This document summarizes different types of headaches: - Tension headaches are the most common and cause dull, tight pressure that worsens through the day. Treatment includes amitriptyline, physiotherapy, and reassurance. - Migraines disproportionately affect women and can cause severe throbbing pain with aura, photophobia, and vomiting. Treatment includes avoiding triggers and using triptans or prophylaxis. - Medication overuse headaches result from overusing compounds like codeine or triptans more than 10-15 days per month and require medication withdrawal. - Cluster headaches cause brief but severe unilateral pain and autonomic symptoms in periodic episodes. Treatment includes sumatriptan injections or

1. Headache
Dr. Mehedi Hasan
Dept. of Medicine
Central Medical College, Comilla.

2. Headache
 Headache is common and causes
considerable worry, but rarely represents
sinister disease

3.  The causes may be divided into primary
(benign) or secondary

4. Primary and secondary
headache syndromes

5. Red flag’ symptoms in
headache
 Sudden-onset headache, maximal
immediately, is always a ‘red flag’
 Should prompt rapid assessment in hospital
for possible subarachnoid hemorrhage or
other sinister causes

6. Red flag’ symptoms in headache

7. Primary headache syndromes
 Tension-type headache
 Migraine
 Medication overuse headache
 Cluster headache
 Headaches associated with specific activities
 Other headache syndromes

8. Tension-type headache
 Most common type of headache

9. Pathophysiology
 Incompletely understood
 Emotions and anxiety are common
precipitants
 Anxiety about the headache itself may lead to
continuation of symptoms

10. Clinical features
 The pain is ‘dull’, ‘tight’ or like a ‘pressure’
 It is of constant character and generalised, but
often radiates forwards from the occipital
region.
 The pain is usually less severe in the early
part of the day, becoming more troublesome
as the day goes on
 Activities are usually continued throughout,
and the pain may be less noticeable when the
patient is occupied

11. Management
 low-dose amitriptyline is often benifitial
 Excessive use of analgesia, particularly those
containing codeine, may maintain and
exacerbate the headache
 Physiotherapy (with muscle relaxation and
stress management) may help
 Most benefit is given by providing a careful
assessment, followed by discussion of likely
precipitants and reassurance

12. Migraine
 Usually appears before middle age
 More common in females

13. Pathophysiology
 Cause of migraine is unknown
 There is increasing evidence that the aura which
occurs before the headache is due to
dysfunction of ion channels causing a spreading
front of cortical depolarisation (excitation)
followed by hyperpolarisation (depression of
activity)
 The headache phase is associated with
vasodilatation of extracranial vessels and may
be relayed by hypothalamic activity

14.  The female preponderance and the frequency
of migraine attacks at certain points in the
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

15.  When psychological factors contribute, the
migraine 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

16. Clinical features
 Prodrome of malaise, irritability or behavioral
change for some hours or days can occur
 Around 20% of patients experience an aura
 The aura is most often visual, consisting of
fortification spectra, which are shimmering,
silvery zigzag lines
 In some there is a sensory aura of tingling
followed by numbness

17.  Migraine headache is 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
 Structural disorders of the brain, or even focal
epilepsy, need to be considered during
assessment of an individual’s limb weakness
or isolated aura without headache to migraine

18. Management
 Avoidance of identified triggers or
exacerbating factors (such as the combined
contraceptive pill) may prevent attacks
 Acute attack- aspirin, paracetamol, NSAID
 Severe attacks can be aborted by one of the
increasing number of ‘triptans’ (e.g.
sumatriptan), which are potent 5-
hydroxytryptamine (5-HT) agonists

19.  If attacks are frequent (more than 3–4 per
month), prophylaxis should be considered
 Drugs used for prophylaxis- calcium channel
blockers, β-blockers, antidepressants
(amitriptyline) and anti-epileptic drugs
(valproate, topiramate)

20. Medication overuse headache
(MOH)
 Medication overuse headache (MOH) can
complicate any other headache syndrome, but
is especially associated with migraine and
tension headache
 Common culprits are compound
analgesia(particularly codeine and other
opiate-containing preparations) and triptans
 MOH is usually associated with use on more
than 10–15 days per month

21.  Management is by withdrawal of the
responsible analgesics

22. Cluster headache
 Cluster headaches is also known as
migrainous neuralgia
 There is a 5 : 1 male predominance

23. Pathophysiology
 Cause is unknown
 Functional imaging studies have suggested
abnormal hypothalamic activity

24. Clinical features
 Strikingly periodic in nature, featuring episodes
of identical headaches beginning at the same
hour for weeks at a time
 Causes severe, unilateral periorbital pain with
autonomic features, such as unilateral
lacrimation, nasal congestion and conjunctival
injection
 Pain is characteristically brief (30–90 minutes)
 The cluster period is typically a few weeks,
followed by remission for months to years

25. Management
 Acute attacks- subcutaneous injections of
sumatriptan or by inhalation of 100% oxygen
 Patients with severe debilitating clusters can
be helped with lithium therapy, although this
requires monitoring

26. 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.
 Lasts less than 10–15 minutes
 The pathogenesis of these headaches is
unknown.
 Patients only need reassurance and simple
analgesia

27. Other headache syndromes

28. Secondary headache
 May be due to structural, infective,
inflammatory or vascular conditions

29. At a glance

30. That’s all for now
Thank you