This document discusses headache disorders and their evaluation and classification. It notes that headaches are among the most common neurological disorders, affecting around 47% of adults annually. The most common types of benign headaches are migraine, tension-type, and cluster headaches. A thorough patient history is the most important part of the evaluation, to help identify headache type and risk factors for underlying conditions. Physical examination may include neurological and general examination, with attention to danger signs in the history that suggest further investigation is needed.

1. Dr PradipMate
(Masters In Pharmaceutical Medicine)

2. Introduction
 Headache disorders are among the most common disorders of the nervous system.
 It has been estimated that 47% of the adult population have headache at least once
within last year in general.
 Headache disorders are associated with
 Personal and societal burdens of pain,
 Disability,
 Damaged quality of life and financial cost.
Headache disorders Fact sheet N°277. WHO.
October 2012. http://www.who.int/mediacentre/factsheets/fs277/en/index.html .

3. Epidemiology
 As many as 90 % of all benign headaches fall under a few categories,
including
 Migraine,
 Tension-type,
 Cluster headache.
 A population-based study found that the one-year prevalence of episodic
tension-type headache was 38 %,
 Most of these people do not present to physicians for care.

4. Indian perspective
J Headache Pain (2012) 13:543–550

5. Classification : The International Classification of Headache
Disorders, 3rd edition (beta version)
Part 1: The primary headaches
• 1. Migraine
• 2. Tension-type headache
• 3. Trigeminal autonomic cephalalgias
• 4. Other primary headache disorders

6. Classification
Part 2: The secondary headaches
• 5. Headache attributed to trauma or injury to the head
and/or neck
• 6. Headache attributed to cranial or cervical vascular disorder
• 7. Headache attributed to non-vascular intracranial disorder
• 8. Headache attributed to a substance or its withdrawal
• 9. Headache attributed to infection
• 10. Headache attributed to disorder of homoeostasis

7. Classification
Part 2: The secondary headaches
• 11. Headache or facial pain attributed to disorder of the
cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or
other facial or cervical structure
• 12. Headache attributed to psychiatric disorder

8. Classification
Part 3: Painful cranial neuropathies, other facial
pains and other headaches
• 13. Painful cranial neuropathies and other facial pains
• 14. Other headache disorders

9. Evaluation of headache
History
Physical examination
• – Neurological examination
• – General physical examination
Investigations
Criteria for diagnosis of headache

10. History
Location of pain
Diffuse
focal
Constant
Spreading
Natural history of pain wave
Fluctuation, constant peak
Symptom free period
Time of day
Associated symptoms
Radiation of pain
Migration
Shifting
Secondary pain

11. History
 Severity of pain
 Characters of pain
 Throbbing
 Neuralgic
 Dull aching etc.
 Precipitating and aggravating factors
 Relieving factors & response to medications
 Other neurological & systemic symptoms

12. Physical Examination
 Systemic
 Hypertension
 Fever
 Focal mass lesion
 Bleeding tendency
 HIV
 Neurological examination
 Cranial nerves & eye ground
 Other neurological examination
 Cranial bruit
 Paracranial structures – eye, ear, nose
 Correlation of headache & physical findings

13. Characteristics of migraine, tension-type, and cluster headache
Symptom Migraine Tension-type Cluster
Location
Unilateral in 60 to 70%;
bifrontal or global in 30%
Bilateral
Always unilateral, usually
begins around the eye or
temple
Characteristics
Gradual in onset, crescendo
pattern; pulsating; moderate or
severe intensity; aggravated by
routine physical activity
Pressure or tightness which
waxes and wanes
Pain begins quickly, reaches a
crescendo within minutes; pain
is deep, continuous,
excruciating, and explosive in
quality
Patient appearance
Patient prefers to rest in a dark,
quiet room
Patient may remain active or
may need to rest
Patient remains active
Duration 4 to 72 hours Variable 30 minutes to 3 hours
Associated symptoms
Nausea, vomiting,
photophobia, phonophobia;
may have aura (usually visual,
but can involve other senses or
cause speech or motor deficits)
None Ipsilateral lacrimation and
redness of the eye; stuffy nose;
rhinorrhea; pallor; sweating;
Horner's syndrome; focal
neurologic symptoms rare;
sensitivity to alcohol
syndromes

14. Headache triggers
Diet
Alcohol
Chocolate
Aged cheeses
Monosodium glutamate
Aspartame
Caffeine
Nuts
Nitrites, Nitrates
Hormones
Menses
Ovulation
Hormone replacement (progesterone)
Sensory stimuli
Strong light
Flickering lights
Odors
Sounds, noise
Stress
Let-down periods
Times of intense activity
Loss or change (death, separation, divorce, job change)
Moving
Crisis
Changes of environment or habits
Weather
Travel (crossing time zones)
Seasons
Altitude
Schedule changes
Sleeping patterns
Dieting
Skipping meals
Irregular physical activity

15. Principles of the headache evaluation
 History —
 A systematic case history is the single most important factor in establishing a headache diagnosis and determining the
future work-up and treatment plan.
 A thorough history also helps focus the physical examination and prevent unnecessary investigation and imaging
studies
 A systematic case history should include the following:
 Age at onset
 Presence or absence of aura and prodrome
 Frequency, intensity and duration of attack
 Number of headache days per month
 Time and mode of onset
 Quality, site, and radiation of pain Zahid H Bajw. Evaluation of headache in adults. Up to Date.
Available from URL: http://www.uptodate.com/contents/evaluation-of-headache-in-adults

16. A systematic case history should include
 Associated symptoms and
abnormalities
 Family history of migraine
 Precipitating and relieving
factors
 Effect of activity on pain
 Relationship with food/alcohol
 Response to any previous
treatment
 Any recent change in vision
 Association with recent trauma
 Any recent changes in sleep,
exercise, weight, or diet
 State of general health
 Change in work or lifestyle
(disability)
 Change in method of birth
control (women)
 Possible association with
environmental factors
 Effects of menstrual cycle and
exogenous hormones (women)

17. A systematic case history should include
 A version adopted by the American Academy of Neurology includes the
following four questions:
 How often do you get severe headaches (ie, without treatment it is difficult to function)?
 How often do you get other (milder) headaches?
 How often do you take headache relievers or pain pills?
 Has there been any recent change in your headaches?
Zahid H Bajw. Evaluation of headache in adults. Up to Date.
Available from URL: http://www.uptodate.com/contents/evaluation-of-headache-in-adults

18. Danger signs on history
 Paying attention to danger signs is important since headaches may be
the presenting symptom of
 A space-occupying mass or vascular lesion
 Infection
 Metabolic disturbance
 A systemic problem.
Zahid H Bajw. Evaluation of headache in adults. Up to Date.
Available from URL: http://www.uptodate.com/contents/evaluation-of-headache-in-adults

19. Danger signs on history
 Sudden onset of headache, or severe persistent headache that reaches maximal intensity within
a few seconds or minutes after the onset of pain, warrants aggressive investigation.
 Cluster headache may sometimes be confused with a serious headache, since the pain from a
cluster headache can reach full intensity within minutes
 The absence of similar headaches in the past is another finding that suggests a possible serious
disorder. The "first" or "worst" headache of my life is a description that sometimes accompanies
an intracranial hemorrhage or central nervous system (CNS) infection
Zahid H Bajw. Evaluation of headache in adults. Up to Date.
Available from URL: http://www.uptodate.com/contents/evaluation-of-headache-in-adults

20. Danger signs on history
 A worsening pattern of headache suggests a mass lesion, subdural hematoma, or
medication overuse headache
 Fever associated with headache may be caused by intracranial, systemic, or local
infection, as well as other etiologies
 Any change in mental status, personality, or fluctuation in the level of consciousness
suggests a potentially serious abnormality.
 The rapid onset of headache with strenuous exercise, especially when minor trauma
has occurred, raises the possibility of carotid artery dissection or intracranial
hemorrhage.
Zahid H Bajw. Evaluation of headache in adults. Up to Date.
Available from URL: http://www.uptodate.com/contents/evaluation-of-headache-in-adults

21. Differential diagnosis of headache with fever
Intracranial infection
Meningitis
Bacterial
Fungal
Viral
Lymphocytic
Encephalitis
Brain abscess
Subdural empyema
Systemic infection
Bacterial infection
Viral infection
HIV/AIDS
Other systemic infection
Other causes
Familial hemiplegic migraine
Pituitary apoplexy
Rhinosinusitis
Subarachnoid hemorrhage
Malignancy of central nervous system

22. Danger signs on history
 Head pain that spreads into the lower neck and between the shoulders may indicate meningeal
irritation due to either infection or subarachnoid blood; it is not typical of a benign process.
 New headache in patients under the age of 5 or over the age of 50 may suggest underlying pathology.
 New headache type in a patient with cancer suggests metastasis.
 New headache type in a patient with Lyme disease suggests meningoencephalitis.
 New headache type in a patient with HIV suggests an opportunistic infection or tumor.
 Headache during pregnancy or postpartum suggests possible cortical vein or venous sinus
thrombosis, carotid dissection, and pituitary apoplexy
Zahid H Bajw. Evaluation of headache in adults. Up to Date.
Available from URL: http://www.uptodate.com/contents/evaluation-of-headache-in-adults

23. Physical examination
 If a complete and careful history does not point to an organic etiology,
further examination is warranted in the following areas:
 Obtain blood pressure and pulse
 Listen for bruit at neck, eyes, and head for clinical signs of arteriovenous
malformation
 Palpate the head, neck, and shoulder regions
 Check temporal and neck arteries
 Examine the spine and neck muscles
Zahid H Bajw. Evaluation of headache in adults. Up to Date.
Available from URL: http://www.uptodate.com/contents/evaluation-of-headache-in-adults

24. Physical examination
A functional neurologic examination including
• Getting up from a seated position without any support,
• Walking on tiptoes and heels,
• Cranial nerve examination
• Funduscopy and otoscopy
• Tandem gait and romberg test
• Symmetry on motor, sensory, reflex and cerebellar
(coordination) tests
Zahid H Bajw. Evaluation of headache in adults. Up to Date.
Available from URL: http://www.uptodate.com/contents/evaluation-of-headache-in-adults

25. Danger signs on examination
 Neck stiffness and especially meningismus suggests meningitis.
 Papilledema suggests the presence of an intracranial mass lesion,
benign intracranial hypertension (pseudotumor cerebri), encephalitis,
or meningitis.
 Focal neurologic signs suggest an intracranial mass lesion,
arteriovenous malformation, or collagen vascular disease
Zahid H Bajw. Evaluation of headache in adults. Up to Date.
Available from URL: http://www.uptodate.com/contents/evaluation-of-headache-in-adults

26. Indications for imaging studies
 Neuroimaging should be considered in patients with nonacute
headache and an unexplained abnormal finding on neurologic
examination.
 Evidence is insufficient to make specific recommendations in the
presence or absence of neurologic symptoms (eg, headache worsened
by Valsalva, causing awakening from sleep, new headache in older
population, or progressively worsening headache).
Zahid H Bajw. Evaluation of headache in adults. Up to Date.
Available from URL: http://www.uptodate.com/contents/evaluation-of-headache-in-adults

27. Indications for imaging studies
 Neuroimaging is usually not warranted for patients with migraine and a
normal neurologic examination,
 Data were insufficient to make a specific recommendation for patients
with tension-type headache.
 Data were insufficient to make a specific recommendation regarding the
relative sensitivity of MRI compared with CT in patients who have an
imaging study performed.

28. Indications for imaging studies
 Given the lack of definitive data, one approach is to consider
neuroimaging in the following situations :
 Recent significant change in the pattern, frequency or severity of
headaches
 Progressive worsening of headache despite appropriate therapy
 Focal neurologic signs or symptoms
 Onset of headache with exertion, cough, or sexual activity
 Orbital bruit
 Onset of headache after age 40 years
Zahid H Bajw. Evaluation of headache in adults. Up to Date.
Available from URL: http://www.uptodate.com/contents/evaluation-of-headache-in-adults

29. Indications for lumbar puncture
 Urgently indicated in patients with headache when there is clinical
suspicion of subarachnoid hemorrhage in the setting of a negative or
normal head CT scan.
 In addition, LP is indicated when there is clinical suspicion of an
infectious or inflammatory etiology of headache.
Zahid H Bajw. Evaluation of headache in adults. Up to Date.
Available from URL: http://www.uptodate.com/contents/evaluation-of-headache-in-adults

31. Etiologic classification of headache in children
Acute
Localized
Associated with URI (sinusitis, otitis media) or viral infection (influenza)
Post-traumatic
Related to oral cavity (dental abscess, TMJ dysfunction)
Brain abscess
First migraine
Generalized
Fever
Systemic infection (influenza)
Central nervous system infection (meningitis, viral encephalitis)
Hypertension, hypertensive encephalopathy
Intracranial hemorrhage
Exertional
First migraine headache
Trauma
Toxins (eg, carbon monoxide), medications (eg, amphetamines, oral
contraceptives), or illicit substances
Acute and recurrent
Migraine headache
Cluster headache
Chronic and non-progressive
Tension-type headache
Psychiatric (depression, school phobia)
Post-traumatic, postconcussive
Medication overuse
Chronic and progressive
Idiopathic intracranial hypertension
Space-occupying lesion (tumor, abscess, hemorrhage,
hydrocephalus, vascular malformation)
Post-traumatic, postconcussive

32. Important aspects of the examination of a child
with headache
Examination feature Possible significance
General appearance
Altered mental status may indicate meningitis, encephalitis, intracranial hemorrhage, elevated
intracranial pressure, hypertensive encephalopathy.
Vital signs
• Hypertension may cause headache or be a response to increased intracranial pressure
• Fever suggests infection (most commonly upper respiratory infection) but may occur with
intracranial hemorrhage or central nervous system malignancy
Head circumference Macrocephaly may indicate slowly progressive increases in intracranial pressure.
Height and weight trajectories Abnormal or altered trajectories may indicate intracranial pathology.
Auscultation of the neck, eyes, and head
Bruit may indicate arteriovenous malformation.
for bruit
Palpation of the head and neck
• Localized scalp tenderness may occur in migraine and tension-type headaches
• Scalp swelling may indicate head trauma
• Sinus tenderness may indicate sinusitis
• Temporomandibular joint (TMJ) and/or masseter tenderness suggests TMJ dysfunction
• Nuchal rigidity may indicate meningitis
• Posterior neck pain may indicate an anatomic abnormality (eg, Chiari malformation)
• Thyromegaly may indicate thyroid dysfunction

33. Important aspects of the examination of a child
with headache
Visual fields
Visual field abnormalities may indicate increased intracranial pressure and/or a space-occupying
lesion.
Funduscopy
• Papilledema may indicate increased intracranial pressure
• Retinal hemorrhages may indicate increased intracranial pressure or head trauma
Otoscopy May demonstrate otitis media; hemotympanum may indicate trauma.
Oropharynx Signs of pharyngitis? Dental decay or abscess?
Neurologic examination (see text for
details)
Abnormal neurologic examination (particularly mental status, eye movements, papilledema,
asymmetry, coordination disturbance, abnormal deep tendon reflexes) may indicate intracranial
pathology but also may occur with migraine headache.
Skin examination
Signs of neurocutaneous disorders (eg, neurofibromatosis, tuberous sclerosis complex, which are
associated with intracranial neoplasms) or trauma (bruises, abrasions, etc).
Spine
Signs of occult spinal dysraphism (eg, midline vascular of pigment changes), which may be
associated with structural abnormalities (eg, Chiari malformation).

34. Clinical features that may indicate intracranial
pathology in children with headache
Headache characteristics
Headache awakens the child or occurs upon waking
Sudden severe headache ("thunderclap" headache, "worst headache of my life")
Associated neurologic signs and symptoms (eg, persistent nausea/vomiting, altered mental status, ataxia, etc)
Headache worsened in recumbent position or by cough, micturition, or defecation
Absence of aura
Chronic progressive headache pattern
Change in quality, severity, frequency, or pattern of headache
Occipital headache
Recurrent localized headache
Lack of response to medical therapy
Headache duration of less than six months

35. Clinical features that may indicate intracranial
pathology in children with headache
Examination findings
Abnormal neurologic examination (eg, ataxia, weakness, diplopia, abnormal eye movements)
Papilledema or retinal hemorrhages
Growth abnormalities (increased head circumference, short stature or deceleration of linear growth, abnormal pubertal progression, obesity)
Nuchal rigidity
Signs of trauma
Cranial bruits
Skin lesions that suggest a neurocutaneous syndrome (neurofibromatosis, tuberous sclerosis complex)
Patient history
Risk factor for intracranial pathology (eg, sickle cell disease, immune deficiency, malignancy or history of malignancy, coagulopathy, cardiac disease with
right-to-left intracardiac shunt, head trauma, neurofibromatosis type 1, tuberous sclerosis complex)
Age <3 years
Family history
Absence of family history of migraine

36. Important components of the headache history for
children and adolescents
Historical feature Possible significance
Headache history
Age at onset
•Migraine headaches frequently begin in the first decade of life.
•Chronic nonprogressive headaches begin in adolescence.
Mode of onset
Abrupt onset of severe headache ("thunderclap headache" or "worst headache of my life") may
indicate intracranial hemorrhage.
What is the headache pattern: acute, acute recurrent,
chronic progressive, nonprogressive daily, or mixed?
Helps to determine the cause (see table "Etiology of headache").
How often does the headache occur?
•Migraines typically occur 2 to 4 times per month; almost never daily.
•Chronic nonprogressive headaches may occur 5 to 7 days per week.
•Cluster headaches typically occur 2 to 3 times per day for several months.
How long does the headache last?
•Migraines typically last 1 to 3 hours in young children and may last longer (48 to 72 hours) in
adolescents.
•The duration of tension headaches is variable; they may last all day.
•Cluster headaches usually last 5 to 15 minutes but may last for 60 minutes.
Is there an aura or prodrome?
Aura or prodrome is suggestive of migraine headaches; if the warning symptoms are focal and
repeatedly located to the same side of the body, a seizure or vascular or structural cause should
be suspected.

37. Is there an aura or prodrome?
Aura or prodrome is suggestive of migraine headaches; if the warning symptoms are focal and repeatedly
located to the same side of the body, a seizure or vascular or structural cause should be suspected.
When do the headaches occur?
•Headaches that wake the child from sleep or occur on waking may indicate increased intracranial
pressure/space-occupying lesion.
•Tension-type headaches typically occur late in the day.
What is the headache quality (throbbing/pulsating, dull aching, squeezing, etc)?
•Migraine headaches have a throbbing/pulsating quality.
•Chronic nonprogressive headaches have a squeezing pressure or tightness that waxes and wanes.
•Cluster headaches have a deep continuous pain.
Where is the pain?
•Occipital location may indicate posterior fossa neoplasms but also may occur in basilar migraine.
•Cluster headaches are usually temporal or retro-orbital.
•Localized pain may suggest a specific secondary etiology (eg, sinusitis, otitis, dental abscess).
What brings the headache on or makes it worse?
•Headache in the recumbent position or with straining/valsalva may indicate an intracranial process.
•Migraines may be triggered by certain foods, odors, bright lights, noise, lack of sleep, menses (in girls), and
strenuous activity.
•Tension-type headaches may worsen with stress, bright lights, noise, strenuous activity.
•Cluster headaches may be worsen with lying down or resting.
What makes the headache go away?
•Migraines typically respond to analgesic medications, dark, quiet room, cool compress, or sleep.
•Chronic tension-type headaches may respond to sleep (but not to analgesic medications).
Are there associated symptoms?
•Neurologic deficits (eg, ataxia, altered mental status, binocular horizontal diplopia) may indicate increased
intracranial pressure and/or a space-occupying lesion.
•Fever may indicate infection, or rarely intracranial hemorrhage.
•Stiff neck may indicate meningitis, complicated pharyngitis, or intracranial hemorrhage.
•Localized pain may indicate localized infection (eg, otitis media, pharyngitis, sinusitis, dental abscess).
•Autonomic symptoms (eg, nausea, vomiting, pallor, chills, flushing, fever, dizziness, syncope, etc) may
indicate migraine or cluster headache.
•Dizziness, numbness, and/or weakness may occur with idiopathic intracranial hypertension.
Do symptoms continue between headaches?
•Persistence of symptoms (neurologic symptoms or nausea/vomiting) between headache episodes is suggestive
of increased intracranial pressure and/or mass lesions.
•Resolution of symptoms between episodes is characteristic of migraine headaches.
Daniel J Bonthius. Approach to the child with headache. Up To Date.
Available from URL: www.uptodate.com.

38. Additional information
Past medical history
Certain underlying conditions increase the likelihood of intracranial pathology
(eg, sickle cell disease, immune deficiency, malignancy or history of malignancy,
coagulopathy, cardiac disease with right-to-left intracardiac shunt, head trauma,
neurofibromatosis type 1, tuberous sclerosis complex).
Medications and vitamins
Medications that may cause headache include oral contraceptives,
glucocorticoids, selective serotonin reuptake inhibitors, and serotonin-norepinephrine
reuptake inhibitors, among others. Medications associated with
idiopathic intracranial hypertension include growth hormone, tetracyclines,
vitamin A (in excessive doses), and withdrawal of glucocorticoids.
Recent change in weight or vision
May be associated with intracranial process (eg, pituitary tumor,
craniopharyngioma, idiopathic intracranial hypertension).
Recent changes in sleep, exercise, or diet May precipitate headaches; may be associated with mood disorder.
Change in school or home environment May be a source of psychosocial stress.
Family history of headache or neurologic disorder Migraine headaches and some tumors and vascular malformations are heritable.
What do child and parents think is causing the pain? Indicates their levels of anxiety about the headache.
Mental health history/symptoms, psychosocial stressors
Chronic nonprogressive headaches may be associated with depression or
anxiety.
Daniel J Bonthius. Approach to the child with headache. Up To Date.
Available from URL: www.uptodate.com.

39. Neuroimaging
 Neuroimaging studies (eg, computed tomography [CT] or magnetic resonance
imaging [MRI]) may detect a variety of disorders that cause secondary
headache, including:
 Congenital malformations
 Hydrocephalus
 Cranial infections and their sequelae
 Trauma and its sequelae
 Neoplasms
 Vascular disorders (such as arteriovenous malformations)
Daniel J Bonthius. Approach to the child with headache. Up To Date.
Available from URL: www.uptodate.com.

40. Neuroimaging indication in children's
 Indications for neuroimaging in children (3 to 18 years) with recurrent headaches that are not
associated with acute trauma, fever, or other obvious provocative cause may include (but are not
limited to) :
 Abnormal neurologic examination and/or seizures
 Recent onset of severe headache
 Change in type or character of headache (for children with recurrent or chronic headaches)
 Suspicion of meningitis, encephalitis, or sinusitis with intracranial extension
 Severe headache in a child with underlying disease process that predisposes to intracranial pathology
(eg, immune deficiency, sickle cell disease, neurofibromatosis, history of neoplasm, coagulopathy,
hypertension) Daniel J Bonthius. Approach to the child with headache. Up To Date.
Available from URL: www.uptodate.com.

41. Cephalagia 2004;4:1-160

42. Disorders causing secondary headache
Clinical Approach to a Patient with Headache
Gurubax Singh, Pritam Gupta, Ankur Gupta, Manoj Khanal

43. Areas of Apparent Agreement on Evidence Quality for Drugs
Rated by at Least 2 of 3 Migraine Prevention Guidelines
Headache 2012;52:930-945

44. Areas of Apparent Divergence About Evidence Quality for
Drugs Rated by at Least 2 Guidelines for Migraine Prevention
Headache 2012;52:930-945