This document discusses various types of headaches including migraines, tension headaches, cluster headaches, and chronic daily headaches. It provides information on the prevalence, characteristics, and potential causes of different headache types. Diagnostic tests and classifications of headaches are outlined. Treatment options are also discussed, differentiating between abortive therapies used for acute headaches and prophylactic drugs prescribed for frequent or chronic headaches.

1. Course 11- Headaches
Nelson Hendler, MD, MS
Former Assistant Professor of Neurosurgery Johns Hopkins
University School of Medicine
Past president-American Academy of Pain Management
www.DiagnoseMyPain.com
www.MarylandClinicalDiagnostics.com

2. Various Types of Headaches
• Incidence of Migraine Headache-US Armed
forces 1998-2010 (1)
• 3% of all men, 6% of all female with migraine,
• 3.9% of men, 11.3% female with some sort of
headache
• If diagnosed with migraine, then less than 1%
had other types of headaches.
• However, what is a migraine?
(1) MSMR. 2012 Feb;19(2):12-7.Outpatient encounters associated with diagnostic
codes for migraine and other types of headaches, active component service
members, 1998-2010.

3. Types of Headaches
• Most common headaches are:
• Muscle Tension Headache
• Migraine-common and classic
• Trigeminal
• Cluster
• Chronic daily headache
Robbins MS, Lipton RB. The epidemiology of primary headache disorders.Semin
Neurol. 2010 Apr;30(2):107-19.

4. Chronic Daily Headache (CDH)
• CDH occurs more than 15 days a month
• Lasts more than 4 hours a day
• If it lasts less than 4 hours a day, it is considered a
trigeminal autonomic cephalalgia (TAC).
• TACs include episodic & chronic cluster headache, episodic
& chronic paroxysmal hemicrania, SUNCT, & hypnic
headache.
• If duration is > or =4 h, then CDH & differential diagnosis is
chronic migraine, chronic tension-type headache, new daily
persistent headache and hemicrania continua.
Bigal ME, Lipton RB. The differential diagnosis of chronic daily headaches: an algorithm-based
approach, J Headache Pain. 2007 Oct;8(5):263-72.

5. Other Classifications
• Most common is muscle tension, then
migraine, with and without auras.
• 10% prevalence
• Female to male ratio of 3 to 1
• Migraine related to estrogen drop
• Cluster Headaches highest morbidity
• No basis of diagnosis…merely descriptions
Monti AA, Rapela FJ, Bacile Bacile EA, Uberti D. Primary cephaleas. A revision of their diagnosis
and therapeutic approach, Rev Fac Cien Med Univ Nac Cordoba. 2006;63(3):53-64.

6. Yet another classification
• Chronic Daily Headache (CDH) defined as headache
15 days a month, for at least 3 months, lasting more
than 4 hours. Not a diagnosis –merely a description
• CDH has 4 subtypes:
• Chronic migraine, chronic tension type headache,
new daily persistent headache and hemicrania
continua-again not diagnoses but descriptions
• Chronic migraine affects about 2% of population
• Chronic migraine sufferers are 70% more likely to
have had stroke
Lipton RB. Chronic migraine, classification, differential diagnosis, and epidemiology.
Headache. 2011 Jul-Aug;51 Suppl 2:77-83

7. Why Headaches Should Be Classified
Based On Origin
• A single symptom may have multiple origins,
such a flat tire, caused by a nail in the tread,
cut sidewall, leaky valve stem, or bad bead
• You have to know the cause in order to
properly repair the tire. This is a DIAGNOSIS
• A single cause (DIAGNOSIS) may have multiple
clinical manifestations, such as syphilis, Lyme
disease, occlusive stroke, etc.
• Defining the origin allows a doctor to treat the
causes and address multiple symptoms

8. Diagnostic Tests for Headache-I
• Headaches are one of the most common symptoms and the list
differential diagnoses has over 300 different types and causes
• The cause of most headaches can be determined by a careful history
and neurologic examination
• The yield of 3026 neuroimaging scans in the evaluation of patients
with headache and a normal neurologic examination is quite low.
• Percentages of various pathologies: brain tumors, 0.8%;
arteriovenous malformations, 0.2%; hydrocephalus, 0.3%; aneurysm,
0.1%; subdural hematoma, 0.2%; and strokes, including chronic
ischemic processes, 1.2%.
• 1440 scans of patients with migraine: brain tumor, 0.3%;
arteriovenous malformation, 0.07%; and saccular aneurysm, 0.07%.
• WMA have been reported on MRI studies of patients with all types of
migraine, with a range from 12% to 46%.
Evans RW. Diagnostic testing for the evaluation of headaches.Neurol Clin. 1996 Feb;14(1):1-26.

9. Diagnostic Tests for Headache -II
• EEG is not useful in the routine evaluation of patients with headache.
• The probability of detecting an aneurysmal hemorrhage of CT scans
performed at various intervals after the ictus is: day 1 0.95%; day 3,
74%; 1 week, 50%; 2 weeks, 30%; and 3 weeks, almost nil
• The probability of detecting xanthochromia with spectrophotometry
in the CSF at various times after a subarachnoid hemorrhage is: 12
hours, 100%; 1 week, 100%; 2 weeks, 100%; 3 weeks, more than
70%; and 4 weeks, more than 40%
• 30% to 90% of patients have various types of headaches after mild
head injury. 1% to 3% of these patients have life-threatening
pathology, including subdural and epidural hematomas, that are
detected on CT and MRI scans
• Headaches are the most common symptom of Temporal Arteritis,
reported by 60% to 90% of patients
Evans RW. Diagnostic testing for the evaluation of headaches.Neurol Clin. 1996 Feb;14(1):1-26.

10. Headache Classification- A meta analysis of all causes
Migraine –vascular origin
Stroke
Common-no aura Classic-with aura
Muscle Tension
No
secondary
vascular
entrapment
With vascular
entrapment
With Nerve entrapment
Nerve Compression
C2
Entrapment
Occipital Neuralgia
Trigeminal neuralgia
from intracranial 5th
nerve compression
Temporal Arteritis
Cluster Headache
Chemical -tyramine, caffeine, etc.
Post-concussion
Cable Frame Sunglasses Infectious
Post-herpetic trigeminal neuralgia Viral encephalitis
BRAIN TUMORS -CNS COMMPRESSION Sinus

11. Common Migraine Headache
• Outstanding research from Denmark clearly
demonstrates that intra-cranial arteries on the
side of the pain are more dilated during migraine
attack, while extra-cranial arteries are not
• This clarifies the patho-physiology of common
migraine
• Treatment can now be directed appropriately
• Amin FM, Asghar MS, Hougaard A, Hansen AE, Larsen VA, de Koning PJ, Larsson HB, Olesen J, Ashina M. Magnetic
resonance angiography of intracranial and extracranial arteries in patients with spontaneous migraine without
aura: a cross-sectional study.Lancet Neurol. 2013 May;12(5):454-61
• Need to examine the vaso-receptors on intra-cranial
vessels.

12. Common Migraine Headache
• Unilateral usually in the temple or parietal region
of the skull
• No aura associated with the headache, i.e. no
antecedent nausea, no visual flashes, no unusual
smells or tastes
• Described as sudden pain onset, which in 5 to 30
minutes which goes to a throbbing, pounding pain
• May last hours to a full day
• If more frequent than once a week, use
prophylactic treatment, less frequently, use
abortive treatments

13. Abortive Therapy for Common Migraine
• Two types of therapy for common migraine
• Abortive: used when migraines occur more
than once a week.
• Prophylactic: used when migraines occur
more frequently than once a week
• When steroids are added to standard abortive
therapy for migraine headaches, they are
effective and safe for preventing moderate or
severe headache recurrence.
Huang Y, Cai X, Song X, Tang H, Huang Y, Xie S, Hu Y. Steroids for preventing
recurrence of acute severe migraine headaches: a meta-analysis Eur J Neurol.
2013 Apr 11.

14. Abortive Therapy for Common Migraine
• Sumatriptan constricts extracerebral arteries
more than cerebral arteries, suggesting that
sumatriptan may exert its anti-migraine action
outside of the blood-brain barrier.
• Amin FM, Asghar MS, Ravneberg JW, de Koning PJ, Larsson HB, Olesen J, Ashina M, The effect of sumatriptan on
cephalic arteries: A 3T MR-angiography study in healthy volunteers. Cephalalgia. 2013 Apr 15
• Other abortive treatments are oxygen which is
minimally effective .
• Bennett MH, French C, Schnabel A, Wasiak J, Kranke P. Normobaric and hyperbaric oxygen therapy for migraine
and cluster headache.Cochrane Database Syst Rev. 2008 Jul 16;(3)
• Aspirin, caffeine, non-steroidal anti-inflamatory
drugs, & DHE 45 all have some degree of benefit
• Gilmore B, Michael M. Treatment of acute migraine headache. Am Fam Physician. 2011 Feb 1;83(3):271-80.

15. Prophylactic Therapy for Common Migraine
• If common migraine headaches occur more
than once a week, then use prophylactic drugs
• Topiramate and valproic acid, both anti-convulsants,
have been used equally effectively
to reduce the number and severity of frequent
common migraine
• Krymchantowski AV, Jevoux CC Topiramate vs divalproex sodium in the preventive treatment
of migraine: a prospective "real-world" study. Headache. 2011 Apr;51(4):554-8.
• Propranolol, a beta blocker alone or in
combination with amitryptiline, an anti-depressant
have been used successfully for a
number of years

16. Classic Migraine Headache
• This has all the features of common migraine
headache, with other added features
• Unilateral, usually in temple or parietal region
• An aura event proceeds the headache
• Auras may be flashing lights, nausea, unusual
smells or tastes,
• Headache is throbbing, pounding, associated with
photopobia (fear of light) and phonophobia (fear
of sound)
• May be relieved by vomiting, abortive medication

17. Chemically Induced Headache
• Two major types-Tyramine and Cogeners
• Tyramine is found in hotdogs, Cheddar
cheese, yogurt, beer, red wine, or aged meat,
• Congeners*, found in darker, amber liquors,
aged in wood casks, cause headaches (1)
• Wood casks have terpenes, norisoprenoids,
eugenol *aldehydes, ketones, alcohols,
phenols & esters (2).
• Avoiding the wrong food is the best approach
(1) http://headaches.about.com/od/headaches101/a/Understanding-Alcohol-Induced-Headaches.htm
(2)Maria João B. Cabrita, Raquel Garcia, Nuno Martins, Marco D.R. Gomes da Silvaand Ana M. Costa Freitas
Gas Chromatography in the Analysis of Compounds Released from Wood into Wine
http://cdn.intechopen.com

18. Mixed Muscle Tension-Vascular Headaches
• The nerves, arteries and veins pass through thick
fibrous fascia, and thick muscle tissue at the back of
the neck –see the next slide
• When a muscle goes into spasm, from stress or
injury, it gets shorted and thicker
• As the opening between the muscles is constricted,
by the thickened muscle, this compresses the vessel
which passes between, causing vessel spasm
• So the clinical presentation is a muscle spasm then
about ½ hour later, a throbbing, pounding
headache
• Treatment is muscle relaxers, not vascular drugs

19. Mixed Muscle
Tension –
Vascular
Headache-
Note how the
blood supply
passes through
layers of heavy
muscle

20. Cable Frame Sunglasses Headache
• Many types of headache are caused by
compression of either arteries or nerves (1)
• One of the easier to diagnosis is a headache at the
back of the ear,radiating up the side of the head,
into the temple
• The onset of headache is precipitated by wearing
cable frame sunglasses with a spring loaded
earpiece to grip the ears, and not fall off, such as
made by Rayban (my sunglasses of choice)
• Treatment is bending the ear pieces or padding
(1) Krymchantowski AV. Headaches due to external compression, Curr
Pain Headache Rep. 2010 Aug;14(4):321-4

21. Headache
due to
Cable
Frame
Sunglasse
scausing
compression of the
lesser and greater
auricular nerve, with
pain at the back of the
ear, and back of the
neck. Obviously,
treatment is to get a
pair of sunglasses
which do not
compress the nerve
Compression
Points

22. Occipital Neuralgia
http://www.hopkinsmedicine.org/neurology_neurosurgery/specialty_areas/headache
/conditions/occipital_neuralgia.html
• Irritation of occipital nerves anywhere along their course
can cause a shooting, zapping, electric, or tingling pain
with symptoms located on the back of the scalp (see next
slide)
• Occipital neuralgia can be diagnosed—and temporarily
treated—by an occipital nerve block
• In patients who do well with temporary “deadening” of
the nerve, a more permanent procedure includes cutting
the nerve surgically, “burning” the nerve with a radio-wave
probe, or eliminating the nerve with a small dose of
an injected toxin

23. OCCIPITAL
NEURALGIA-pain
starts at the
back of the neck at
the upper spine, and
radiates up the back
of the neck like a
stripe, usually ending
at the top of the
head.
PAIN

24. C2 Entrapment & Other Cervical Headaches
Long, DM, Davis, RF, Speed, WG, and Hendler, NH, Fusion for Occult Posttraumatic Cervical
Facet injury, Neurosurgery Quarterly, Vol.16, No. 3, pp 129-138, Sept. 2006
• Headache, at the back of the head, top of the head,
or in C2 entrapment, over the ear, radiating to the
eyebrow or the eye, is cervical in origin
• Effective diagnostic procedures were facet blocks,
root blocks, and provocative discogram
• When properly diagnosed, a posterior cervical
fusion was performed C1-C3 or C2-C4, or other
combinations
• 79% of patients had complete relief, and 14% had
satisfactory improvement

25. Cervical Facet
Blocks
confirms, on a
physiological
basis, the
cause of the
pain.
If a provocative
discogram is
also positive,
this confirms
the anatomical
picture, and a
posterior fusion
is performed
From:"Cervical Spine Trauma", Dr. John J. Carbone, M.D., Johns Hopkins
University, Presented at the Johns Hopkins Orthopaedic Review Course,
Baltimore, June, 2003. -- http://www.netorthodoc.org/1025/1025pp.pdf

26. Ice Cream Headache (Brain
Freeze) • A family favorite of mine (see next slide)
• The pain is felt in the forehead, nose, and eyes
• An ice cream headache is set-off when an unusually
cold substance, consumed rapidly, passes over the
palate and back of the throat
• Constriction or spasm of the sphenopalatine artery
is thought to be the cause
• Treatment is running your tongue rapidly, for 60
seconds, on the roof of your mouth, to warm it
http://www.hopkinsmedicine.org/neurology_neurosurgery/specialty_areas/headache/conditions/ice_crea
mEditor_headache.html
Letter to the Editor, Slurpee Headache, due to Sphenopalatine Artery Spasm, New England Journal of
Medicine

27. Hendler’s Ice Cream- The largest selling ice cream in the State of
Maryland, from 1905 until 1970. Hendler’s Ice Cream was sold to
Borden’s Ice Cream

28. Symptoms of Cluster Headache
• excruciating severe stabbing and boring one sided
pain located in the temple and the orbit
• The attacks can be associated with conjunctival
injection and restlessness and migrainous features.
• The duration of attacks can be 30 minutes
• The frequency can be 4 to 5 per 24 hours.
• Vital signs and physical and neurological
examination are normal
• unenhanced brain computed tomography had been
normal
Edvardsson B, Persson S.Cluster headache and parietal glioblastoma multiforme. Neurologist. 2012
Jul;18(4):206-7

29. Cluster Headache Treatment?
• The pain and autonomic symptoms of cluster
headache (CH) result from activation of the
trigeminal parasympathetic reflex, mediated
through the sphenopalatine ganglion (SPG)
• The efficacy of on-demand SPG stimulation for
chronic cluster headache was tested
• Pain relief was achieved in 67.1% of full stimulation-treated
attacks
• 36% had a ≥50% reduction in attack frequency
Schoenen J, Jensen RH, Lantéri-Minet M, Láinez MJ, Gaul C, Goodman AM, Caparso A, May A. Stimulation of
the sphenopalatine ganglion (SPG) for cluster headache treatment. Pathway CH-1: A randomized, sham-controlled
study. Cephalalgia. 2013 Feb 14.

30. Sinus Headaches are not Sinusitis
• Patients with sinus headaches usually complain of
pain and pressure sensation around the sinuses and
periorbital area; most are misdiagnosed with
sinusitis
• The aetiology of “sinus headache” in patients with
negative endoscopic or computed tomography (CT)
scan findings was allergic & vascular abnormalities
• Nasal obstruction, nasal discharge and sinus
sensitivity are seen in other types of headaches
Kaymakci M, Cikriklar HI, Pay G.The aetiology underlying sinus headaches. J Int Med Res. 2013
Feb;41(1):218-23.

31. Headache from Encephalitis
• Patients with viral infections of the central nervous
system (CNS) may present with a variety of
neurological symptoms, most commonly dominated
by either encephalitis or meningitis.
• The encephalitis headache is all over the head
• Often it is accompanied by a low grade fever, some
photo sensitivity, and malaise
• Sometimes features are non-specific
• A spinal tap may prove a definitive diagnostic test
Studahl M, Lindquist L, Eriksson BM, Günther G, Bengner M, Franzen-Röhl E, Fohlman J, Bergström T,
Aurelius E.Acute viral infections of the central nervous system in immunocompetent adults: diagnosis
and management. Drugs. 2013 Feb;73(2):131-58.

32. Intra-Cranial Bleed
• The old rule that the “first headache, or the worst headache”
is dangerous applies to this
• Rupture of a saccular intracranial aneurysm (SIA) causes
“thunderclap headache”
• Retrospective study of 199 consecutive patients with SIA
• During the year before rupture, 124 (62.3%) had one or more
types of headache.
• These headaches were migraine without aura (39.2%),
migraine with aura (1%), probable migraine (2%), tension-type
headache (19.6%), and cluster headache (1%)
• Only the prevalence of migraine without aura was
significantly higher in patients with SIA (OR 6.7, 95% CI 3.8-
11.9, p < 0.0001)
Lebedeva ER, Gurary NM, Sakovich VP, Olesen J. Migraine before rupture of
intracranial aneurysms, J Headache Pain. 2013 Feb 20;14(1):15

33. Headache due to Brain Tumors
• Sudden-onset headache is a common and often
alarming presentation. The location varies
• If the headache persists, then more testing is
needed –CT, MRI, MRA, EEG and PET
• A small proportion may be indicative of a
catastrophic etiology. Autopsy reports indicate:
• Vascular events 60.4% ,primary brain tumours/cysts
16.7% , and meningitis 6.25%.
• Aneurysms accounted for the majority of vascular
cases 22.9%
Lynch KM, Brett F.Headaches that kill: a retrospective study of incidence, etiology and clinical features in
cases of sudden death. Cephalalgia. 2012 Oct;32(13):972-8.

34. Temporal Arteritis (Giant Cell Arteritis)
• Polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) are inflammatory
diseases affecting white individuals >50 years & women 2-3 times more than men.
• PMR and GCA occur together more frequently than expected by chance.
• GCA is a large-vessel and medium-vessel arteritis predominantly involving the
branches of the aortic arch.
• Clinical manifestations of GCA may be a new headache, palpable tender vessel on
the side of the pain, jaw claudication and visual loss.
• GCA usually remit within 6 months to 2 years from disease onset. Some patients,
however, have a relapsing course and might require long-standing treatment.
• Diagnosis of GCA is based on clinical features & elevated levels of inflammatory
markers such as sed rate but check C3, C4, Rheumatoid factor, SSA, SSB,
• Temporal artery biopsy remains the gold standard to support the diagnosis of GCA;
• Imaging studies are useful to delineate large-vessel involvement in GCA.
• Glucocorticoids remain the cornerstone of treatment, but patients with GCA
require high doses. Treatment is urgent to avoid blindness
• Synthetic immunosuppressive drugs also have a role in disease management
Salvarani C, Pipitone N, Versari A, Hunder GG. Clinical features of polymyalgia rheumatica and
giant cell arteritis, Nat Rev Rheumatol. 2012 Sep;8(9):509-21.

35. Post-Concussion Headache
• Incidence of approximately 3.8 million sports-related
concussions per year
• The presence of new onset or persistent headache
following injury often complicates return to play
decisions.
• Now evident that recurrent head trauma may be
associated with the development of some chronic
neurodegenerative disorders.
• Improved prevention and management of this
injury will occur with ongoing educational and
research efforts.
Seifert TD. Sports concussion and associated post-traumatic headache.Headache. 2013 May;53(5):726-36