2. Objectives
• Proper diagnosis of headache
• Understanding different types of headache in terms
of Ayurveda
• Red flags identification & prompt evaluation
• Utilizing potentials of AYUSH systems in the
management of headache at different stages
3. Headache
• Most common, yet the most difficult clinical problem
encountered by the physician.
• Pain anywhere in the head, usually confined to cranial vault
• Includes head pain & facial pain
• History is the only clinical guide for diagnosis and further
management
• 3rd highest cause worldwide of years lost due to disability
(YLD)
9. Tension-type headache (TTH)
• Chronic head pain syndrome characterized by
bilateral, tight bandlike discomfort
• Gradual onset, Mild to moderate intensity, lasting
minutes to days
• Episodic or chronic (present >15days/month)
• Pain does not worsen with routine physical activity
• Not asso. With nausea, but photophobia or
phonophobia may be present
10. Migraine
• 6th highest cause of YLD
• Afflicts 10-15% of general population
• 15% of women , 6% of men
• Usual age of onset : 15-35 years
• Mostly affected in the age group of 25-45 years
• About 70% have a positive family history in a first-
degree relative
• Unknown mode of genetic transmission
16. Migraine with aura
Typical Aura
• Fully reversible visual,
sensory, speech/
language symptoms;
• No motor, brainstem or
retinal symptoms
Brainstem Aura
• Fully reversible brainstem
symptoms: dysarthria,
vertigo, tinnitus, hypacusis,
diplopia, ataxia not
attributable to sensory
deficit, decreased level of
consciousness (GCS < 13);
• No motor, or retinal
symptoms
17. Migraine with aura
Hemiplegic migraine
• Fully reversible motor
weakness & visual,
sensory and/or
speech/language
symptoms
Retinal Migraine
• Fully reversible mono
ocular positive and/or
negative visual
phenomenon
(scintillations, scotomata,
blindness) confirmed
during an attack by visual
field examination or
patient’s drawing
18.
19. Migraine in women
• 2-3 times more common
• 14% of women experience migraine associated with
periods (usually during first 3 days)
• Risk of migraine increased 10 times in women on OCP
• OCP increase frequency of migraines
• Almost half women experience improvement in migraine
during pregnancy
• Frequency decreases in 2/3 women after menopause
20.
21. Abdominal Migraine
• Childhood periodic syndrome
• Attacks of abdominal pain
Lasting 1-72 hours
Midline location, peri umbilical or poorly
localised
Dull ache with moderate or severe intensity
May be asso. With anorexia, nausea,
vomiting, pallor
28. Secondary causes for sudden onset severe
headache
First presentation of any sudden onset severe headache should be vigorously
investigated with neuro imaging (CT, MRI, MRA) & CSF examination (LP)
29. Hypnic headache
• Developing only during sleep, and causing wakening
• Lasting ≥15 min and for up to 4 h after waking
• No cranial autonomic symptoms or restlessness
• Moderately severe & generalised
• Mostly, patients are female & onset after age 60
• Rule out poorly controlled hypertension
30. New daily persistent headache (NDPH)
Primary
• In both males &
females
• Migrainous or tension
type headache
Secondary
• SAH
• Low CSF volume
• Raised CSF pressure
• Post traumatic
• Chronic meningitis
32. • Trauma or injury to the head and/or neck
• Cranial/cervical vascular
disorder
• Non-vascular intracranial disorder
• Substance abuse or its withdrawal
• Infection
• Disorder of homeostasis
• Disorder of the cranium, neck, eyes, ears,
nose, sinuses, teeth, mouth, TMJ or other
facial or cervical structure
• Psychiatric disorder
35. Trigerminal Neuralgia
• Usually in middle or late ages
• Sudden, severe, brief paroxysms of
excruciating pain
• Lasting fraction of seconds to 2 min.
• Sec. to dental infection or fillings,
multiple sclerosis, basilar artery
aneurysm, cerebello pontine angle
tumors
38. Red Flags
• Onset > 50years
• Sudden onset
• Headaches increasing in
frequency and severity
• New-onset headache in
HIV or cancer patients
• Signs of systemic illness
• Focal neurologic signs
• Papilledema
• Subsequent to trauma
• Pain induced by
bending, lifting,
coughing
• Disturbs sleep
• Local tenderness
47. Vatika Shirashoola
• Severe pain at temporal, frontal,
orbital region
• Pulsatile
• Kandara hanu sangraha
• Tinnitus
• Photophobia
• Rhinorrhea
• Relief by Snehana, Ushna,
Svedana, massage, bandage
• Tension Headache
• Migraine
48. Ardhavabhedaka
• Hemicrania
• Self limiting
• Episodic pain, once in
15 or 30 days
• Damage to eyes, ears
• Character of pain similar
to Vatika Shirashula
• Trigerminal autonomic
cephalalgia
49. Paittika/Raktaja Shirashula
• Burning pain of head &
eyes
• Fever
• Thirst
• Sweating
• Giddiness
• Relief at night & by cold
application
• Migraine
50. Kaphaja Raktashula
• Anorexia
• Heaviness of head
• Non pulsatile
• Vomiting
• Peri-orbital edema
• Lethargy
• Severe pain at night
• Sinusitis
66. 1. A 46 years old male patient admitted with neck pain &
headache. He had undergone Pindasveda &
Shirodhara. In between, his symptoms got aggravated
& he developed fever , with temperature above 100
degree . He was referred to higher centre & was
diagnosed as Tuberculous Meningitis
67. 2. A 53 year old woman with c/o severe attacks of vertigo while she was in bed.
At the end of each attack, there was a generalised throbbing headache. She
had migraine since she was 14 years old, always associated with vertigo. In
the present episodes, Vertigo was more severe than headache. She has the
habit of skipping meals , occasionally complains of constipation. Vitals were
stable
Diagnosis : Vata paittika Shirashula
Treatment : Ashtavarga, Avipathichurna, Kalyanaka Kashaya
Nasya with Anutaila, Varanadi Ksheera Ghrita
Karnapurana with Ksheerabala
Thala with Ksheerabala & Panchagandhachurna
Kalyanaka Ghrita
68. • 3. A 62 years old male hypertensive patient complains about
severe unilateral headache involving temporal & orbital region,
at 2 pm which awakens him from sleep. Also showed nasal
congestion. Initially the treatment was done for Kaphaja
Shirashula, as the patient had reported recurrent attacks of
sinusitis. Complaints of sinusitis relieved Neurological
evaluation was carried out.
• Diagnosis – Sannipataja Shoola
• Pathyashadanga Kashaya, Manasamithra Vataka
• Snehapana with Kalyanakam ghrita
• Virechana with Gandhraveranda
• Sirodhara with Ksheerabala
• Nasya with Anutaila, ksheerabala
Editor's Notes
YLD - Global Burden of Disease Study, updated in 2013
Intracranial : arteries of circle of villis, proximal dural arteries, dural venous sinuses & veins, dura,
currently accepted that intra cranial pain sensitive structures are limited to dura matter & its feeding vessels; small cerebral vessels & pia matter are insensitive to pain. Denys Fontaine et al., 2018, brain – a journal of neurology, dural & pial pain sensitive structures in humans : new inputs from awake craniotomies – dura matter of skull base & falx cerebriare pain sensitive structures, small cerebral vessels & sulcal pia matter were sensitive to mechanical pain stimulation
Brain parenchyma – insensitive to pain
Extra- cranial
Structure of eye, ear nasal cavity, PNS
TMJ
Trigerminal , facial, glosso pharyngeal, vagus & first 3 cervical nerves
Intra – cranial
Cranial vault – skin, sub cutaneous tissue, muscles, arteries, peri osteum of skull
Venous sinuses & tributaries
Arteries before penetrating brain parenchyma
Meninges at base of brain
Secondary
Mild/life threatening
Usually non- recurrent
Underlying organic disease
Requires prompt evaluation & investigations
Primary
Benign
Recurrent
No organic disease as their cause
Often results in considerable disability, decrease in patient’s QoL
Represent 90% of the total headache
Sec. headache
Structural or metabolic abnormality / systemic illness
Mild – common, but rarely worrisome
Life threatening –relatively uncommon
SECONDARY – structural or metabolic abnormality: – Extracranial: sinusitis, otitis media, glaucoma, TMJ ds – Inracranial: SAH, vasculitis, dissection, central vein thrombosis, tumor, abscess, meningitis – Metabolic disorders: CO2 retention, CO poisoning
Simple analgesics, NSAID, TCA, amytriptiline
Tension-type headache is very common, with a lifetime prevalence in the general population between 30% and 78%.
The exact mechanisms is not known.
Peripheral pain mechanisms responsible for Infrequent and Frequent episodic tension-type headache
Central pain mechanisms-Chronic tension-type headache
Increased pericranial tenderness typically present interictally, exacerbated during actual headache and increases with the intensity and frequency of headaches.
Second most common cause of headache
6th highest cause of YLD
Benign & recurring syndrome ass. with neurologic dysfunctions
Usually not asso. With serious or life threatening illnesses
Afflicts 10-15% of general population
15% of women , 6% of men
Usual age of onset : 15-35 years
Mostly affected in the age group of 25-45 years
About 70% have a positive family history in a first-degree relative
Unknown mode of genetic transmission
YLD - Global Burden of Disease Study, updated in 2013
It is more common in women, usually by a factor of about 2:1, because of hormonal influences.
Life threatening in women on oral estrogens or contraceptives
Brain of migraeuneur is particularly sensitive to environmental & sensory stimuli. This sensitivity is amplified in females during menstrual cycle. Headache can be initiated or amplified by triggers. Knowledge of a patient’s susceptibility to specific triggers can be useful in management strategies involving lifestyle adjustments
Usually fronto - temporal.
In children and adolescents, more often bilateral than in adults.
Migraine attacks can be associated with cranial autonomic symptoms and symptoms of cutaneous allodynia.
Migraine without aura often has a menstrual relationship.
Status migrainosus - unremitting for >72 hours, pain and/or associated symptoms are debilitating
2 Persistent aura without infarction – In migraine with aura patients, Neuroimaging demonstrates ischaemic infarction in a relevant area
3 Migrainous infarction - cerebral infarction occurring during the course of a typical attack of Migraine with aura.
4 Migraine aura-triggered seizure
Recurrent gastrointestinal disturbance
1.6.1.1 Cyclic vomiting syndrome
1.6.1.2 Abdominal migraine
1.6.2 Benign paroxysmal vertigo
1.6.3 Benign paroxysmal torticollis
MIGRAINE IN WOMEN • Migraine 2-3x more common than in men – Possibly some hormonal association • 14% of women experience migraine associated with periods – Usually during first 3 days • Risk of migraine increased 10x in women on OCP – OCP increase frequency of migraines – Almost half women experience improvement in migraine during pregnancy. – Migraine frequency decreases in 2/3 women after menopause
Short sleep very effective
Unusual for the child actually to complain of headache until about 10 years of age
Prevalence 5%
Sex ratio 1:1
Abdominal symptoms often predominant
Attacks of pallor, nausea & vomiting with occasional complaints of blurred vision
Attacks may be precipitated by exertion
Extremely brief attacks – 15 to 20 min. with sudden & complete recovery
Often respond to conservative management
Secondary SUNCT – post. Fossa or pituitary lesions – pituitary function test, brain MRI with pituitary views
SUNA
Primary cough headache
Sudden onset, lasting between 1s – 2h
Precipitated by coughing, straining, valsalva manoeuvre
Exclude chiari malformation or any lesion obstructing CSF pathways or displacing cerebral structures
Primary Exertional headache
Features of both cough headache & migraine
Precipitated by any form of exercise
Lasting for 5s – 24 h
Pulsatile, bilat., throbbing
Weight lifter’s headache
Primary Sex headache
Precipitated by sexual excitement
More often in men
Begins as a dull bilat. Headache, suddenly become intense just before or with orgasm
Can be prevented by ceasing sexual activity before orgasm
Lasting from 1m – 24 h, subside within 6 months
Primary thundercalp headache
Sudden onset of severe headache in the absence of any known provocation
(occasionally unilateral & throbbing)
Also precipitated by day naps
Trauma – onset within 7 days of trauma
Vascular- arterial/venous disorder, malformations, haemorrhage, ischemia, thrombosis, arteritis
Non vacular- malignancy, inflammations, injections, low or raised CSF pressure, epilepsy,CM
Substance – Medicine, narcotics, alcohol
Infection – intracranial, systemic
Homeostasis – hypoxia, hypercapnia, dialysis, cardiac, hypothyroidism, fasting
Gabapentine, carbamazepine
Onset > 50years (temporal arteritis, mass lesion)
Sudden onset (SAH, hemorrhage into a mass lesion/vascular malformation, mass lesion esp. posterior fossa mass)
Headaches increasing in frequency and severity (mass lesion, subdural hematoma, medication overuse)
New-onset headache in patient with risk factors for HIV infection or cancer (brain abscess, meningitis, metastasis
Signs of systemic illness (e.g. fever, stiff neck, rash indicating meningitis)
Known systemic illness (hypertension, makignancy)
Focal neurologic signs (mass lesion, vascular malformation, stroke, collagen vascular disease)
Papilledema (mass lesion, pseudotumor cerebri, meningitis)
Headache subsequent head trauma (ICH, subdural hematoma, epidural hematoma, post traumatic headache)
Pain induced by bending, lifting, coughing (intracranial hypertension, glaucoma)
Pain that disturbs sleep or presents immediately upon awakening (cluster headache)
Pain asso. With local tenderness eg. region of temporal artery (temporal arteritis)
Migraine triggers – Sannikrishta nidana
No mentioning about other nidanas of svatantra roga
V Sula Hot milk at night
Black gram, green gram with ghee
Oil with milk
Ksheerakashaya – Varanadi, Panchamula
Kashaya- Kalyanaka, Vidaryadi, Ashtavarga, Dhanadanayanadi, Pathyashadanga,
Ghrita – Kalyanaka, Pippalyadi, Vidaryadi
Pinda, Upanaha Sveda with Shashtika, goat’s meat Dashamula Ksheera Dhara, Taila Dhara, Shiro abhyanga with Asana vilvadi, Asaneladi, Balaguluchyadi
Nasya – Varanadi ksheeraghrita, Ksheerabala
Ksheeradhooma
Lepa,
Ardhavabhedaka – Avapeeda nasya followed by ghrita nasya, Pratisyaya chikitsa
Ananthavata – Suryavartha chikitsa
