Headache is a common pain problem that can have various causes. The document discusses the main types of headaches including those due to vasodilation, traction, inflammation, muscle spasm, referred pain, and psychogenic factors. It then focuses on migraine headaches, providing details on characteristics, pathogenesis, diagnostic criteria, treatment and variants. Tension-type headaches and cluster headaches are also summarized, with the key points being their recurrent but mild-moderate pain, and the severe unilateral pain of cluster headaches that occurs in bouts. A headache diary and red flag signs are important for properly evaluating the type and cause of a patient's headaches.

2. • Headache or Cephalalgia is “a diffuse pain in various parts of the head,not confined
to the distribution of any nerve”.
• Headache is the most common pain problems encountered in family practice.
• Some intracranial structures have receptors for pain like major venous
sinuses,arteries round the base of the brain,the meningeal arteries,the dura of
anterior & posterior fossae and all extra cranial tissues.
• The most important mechanism underlying headache are:
1. Vasodilation
2. Traction on intracranial structures
3. Inflammation
4. Muscle spasm
5. Referred pain and
6. Psychogenic headache.

3. 1.HEADACHE DUE TO VASODILATION:
Vascular Headache
Abrupt elevation of blood pressure may cause headache.
It typically throbbing in nature.
Eg:Migraine,Chronic Hypertension
2.HEADACHE DUE TO TRACTION:
Traction on great vessels and dura athe base of the brain cause headache.
Pain is increased by sudden movement of the head.
Eg:Cerebral tumour
3.HEADACHE DUE TO INFLAMMATION:
Meningeal irritation due to Meningitis,Haemorrhage
Produces headache which is increased by head movement,coughing or straining.
Neck rigidity is an importsnt sign of meningeal inflammation.

4. 4.HEADACHE DUE TO MUSCLE SPASM:
Most common mechanism of headache.
Intensity vary from a feeling of tightness to a true aching pain.
Usually bilateral.
5.REFERRED HEADACHE:
Disease of structures in the head may cause pain referred to the cranium.
Eye disease such as glaucoma & iritis cause frontal headache.
Nasal and sinus disease cause pain in the molar,nasal and frontal areas.
Dental,aural and temporo-mandibular joint disease may cause pain spreading beyond
the primary area of pain.
6.PSYCHOGENIC HEADACHE:

5. • The International Classification Of Headache Disorders -2 (ICHD-2) was developed in
order to provide specific operational criteria for the major headache syndromes.
The three basic subtypes of headaches or facial pain in the ICHD-2 system:
Primary headache syndrome
 Migraine without aura/Migraine with aura
 Tension-type headache
 Cluster headache
 Secondary headache syndrome

6. Secondary headache syndromes:
• Headache attributed to head & neck trauma
• Headache attributed to cranial/cervical vascular disorder
• Headache attributed to non-vascular intracranial disorder
• Headache attributed to a substance or its withdrawl
• Headache attributed to infection
• Headache attributed to disorder of homeostasis,
• Headache or facial pain attributed to disorder of
cranium,neck,eyes,ears,nose,sinuses,teeth,mouth or other cranial structures
• Headache attributed to psychiatric disorder.

8. MIGRAINE:
EPIDEMIOLOGY:
• Worldwide,migraine affects nearly 15% of people.
• Rates of migraine is lower in Asia and Africa.
• Women(19%) > Men(11%). There is slight predominance in boys during pre
pubertal years.
• Commonly begin between ages 15-24,highest prevalence in ages 35-45.
• Chronic migraines in about 1.4 – 2.2 % of population.
CHARACTERISTICS:
• Unilateral, may move to the other side
• “Throbbing” ”Pulsatile” in nature.
• Lasts for 3 hours to 4 days.
• Moderate to Severe.
• Worsens with physical activity.
• Associated with Nausea ,Vomitting,Photophobia and Phonophobia.

9. AURA:
• Aura are complex neurological symptom that precede or
accompany migraine or occur in isolation.
Common types:
Visual Aura
• Photopsia/Flashing of lights
• Scotoma (came from the Greek word for darkness: skotos):
a blind spot or area of reduced vision surrounded by a
normal visual fieldPositive & Negative Scotoma
• Scintillating scotoma
• Fortification scotoma
Sensory Aura/Motor Aura

10. PHASES OF MIGRAINE:
Unlike most headahes,migraine has distinct stages,although not all sufferers experience
each one.
1. Prodrome(60%) which occurs hours or days before the headache.
2. Aura(30%) ,which immediately precedes the headache.
3. Headache(100%) or Pain Phase
4. Postdrome(70%),the effects experienced following the end of a migraine attack

12. PATHPHYSIOLOGY:
• Cortical Spreading Depression starts from Occipital lobe to forward.
• The distal Trigeminal nerve terminals initiate cascade of events by releasing
Substance P,Neurokinin A ,Calcitonin Gene-Related Peptide (CGRP) and
others(Serotonin,Glutamate ,Prostaglandins and Inflammatory cytokines) which bind
to the receptors of intracranial blood vessels causing Vasodilation & Plasma protein
extravasationSterile inflammation,HEADACHE is experienced.
• Signals reach Trigeminal Nucleus Caudalis in Brain stemThalamusSensory
Cortex.
• Sensitization of 1st order neuron is Peripheral sensitization which is the reason for
throbbing type of pain.

14. MANAGEMENT OF MIGRAINE:
Pharmacological treatments:
• Propanolol & Timolol.Adverse effects are anhedonia,lassitude and
irritability.Caution in prescribing to patients with depression.
• Divalproex sodium & Topiramate.Used as migraine prophylactic agents and in
chronic migraine.
• Amitriptyline,a TCA has strong efficacy.Side effects:Weight gain and Sedation.
• Drugs with lesser efficacy & tolerability:Other ACE,TCA,CCB,MAOI,NSAIDS

15. Acute Treatment of Migraine:
Almotriptan(12.5mg)
Eletriptan(80mg)
Frovatriptan(2.5mg)
Naratriptan(2.5mg)
Rizatriptan(10mg)
Zolmitriptan(2.5mg)
Sumatriptan(50mg)
Others:Ergot derivatives,NSAIDS,Aspirin(325mg)
Non pharmacological Treatment:
• Biofeedback
• Relaxation training
• Cognitive behavioural therapy
• Herbal treatment such as with Feverfew- Tanacetum parthenium
• Dietary supplements such as Magnesium,Vitamin D

16. MIGRAINE VARIANTS:
1.Migraine without aura or Common Migraine
2.Migraine with aura or Classic Migraine
3.Basilar Migraine:
• A less-common form of migraine syndrome with prominent brainstem symptoms
like vertigo,staggering,incoordination of the limbs,dysarthria & tingling in both
hands and feet.
4.Ophthalmoplegic & Retinal Migraine:
• Recurrent unilateral headache associated with weakness of extra ocular muscles.
• A transient 3rd nerve palsy with ptosis,with/without involvement of pupil.
• Retinal migraine is migraine with visual disturbance or even temporary blindness in
one eye.
5.Migraine in Young children:
• Child appears limp,pale and complaints of abdominal pain ,vomiting(Abdominal
migraine)
• Another variant in child is episodic vertigo & staggering followed by headache.

17. 6.Migraine followed by Head injury
7.Familial hemiplegic migraine/Sporadic hemiplegic migraine
• Mutation in two genes: CACNA1A and SCNA1.
8.Status Migrainosus:
• As many as 3 or 4 attacks may occur each week,leaving the scalp on one side
continuously tender.
• Migraine that lapses into a condition of daily or virtually severe continuous
headache.
9.Migraine with CSF Lymphocytic Pleocytosis or
Headache with Neurological Deficits and CSF Lymphocytosis (HaNDL)
• Migraine in susceptible individuals with aseptic meningitis.

18. TENSION TYPE HEADACHE (TTH)
• Common type of primary headache.
• Female > Male
• Age of onset (25 to 30 years) .The peak prevalence between ages 30 to 39 and
decreases slightly with age.
• Tension type headaches (TTH) are recurrent episodes of headache lasting from 30
minutes to 7 days.
• The pain is typically pressing or tightening in quality,non-pulsating.
• Mild to moderate intensity
• Bilateral in location
• Does not worsen with the routine physical activity.
• No associated symptoms, but photophobia or phonophobia may be present.
• Other terms such as Psychogenic headache, stress headache, psychomyogenic
headache. However, the term “tension type headache” (TTH) has been chosen by
the ICHD I in 1988 and have been retained by ICHD II in 2004 . The words “tension”
and “type” underscore its uncertain pathogenesis and indicate that some kind of
mental tension(Stress,Hunger,Sleep deprivation) may play a causative role.

19. CLUSTER HEADACHE:
• Also called as Horton’s Disease.
• Cluster refers to a “clustering in time” with the
headache bouts occurring everyday to several
times a day over a period of days to
weeks,followed by a lengthy headache-free
interval.
• Male > Female
• Unilateral,Retro-orbital in location.
• Severe.
• Lacrimation,Congestion,Rhinorrhoea,Drooping of
eyelids and agitation.
• Pain lasts for 15-180 minutes.
• If left untreated,attack frequency will range from
one to 8 attacks every 24 hours.
• Rx-Oxygen,Ergots,Triptans.

20. HEADACHE DIARY/SUBJECTIVE ASSESSMENT:
• Quality
• Frequency,Intensity,Duration,Location
• Radiation
• Onset: Gradual,Sudden(Thunderclap)
• Any associated symptoms
• Any aggrevating/relieving symptoms
• Past medical history
Systemic disease/HIV/Trauma
• Treatment history
Analgesic abuse,Recreational drugs,Birth control pills.
• Family history:
Migraine/Subarachnoid haemorrhage/Stroke
• Also ask about:
 Amount of sleep the previous night
 Emotional condition
 Food consumed in the past 24 hours
Tyramine rich food,Chocolate,Cheese,Alcohol particularly Red wine

21. RED FLAG SIGNS:
“Worst” headache ever/Thunderclap
First Severe Headache
Abnormal Neurological Examination
Fever
Vomitting that precedes headache
Pain induced by Coughing,Bending,Lifting
Pain that disturbs sleep or presents immediately upon awakening
Age > 50
Headache with local tenderness-region of temporal artery.

22. THANK YOU!