuctival
injection, autonomic disturbance
4.Usually retro orbital, supra orbital
5.Treatment with steroids, verapamil

SUNCT Sudden Unilateral Neuralgiaform

heaache with Conjectival injection and
Tearing
The secondary headaches( with identifiable cause)

Headache attributed to head trauma and or neck trauma

Headache attributed to non-vascular, non-infectious, intracranial disorder
Headache attributed to substances or their withdrawal
Headache attributed to infection
Headache attributed to disturbance of homoeostasis
Headache or facial pain attributed to disorder of cranium, neck, eyes, ears,
nose, sinuses, teeth, mouth, or other facial or cranial structures.
Headache attributed to psychiatric neuralgias, and central causes of facial
pain disorder
Headache associated with metabolic disorders
Trigeminal, glossopharyngeal neuralgia
Theories of headache

1.Vasogenic
Intracranial vasoconstiction followed by
rebound vasodilatation

2. Neurogenic
brain is the centre point of headache

3.Others
Stimulation of trigeminovascular fibres
around the pial vessels
Emotional triggers modulate activity of
vessels near meninges…..
Cardiological conditions
Others
1.Nitrate related 1.Anaemia
2.Hypertension 2.Hypoxia
3.Hypercapnia
Nephrology related
4.Sleep apnea
1.Acute glomerulonephritis
2.Pyelonephritis 5.Hypothyroidism
3.Dialysis related

Rheumatological conditions
1.Temporal arteritis
2.SLE
3.Antiphospholipid antibody
syndrome
Headache in women

1.Migraine
2.Tension headache
3.Pregnancy related 1.Pre eclampsia
2. Pituitary
apoplexy

Headache in elderly

1.Temporal arteritis
2.Mass lesions
3.Hypertension, SAH
4.Glaucoma
Acute severe new- onset headache (first
or worst)

Crash migraine
Cluster headache
Systemic lupus erythematosus
Temporal arteritis
Accelerated hypertension
Phaeochromocytoma
Acute intoxications
Acute febrile illness
Acute pyelonephritis
Acute mountain sickness
Gold standard in the management of headache

Good clinical history and

general and neurological examination”
including fundoscopy

When and Who to investigate?????

Red flag signs

Head or neck injury

New onset of headache first/ worst ever
headache
Onset of new headache type,
Change for worse in pattern of existing
headache.
Progressively worsening headache
Age > 50 years
Neurological signs or symptoms
Systemic signs or symptoms
Secondary risk factors such as a history of
cancer or human immunodeficiency virus
infection
Yellow flags

Wakes patient from sleep at night

Headache always occurs on the same side
Prominent effect of change in posture on pain
All primary headache blood investigations are normal

Reasons to consider blood tests to evaluate headaches

Inflammatory disease
Infectious disease
Prolactin level
Complete haemogram
TSH, serum calcium
BUN,Creatinine
When to consider neuroimaging

Temporal profile and headache features:

1. The first or worst headache (thunderclap
headache)
2. Subacute headache with increasing frequency
or severity
3. Progressive or new daily persistent headache
4. Chronic daily headache
5. Side-locked
6. Headache not responding to treatment

Demographics:
1. New headache in patient with cancer or HIV
2. New headache age > 50
3. Headache and seizures

Associated symptoms and signs:

1. Fever, stiff neck, nausea and vomiting
2. Focal neurological symptoms or signs
3. Papilledema, cognitive impairment or
personality change
MOST IMPORTANT INDICATION IS……………….

REASSURANCE , REASSURANCE, REASSURANCE

Carry home message

1.Spare time on history

it solves the puzzle
2.Ascertain whether its primary or secondary
3.Investigate as and when needed…
Nothing routine here
4.Never miss a red flag/ yellow flag sign…..