This document provides an overview of approaches to evaluating and diagnosing headaches. It outlines the various pain-sensitive structures in the head and skull that can cause headaches, as well as common causes like muscle spasms, inflammation, increased pressure, and diseases of the ear, eye and sinuses. The assessment involves taking a detailed history and performing focused exams of extracranial structures, neurological function, and "warning signs" that necessitate further testing. Common headache types like tension, migraine, cluster and trigeminal neuralgia are described along with their typical symptoms, risk factors, treatments and prophylaxis options.

1. Approach to Headache
Who hasn’t had one?

2. Pain sensitive struc. in skull
 Skin, muscles, periosteum
 Eye, ear, paranasal sinuses
 Venous sinuses & veins
 Dura at base of skull
 Arteries in dura & pia arachnoid
 Nerves- V, IX, X, C1-3

3. Causes of headache
 Spasm/trauma/inflammation of muscles
 Distention of cranial arteries
 Traction of intracranial veins/sinuses
 Compression/traction/inflammation of nerves
 Meningeal irritation
 Increased intracranial pressure
 Diseases of eye/ear/paranasal sinuses

4. History
 Onset
 Progression
 Frequency
 Duration
 Location
 Character
 Severity
 Aura
 Eye/ear/nose symp.
 Precipitating factors
 Relieving factors
 Effective treatment
 Other medical
problems

5. Focused general examination
 Vital signs
 Extracranial structures- muscles,
arteries, paranasal sinuses
 Evidence of meningeal irritation
 Neck flexion
 Kernig sign
 Brudzinski sign

6. Focused neurological exam.
 Consciousness, coherence, orientation
 Pupils- symmetry, reactivity
 Ocular motility, visual fields, optic fundi
 Facial sensation & symmetry
 Muscle tone, strength, DTR
 Response to painful stimuli
 Plantar response
 Gait & coordination

7. Warning signs
 New or different headache
 Progressive headache
 New headache after 50
 Headache of maximum severity at onset
 Headache precipitated by Valsalva maneuver
 Associated seizures
 Associated focal neurological deficit
 Associated fever, HT, myalgia,
scalp tenderness

8. Investigations, if required
CT scan or MRI
CSF examination
Angiography

9. Tension headache
 Usually bilateral
 Over temple, cranium or back of neck
 Described as tightness or pressure
 Gradual onset & progression
 Worsens over the day
 Asso. with depression or anxiety
 Relieved with NSAIDs, TCA, anxiolytics

10. Migraine
 Periodic, hemicranial, throbbing pain
 More in young females
 Associated with nausea/vomiting
 Aura +/-
 Family history +ve in 60%
 May have neurologic symptoms/signs
 Treatment- NSAIDs &/or Triptans, opioids
 Prophylaxis- Propranolol, Amitriptyline, SSRI,
Verapamil

11. Cluster headache
 More in young men
 Episodic, onset when asleep
 Bouts lasting 4-8 weeks
 Unilateral, periorbital, constant, nonthrobbing
 Asso. with lacrimation, rhinorrhoea etc.
 Treatment- 100% oxygen, Triptans
 Prophylaxis- Lithium carbonate, Verapamil,
Valproate, Topiramate

12. Giant cell arteritis
 Elderly
 Headache, with systemic symptoms
 Tenderness over temporal artery &
scalp
 May cause loss of vision
 ESR raised
 Treatment- steroids

13. Trigeminal neuralgia
 More in women
 Episodes of unilateral sudden lancinating
facial pain
 Limited to distribution of Vth cranial n.
 Suspect multiple sclerosis in young
 Treatment- Oxcarbazepine, Carbamazepine,
Gabapentin
 Surgical exploration/ gamma radiosurgery
help in intractable cases