Headache is a common condition encountered by clinicians in general practice and primary care on a daily basis. Although most headaches are mild, some can be severe and debilitating. It is therefore crucial to recognize common symptoms, identify warning signs, and develop an appropriate management plan for headaches.

1. HEADACHES
A PRESENTATION BY DR KEMI DELE-IJAGBULU
DECEMBER 2023

2. WHAT ARE HEADACHES
A headache is the sensation of pain in the head or face that’s often described
as a pressure that’s throbbing, constant, sharp or dull.
Headaches are a common presentation in any primary healthcare clinic.
They’re the most common form of pain and everyone will experience some
form of headaches at some point in their lives.
They can be mild, severe, or even life-threatening.
Headaches also differ greatly in regard to pain type, severity, location and
frequency.

3. CLASSES OF HEADACHES
Headaches are classified as primary or secondary.
Primary headache
This means the headache itself IS the medical problem
However, it may be triggered or exaggerated by many other factors, such as
muscle tension, stress, exposure to certain foods, medications, dehydration,
hormone changes or even genetic predisposition.
Secondary headache
This headache is related to an underlying medical condition or trauma.
An example of this would be a headache due to neck injury, eye problems, jaw,
teeth or sinus infection, or following lumbar puncture/spinal anaesthesia

4. WHAT TO DO
WHEN YOU SEE
A CLIENT WITH
HEADACHES?
TWO THINGS:
Exclude the red flags
Classify and Treat accordingly
This is particularly true for clients who
visit the clinic repeatedly complaining
of headaches

5. RED FLAGS FOR
HEADACHE
Red flags including
sudden onset
high pain intensity
pattern of change of a preexisting
headach
focal neurological signs
seizure
systemic signs and
precipitation by physical activity

6. RED FLAG/CAUSES OF HEADACHES

7. INTRACRANIAL RED FLAG/CAUSES
OF HEADACHES

8. In the following slides,
we shall be considering
a few specific examples
or types of primary and
secondary headaches.

9. TYPES OF
HEADACHES

10. Primary headaches typically are not dangerous, however, they can be very
painful, constantly dull-aching or throbbing, and disrupt your day-to-day life.
Types of primary headaches include:
Tension-type headaches (most common
type of headache).
Migraine headaches.
Cluster headaches.
PRIMARY HEADACHES

11. Primary headaches can be triggered by lifestyle factors or situations such as
Alcohol, particularly red wine.
Certain foods, eg processed meats that contain nitrates (food-triggered
headaches).
Consuming nicotine (nicotine headache).
Physical activity, such as exercise (exertion headaches).
Skipped meals (hunger headache).
Changes in sleep or lack of sleep.
Poor posture.
Valsalva motions such as coughing, sneezing, blowing your nose, straining when
having a bowel movement, or laughing or crying vigorously (primary cough
headaches)
PRIMARY HEADACHES

12. Tension-Type Headache
Tension headaches are the most common type of headache.
Stress and muscle tension are often factors in these headaches.
These headaches may feel like pressure on the forehead and temples.
Tension headaches typically cause a steady ache, rather than a throbbing
one, and tend to affect both sides of the head.
Typically, they do not cause nausea, vomiting, or sensitivity to light.
Treatment is by the step-ladder pain management - plain analgesic first,
then NSAID, then mild opioid, then stronger opioid, and others such as
anxiolytics, and antiepileptic medications.
PRIMARY HEADACHES

13. Cluster Headache
Cluster headaches are sudden, excruciating headaches that usually affect
one side of the head and the area around the eyes.
These headaches occur in patterns or clusters - They have bouts of frequent
attacks, known as cluster periods which may last from weeks to months, then
followed by long periods of relief (remission).
Associated with ipsilateral red eye, tearing, rhinorrhoea, ptosis, & eye swelling
It mostly affect young people about 20-40 years olds.
Treatments include avoiding triggers, using abortive treatments (eg, oxygen,
“triptans”) and preventive agents (eg, verapamil, CGRP). Newer treatment
include electrical stimulation/pulses at the back of the neck.
PRIMARY HEADACHES

14. Migraine
A migraine is more than a headache – it is a neurological disease.
Migraine is a type of headache characterized by recurrent attacks of
moderate to severe throbbing and pulsating pain on one side of the head
Migraine headaches are sometimes preceded by warning symptoms.
Triggers include hormonal changes, certain food and drink, stress and
exercise. They are often accompanied by symptoms such as nausea,
vomiting, sensitivity to light and/or sound.
A third of patients have migraine aura that may cause them to see: flashing
or shimmering lights, zigzag lines, stars, blind spots, etc
PRIMARY HEADACHES

16. Thunderclap headache
This is headache that strikes suddenly like a clap of thunder. It is a severe
headache that comes on rapidly, reaching peak intensity in under one
minute. It is rare but it often signifies a serious condition requiring immediate
medical attention. Common causes of thunderclap headaches:
blood vessel tears, ruptures, or blockages eg
subarachnoid haemorrhage
stroke
brain injury
vasculitis - inflammation of blood vessels)
reversible cerebral vasoconstriction syndrome (RCVS) etcetera
SECONDARY HEADACHES

17. Meningitis
Meningitis is an infection and inflammation of the cerebrospinal fluid and the
meninges (i.e., fluid and membranes surrounding the brain and spinal cord).
The client with meningitis typically presents with headache, fever, a stiff neck,
and photophobia. Their consciousness may be intact.
Clients with HIV infection often presents with chronic and subacute meningitis
(cryptococcal and tuberculous meningitis) or other infections - tuberculoma,
toxoplasmosis, progressive multifocal leukoencephalopathy (PML). It is helpful
to first exclude these diseases in HIV patients with ongoing headaches
SECONDARY HEADACHES

18. The CNS manifestations of HIV/AIDS (neuroAIDS) are often secondary to a
wide range of neurodegenerative, infectious, inflammatory, or neoplastic
conditions that are usually opportunistic in nature. Examples:
Toxoplasmosis (most common)
Cytomegalovirus (CMV)
Fungal infections
cryptococcosis
candida
aspergillus
Tuberculosis - tuberculous meningitis and tuberculoma
Neurosyphilis
Progressive multifocal leukoencephalopathy (PML)
Bacterial
Primary CNS lymphoma
NEURO-AIDS

19. Other common secondary headaches that are of milder consequences
include:
Sinus headaches - caused by inflammation and congestion in sinus
cavities, flu, rhinitis, ear ache/infections, and dental conditions
1.
Spinal headaches - caused by low pressure or volume of cerebrospinal
fluid, possibly the result of spontaneous cerebrospinal fluid leak, spinal tap
or spinal anesthesia. It may be associated with other complications
2.
Medication overuse headaches (caused by overuse of pain medication)
3.
Brain freeze - such as ice cream headaches or other iced deserts
4.
OTHER SECONDARY HEADACHES

20. Headache is typically not a symptom of hypertension.
Rather, they are sometimes associated symptoms - some conditions that
cause or precipitate headaches can also cause a rise in blood pressure, for
example, stress, alcohol intake.
However, in severe cases of hypertension (BPs more than 180/100) such as in
imminent eclampsia or other hypertensive crises, headache is a known
manifestation. This is due to the buildup of pressure in the intracranium
space.
Individuals with high blood pressure may have other conditions that cause or
precipitate/trigger headaches - such as stress. These conditions can at the
same time cause a rise
“HYPERTENSION” HEADACHES

21. TREATMENT OF
HEADACHES
Headaches, like any other Pain
management may be time-consuming
and tedious for the patient, and also
stressful for the clinicians who get to see
them all the time.
Ease Pressure on Your Scalp/Head
Try a Cold Pack.
Use a Heating Pad or Hot Compress.
Dim the Lights.
Try Not to Chew.
Hydrate. Drink Water. Stay Hydrated
Get Some Caffeine or Tea
Try Cognitive-Behavioural Therapy
Limit Alcohol
Get Adequate Sleep
Vitamin BCo
Practice Relaxation
Practice Yoga
Accupuncture
Take Some Ginger
Identify underlying cause

22. WHO STEPLADDER APPROACH
First Step - Mild pain:
non-opioid analgesics such as nonsteroidal anti-inflammatory
drugs (NSAIDs) or acetaminophen with or without adjuvants
Second Step - Moderate pain:
weak opioids (hydrocodone, codeine, tramadol) with or without
non-opioid analgesics and with or without adjuvants
Third Step - Severe and persistent pain:
potent opioids (morphine, methadone, fentanyl, oxycodone,
buprenorphine, tapentadol, hydromorphone, oxymorphone) with or
without non-opioid analgesics, and with or without adjuvants

24. In conclusion
Prioritise lifestyle management /modification. It
can make all the difference in the world.
Always exclude red flags in headache.
Reassure your clients if no red flags identified.
Treat secondary headaches whenever applicable.
Follow the WHO stepladder approach.
Manage mental health issues.
Headaches can become chronic and centralised.
Specific headaches require specific management,
for example, migraine.
If unsure, refer

25. THANK YOU
Presented by Dr KD Dele-Ijagbulu
kemiowonibi@gmail.com