The document discusses different types of primary headaches including tension headaches, migraines, trigeminal neuralgia, and cluster headaches. Tension headaches are the most common and caused by stress or poor posture. Migraines affect more women and involve severe throbbing pain along with nausea and sensitivity to light and sound. Trigeminal neuralgia causes sharp, brief pain in the face triggered by certain activities. Cluster headaches occur in cycles with multiple headaches per day that involve eye and facial pain. The document outlines symptoms, causes, and treatment options for the different primary headache syndromes.

1. HEADACHE
Dr. Bimalesh Yadav
PRECEPTER: DR SUKDEV MANNA

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CONTENTS
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Diagnosis
PREVENTION
&TREATMENT
INTRODUCTION
TYPES
PRIMARY
HEADACHE
SYNDROMES

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INTRODUCTION
Definition : Pain or discomfort in the head , scalp , or
neck.

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CLASSIFICATION
I. PRIMARY HEADACHE
 A headache that is not caused by another
underlying disease, trauma or medical condition.

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 Intrinsic dysfunction of the nervous system
 Most patients presenting with headache have primary
headache syndromes
 Episodic headache: more common
 Chronic headache: attacks occurring more frequently
than 15 days/month for more than 6 months
Cont.

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 PRIMARY HEADACHE SYNDROMES
 Tension type headache
 Migraine
 Trigeminal Neuralgia
 Cluster headache
 Others

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 <2% of headaches in primary care offices
 Caused by exogenous disorders:
o Head trauma
o Vascular disease
o Neoplasms
o Substance abuse or withdrawal
o Infection/Inflammation
o Metabolic disorders
o others
II. SECONDARY HEADCHE

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I- TENSION TYPE
 Most common-69%
 Episodic or chronic
 Primary disorder of CNS pain
modulation
 seen equally in both sexes

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 Precipitating factors
 Stress: usually occurs in the afternoon after long stressful work
hours or after an exam
 Sleep deprivation
 Uncomfortable stressful position and/or bad posture
 Irregular meal time (hunger)
 Eyestrain
 Caffeine withdrawal
 Dehydration

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SYMPTOMS & SIGNS
 Gradual onset , radiate forward from occiput
 Bilateral, dull, tight, band like pain
 Less in morning, pain increase as day goes on
 No accompanying N,V, throbbing, sensitivity to
light, sound or movement

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 Management
 Paracetamol,Aspirin,NSAIDs
 Behavioral approach-relaxation
 Chronic-amitriptyline

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II- MIGRAINE
 2nd most common-16%
 15% women and 6% men
 Severe, episodic, unilateral,throbbing pain
 Nausea,Vomiting
 Sensitivity to light ,sound, movement
 Genetic predisposition

18. THE STAGES OF A MIGRAINE ATTACK

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PATHOPHYSIOLOGY
 Different theories suggest different causes
I. Vascular theory :
 vasoconstriction followed by vasodilation with resulting in
changes in blood flow causes the throbbing pain .
II. Second theory :
 pain results from muscular tension
III. Biochemical changes:
 changes in serotonin level

20. TRIGGERS: CHANGES IN DAILY CYCLES

21. TRIGGERS: ENVIRONMENT OR DIET

22. MENTAL TRIGGERS

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CLASSICAL MIGRAINE OR MIGRAINE WITH AURA
 Symptom Triad
 Paroxysmal headache
 nausea &/or vomiting
 aura of focal neurological events(visual) 20-25%

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AURA
 Flashing lights, silvery zigzag lines moving across visual
field over a period of 20 minutes
 Sometimes leaving a trail of temporary visual field loss
 Sometimes-Auditory ,Olfactory, gustatory hallucinations
 Sensory aura-spreading front of tingling and numbness,
from one body part to another

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COMMON MIGRAINE /MIGRAINE WITHOUT AURA
 Paroxysmal headache
 Vomiting +/-
 NO AURA

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DIAGNOSIS
 Simplified Diagnostic Criteria for MIGRAINE
At least 2 of the following + At least 1 of the following:
o Unilateral pain o Nausea/vomitting
o Throbbing pain o Photophobia and phonophobia
o Aggravation by
movement
o Moderate or severe
intensity
Harrison's Principles of Internal Medicine, 21e

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MANAGEMENT
 Non drug treatment
 Preventive therapy
 Abortive therapy

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 Non drug treatment
 Avoid headache triggers: foods, drugs, activities
 Avoid frequent abortive treatment
 Stop smoking
 Normalize sleeping and eating
 Exercise
 Relaxation and biofeedback
 Psychotherapy

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 Preventive Treatment
 Tricyclic antidepressants (first-line)
o Amitriptyline
 Beta-blockers (first-line)
o Atenolol, nadolol
 Ca++ channel blockers – less effective
o Verapamil most commonly used

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 Preventive Treatment
 Anticonvulsants (second-line; valuable)
 Valproate and topiramate are quite effective
 Gabapentin
 Lamotrigine, levetiracetam
 Pregabalin

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 Preventive Treatment
 Ergots: Rarely used for prevention
o Side effects may be problematic
o Methysergide: fibrosis (use 6 months max)
 MAOIs: Can be very effective
o Tyramine-free diet a must
o Numerous drug interactions

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 Abortive Treatment
 Simple and combined analgesics e.g NSAIDs.
 Mixed analgesics (barbiturate plus simple analgesics)
 Ergot derivatives
 Triptans
 Opioids

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 OtherAgents
 Antiemetics/Neuroleptics:
o often combined with abortive agents
o Prochlorperazine, hydroxyzine, promethazine, metoclopramide

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III- Trigeminal Neuralgia
 Lancinating pain in 2nd and 3rd divisions of
trigeminal nerve
 >50yrs
 Severe, brief ,repetitive pain causing patient to flinch
 Precipitated by touching trigger zones: washing, shaving,
eating, cold wind

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Pathophysiology
 Compression of trigeminal Nerve by aberrant
loop of cerebellar arteries as nerve enters
brainstem
 Other benign compressive lesions
 Multiple sclerosis: occurs due to plaque of
demyelination in trigeminal root entry zone

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Management
 Carbamazepine
 Intolerant-Gabapentin/Pregabalin
 Injection of alcohol into peripheral branch of nerve
 Posterior craniotomy to relieve vascular compression of
trigeminal nerve

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IV- CLUSTER HEADACHE
 Headaches occur during a short time span.
 The cluster then recurs periodically.
 A typical cluster of headaches may last 4-
8weeks with 1-2 headaches/day during the
cluster.
 Patient may be free 6months to 1year before
another cluster of headache occurs.
 Male to Female ratio 5:1

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Symptoms & Signs
 Abrupt onset of headache originating in the eye and spreading
over the temporal area.
 Pain extremely severe and last 20-60minutes
 The headache associated with
 Nasal stuffiness
 Rhinorrhoea
 Redness of the Eye
 Flush and edema of the cheek

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Management
 Acute:
 Oxygen inhalation 100%
 Triptans/ergots
 Indomethacin

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Management
 Chronic/Preventive:
 Verapamil, lithium
 Valproate, topiramate
 Prednisone burst
 Melatonin
 Ergots

44. References:
• Harrison’s principles of internal medicine( 21st
edition)
• American Migraine Foundation
• Bhupendra et al. (European Journal of Biomedical and
Pharmaceuticals Sciences)
• Murtagh’s general practice, 5th edition
• Manadhar et al. (The Journal of Headache and
PainOfficial Journal of the "European Headache
Federation“)
• UpTodate

45. Thanks