Headaches can be caused by many factors and require evaluation to determine the cause. Sudden, severe headaches require prompt evaluation to rule out serious underlying issues. Migraines typically involve throbbing pain and associated symptoms like nausea while tension headaches feel like pressure across the entire head. Treatment depends on the identified cause but may include medications, lifestyle changes, and reassurance when risks of serious conditions are low.

1. Headache
Dr. Avatar Verma
KISTMCTH
076/03/06

2. • Headache is among the most common reasons to seek medical attention, and
responsible for more disability than any other neurologic problem
• Common and causes considerable worry, but rarely represents sinister disease
• Causes may be Primary (benign) or Secondary, and most have primary
syndromes
• Tempo of evolution is critical; Sudden-onset headache, maximal immediately,
is always a ‘red flag’ and prompt rapid assessment for possible subarachnoid
hemorrhage or other sinister causes, even only 10–25% serious pathology
• Evolves over hours to days is much less likely to be sinister

3. • The tempo of evolution of headache is critical; sudden-onset headache,
maximal immediately, is always a ‘red flag’ (Box 26.11) and should
prompt rapid assessment in hospital for possible subarachnoid
hemorrhage or other sinister causes, even though only 10–25% of
patients harbor serious pathology
• Clues to other possible causes (e.g. rash in meningitis) should be sought
(p. 1201)
• Headache that evolves over hours to days is much less likely to be
sinister

8. • Establish whether the headache comes and goes, with periods of no
headache in between (usually migraine), or present almost all the time
• Associated symptoms, such as preceding visual symptoms,
nausea/vomiting or photophobia/ phonophobia, support a diagnosis of
migraine, but progressive focal symptoms or constitutional upset like
weight loss or fever, may suggest a more sinister cause (e.g. cancer or
meningitis)
• Migraine patients typically retire to bed to sleep in a dark room, whereas
cluster headache often agitated and restless

9. • Headaches present for months or years are almost never sinister (although
paradoxically worry patients), whereas new-onset especially in elderly, more of
concern
• Over 60 years pain localised to one or both temples, temporal arteritis should be
considered, especially if temporal pulses are absent and/or arteries are enlarged and
tender
• Most outpatients will have migraine (intermittent, lasting a few hours, associated with
migrainous symptoms) or chronic daily headache syndrome (often present for months
to years, without associated symptoms and refractory to analgesia)
• Easy to recognise but patients are often worried, so elicit such concerns and explain
why sinister disease is unlikely and investigation is rarely required
• Sinusitis, ‘eye strain’, food allergies and uncomplicated hypertension are never the
explanation for persistent headache

10. CLINICAL EVALUATION OF ACUTE, NEW-
ONSET HEADACHE
• New, severe headache has a differential diagnosis that is quite different from
recurrent headaches over many years
• Have probability of finding a potentially serious cause is considerably greater
• Require prompt evaluation and appropriate treatment
• Serious causes include meningitis, subarachnoid hemorrhage, epidural or
subdural hematoma, glaucoma, tumor, and purulent sinusitis

11. • Careful neurologic examination is an essential first step
• Patients with an abnormal examination or a history of recent-onset headache
should be evaluated by a computed tomography (CT) or magnetic resonance
imaging (MRI) study of the brain
• As an initial screening procedure CT and MRI methods appear to be equally
sensitive
• In some LP is also required, unless a benign etiology can be otherwise
established.

12. • Evaluation include cranial arteries by palpation; cervical spine by the
effect of passive movement of the head and by imaging;
• Investigation of cardiovascular and renal status by blood pressure
monitoring and urine examination;
• Eyes by funduscopy, intraocular pressure measurement, and refraction

13. • Psychological state should also be evaluated because a relationship exists between head
pain, depression, and anxiety
• To identify comorbidity rather than explanation for the headache, because troublesome
headache is seldom simply caused by mood change
• Medicines with antidepressant actions are also effective in the preventive treatment of
both tension-type headache and migraine, each symptom must be treated optimally
• Recurrent headache disorders may be activated by pain that follows otologic or
endodontic surgical procedures
• Treatment of the headache is largely ineffective until the cause of the primary problem
is addressed
• Brain tumor is a rare cause of headache and even less commonly a cause of severe pain

14. Tension-type headache
• Most common type and is experienced to some degree by the majority
of the population
• Pathophysiology
• Incompletely understood
• Emotions and anxiety are common precipitants and sometimes
associated depressive illness
• Anxiety about the headache itself may lead to continuation

15. • Patients often become convinced of a serious underlying condition
• Muscular spasms may worsen this in some patients

16. Clinical features
• Characterized as ‘dull’, ‘tight’ or like a ‘pressure’, and there may be
sensation of a band round the head or pressure at the vertex
• Constant and generalised, but often radiates forwards from the
occipital region
• Pain can remain unabated for weeks or months without interruption,
although the severity may vary, and there is no associated vomiting or
photophobia

17. • Activities are usually continued and pain may be less noticeable when the
patient is occupied
• Less severe in the early part of the day, becoming more troublesome as the
day goes on
• Tenderness may be present over skull vault or in occiput but easily
distinguished from the triggered pains of trigeminal neuralgia and the
exquisite tenderness of temporal arteritis
• Analgesics may be taken with chronic regularity despite little effect, and may
serve to perpetuate the symptoms

18. Management
• Provide careful assessment, followed by discussion of likely precipitants
and reassurance that the prognosis is good
• Excessive use of analgesia, particularly containing codeine, may maintain
and exacerbate the headache

19. • Physiotherapy (with muscle relaxation and stress management) may help and
low-dose amitriptyline can provide benefit
• Evidence that patients benefit from a perception that their problem has been
taken seriously and rigorously assessed
• Investigation contribute to such reassurance, especially if concerns about
underlying lesion are strong, but should understand the purpose and likely
outcome of such imaging

20. Migraine
• Usually appears before middle age; affects about 20% of females and
6% of males at some point in life
• Some assume that migraine is a term encompassing any severe
headache but has a characteristic presentation

21. Pathophysiology
• Cause is unknown but increasing evidence that aura is due to dysfunction of
ion channels causing a spreading front of cortical depolarisation (excitation)
followed by hyperpolarization (depression of activity)
• Spreads over the cortex at a rate of about 3 mm/minute, corresponding to the
aura’s symptomatic spread
• The headache phase is associated with vasodilatation of extracranial vessels
and may be relayed by hypothalamic activity

22. • Activation of the trigemino vascular system is probably important
• Genetic contribution is implied by frequently positive family history, and
similar phenomena occurring in disorders such as CADASIL
• Female preponderance and the frequency of attacks at certain points in
menstrual cycle also suggest hormonal influences
• Oestrogen-containing oral contraception sometimes exacerbates migraine, and
increases the small risk of stroke in patients who suffer from migraine with
aura
• When psychological factors contribute, attack often occurs after a period of
stress, being more likely on Friday evening at the end of the working week or
at the beginning of a holiday

23. Clinical features
• Some report a prodrome of malaise, irritability or behavioural change for some hours or days
• Around 20% experience an aura, and are said to have migraine with aura (previously known
as classical migraine)
• Aura is most often visual, consisting of fortification spectra, which are shimmering, silvery
zigzag lines that march across the visual fields for up to 40 minutes, sometimes leaving a trail
of temporary visual field loss (scotoma)
• In some sensory aura of tingling followed by numbness, spreading over 20–30 minutes, from
one part of the body to another
• Dominant hemisphere involvement may cause transient speech disturbance
• 80% with characteristic headache but no ‘aura’ are said to have migraine without aura

24. • Usually severe and throbbing, with photophobia, phonophobia and vomiting
lasting from 4 to 72 hours
• Movement makes the pain worse, and patients prefer to lie in a quiet, dark room
• Caution should be taken when limb weakness or isolated aura without headache
to migraine
• In such cases, structural disorders of the brain, or even focal epilepsy, considered
• In some aura do not resolve, leaving more permanent neurological disturbance
• This persistent migrainous aura may occur with or without evidence of brain
infarction

26. Management
• Avoidance of identified triggers or exacerbating factors (chocolate, cheese,
redwine, combined contraceptive pill) may prevent attacks
• Treatment of acute attack consists of simple analgesia with aspirin, paracetamol or
non-steroidal anti-inflammatory agents
• Nausea may require an antiemetic such as metoclopramide or domperidone
• Severe attacks can be aborted by one of the increasing number of ‘triptans’ (e.g.
sumatriptan), which are potent 5-hydroxytryptamine (5-HT) agonists
• These can be administered orally, by subcutaneous injection or by nasal spray

27. • Avoid accelerating use
• Overuse of analgesia, including triptans, contribute to medication
overuse headache
• If frequent (more than 3–4 per month), prophylaxis considered
• Vasoactive drugs (calcium channel blockers and β-adrenoceptor
antagonists (β-blockers)), antidepressants (amitriptyline, dosulepin) and
anti-epileptic drugs (valproate, topiramate)
• Women with aura should avoid oestrogen treatment for either oral
contraception or hormone replacement, although the increased risk of
ischaemic stroke is minimal

28. Medication overuse headache
• With increasing availability of over-the-counter medication, headache
syndromes perpetuated by analgesia intake are becoming common
• Can complicate any other headache syndrome, especially associated
with migraine and tension headache
• Most common culprits are compound analgesia (particularly codeine
and other opiate-containing preparations) and triptans, and MOH is
usually associated with use on more than 10–15 days per month

29. Management
• Withdrawal of responsible analgesics
• Migraine prophylactics may be helpful in reducing the rebound
headaches
• In severe cases, hospital admission with or without a course of
corticosteroids may be helpful

30. Cluster headache
• Cluster headaches (also known as migrainous neuralgia) are much less
common than migraine
• 5 : 1 male predominance and onset is usually in the third decade

31. Pathophysiology
• Cause unknown, but differs from migraine in its character, lack of
genetic predisposition, lack of provoking dietary factors, opposing
gender imbalance and different drug effect
• Functional imaging studies have suggested abnormal hypothalamic
activity
• Patients are more often smokers with a higher than average alcohol
consumption

32. Clinical features
• Cluster headache is strikingly periodic, featuring runs of identical
headaches beginning at the same hour for weeks at a time (the
eponymous ‘cluster’)
• Patients may experience either one or several attacks within a 24-hour
period
• Severe, unilateral periorbital pain with autonomic features, such as
unilateral lacrimation, nasal congestion and conjunctival injection
(occasionally with the other features of Horner’s syndrome)

33. • Severe, is characteristically brief (30–90 minutes)
• Patients are often highly agitated during the headache phase
• Cluster period is typically a few weeks, followed by remission for
months to years, but a small proportion do not experience remission

34. Management
• Acute attacks: Subcutaneous injections of sumatriptan or inhalation of
100% oxygen
• Brevity of the attack probably prevents other migraine therapies from being
effective
• Migraine prophylaxis is often ineffective too but can be prevented in some
by sodium valproate, verapamil, methysergide or short courses of oral
corticosteroids
• Severe debilitating clusters can be helped with lithium therapy, although
this requires monitoring

35. Headaches associated with
specific activities
• These usually affect men in their thirties and forties
• Patients develop a sudden, severe headache with exertion, including sexual
activity
• Usually no vomiting and no neck stiffness, and the headache lasts less than
10–15 minutes, though a less severe dullness may persist for some hours
• Subarachnoid haemorrhage needs to be excluded by CT and/or CSF
examination after a first event

36. • The pathogenesis of these headaches is unknown
• Although frightening, attacks are usually brief and patients may only
need reassurance and simple analgesia for the residual headache
• The syndrome may recur, and prevention may be necessary with
propranolol or indomethacin

37. Other headache syndromes
• A number of rare headache syndromes produce pains about the eye
similar to cluster headaches
• These include chronic paroxysmal hemicrania and SUNCT (short-
lasting unilateral neuralgiform headaches with conjunctival injection
and tearing)
• The recognition of these syndromes is useful since they often respond
to specific treatments such as indomethacin.