The document provides a comprehensive overview of headaches, categorizing them into primary and secondary types according to the International Classification of Headache Disorders. It discusses the prevalence, epidemiology, differential diagnosis, and treatment options for various headache syndromes, including migraines and tension-type headaches. Key treatment methods include both prophylactic and abortive medications, alongside non-pharmacologic interventions.

1. Headache
Dr. Dikshya Upreti
PG Resident
Department of Psychiatry
NMCTH

2. Introduction
• Headache is one of the most common complain.
• It is symptoms rather than disease.
• Headache is pain or discomfort in head, neck, scalp.

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

4. The International Classification of Headache Disorders, 3rd edition
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
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

5. The International Classification of Headache Disorders, 3rd edition
Part 3: Painful cranial neuropathies and facial pain
13. Painful cranial neuropathies and other facial pains
14. Other headache disorders

6. 1. Migraine
1.1 Migraine without aura
1.2 Migraine with aura
1.3 Chronic migraine
1.4 Complications of migraine
1.5 Probable migraine
1.6 Episodic syndromes that may be associated with migraine

7. 1.1 Migraine without aura
A. At least 5 attacks fulfilling criteria B-D
B. Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)
C. Headache has 2 of the following characteristics:
1. unilateral location
2. pulsating quality
3. moderate or severe pain intensity
4. aggravation by or causing avoidance of routine physical
activity (eg, walking, climbing stairs)
D. During headache 1 of the following:
1. nausea and/or vomiting
2. photophobia and phonophobia
E. Not better accounted for by another ICHD-3 diagnosis
* When <5 attacks but criteria B-E are met, code as 1.5.1 Probable migraine without aura.

8. 1.2 Migraine with aura
1.2.1 Migraine with typical aura
1.2.2 Migraine with brainstem aura
1.2.3 Hemiplegic migraine
1.2.4 Retinal migraine

9. 1.2 Migraine with aura
A. At least 2 attacks fulfilling criteria B and C
B. 1 of the following fully reversible aura symptoms:
1. visual
2. sensory
3. speech and/or language
4. motor
5. brainstem
6. retinal
C. 3 of the following 6 characteristics:
1. 1 aura symptom spreads gradually over ≥5 min
2. 2 symptoms occur in succession
3. each individual aura symptom lasts 5-60 min
4. 1 aura symptom is unilateral
5. 1 aura symptom is positive
6. aura accompanied, or followed in <60 min, by headache

10. Migraine with brainstem aura
1. At least two of the following fully reversible brainstem symptoms:
A. Dysarthria
B. Vertigo
C. Tinnitus
D. Hyperacusis
E. Diplopia
F. Ataxia not attributable to sensory deficit
G. Decreased level of consciousness (GCS < 13)

11. 1.3 Chronic migraine
A. Headache (TTH-like and/or migraine-like) on ≥15 d/months for >3 months
and fulfilling criteria B and C
B. In a patient who has had ≥5 attacks fulfilling criteria B-D for
1.1 Migraine without aura and/or criteria B and C for
1.2 Migraine with aura
C. On ≥8 d/months for >3 months fulfilling any of the following:
1. criteria C and D for 1.1 Migraine without aura
2. criteria B and C for 1.2 Migraine with aura
3. believed by the patient to be migraine at onset and relieved by a triptan
or ergot derivative
D. Not better accounted for by another ICHD-3 diagnosis

12. 2. Tension-type headache (TTH)
2.1 Infrequent episodic tension-type headache
2.2 Frequent episodic tension-type headache
2.3 Chronic tension-type headache
2.4 Probable tension-type headache

13. 2.1 Infrequent episodic TTH
A. At least 10 episodes of headache occurring on <1 d/month (<12 d/y) and
fulfilling criteria B-D
B. Lasting from 30 min to 7 days
C. 2 of the following 4 characteristics:
1. bilateral location
2. pressing or tightening (non-pulsating) quality
3. mild or moderate intensity
4. not aggravated by routine physical activity
D. Both of the following:
1. no nausea or vomiting
2. no more than one of photophobia or phonophobia
E. Not better accounted for by another ICHD-3 diagnosis

14. 2.2 Frequent episodic TTH
A. At least 10 episodes occurring on 1-14 d/mo for >3 mo (12 and <180
d/y) and fulfilling criteria B-D
B. Lasting from 30 min to 7 days
C. 2 of the following 4 characteristics:
1. bilateral location
2. pressing or tightening (non-pulsating) quality
3. mild or moderate intensity
4. not aggravated by routine physical activity
D. Both of the following:
1. no nausea or vomiting
2. no more than one of photophobia or phonophobia
E. Not better accounted for by another ICHD-3 diagnosis

15. 3. Trigeminal autonomic cephalalgias (TAC)
3.1 Cluster headache
3.2 Paroxysmal hemicrania
3.3 Short-lasting unilateral neuralgiform headache attacks
3.4 Hemicrania continua
3.5 Probable trigeminal autonomic cephalalgia

16. Cluster headache
A. At least 5 attacks fulfilling criteria B-D
B. Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting
15-180 min (when untreated)
C. Either or both of the following:
1. 1 of the following ipsilateral symptoms or signs:
a) conjunctival injection and/or lacrimation
b) nasal congestion and/or rhinorrhoea
c) eyelid oedema
d) forehead and facial sweating
e) miosis and/or ptosis
2. a sense of restlessness or agitation
D. Frequency from 1/2 d to 8/d for > half the time when active
E. Not better accounted for by another ICHD-3 diagnosis

17. 4. Other primary headache disorders
4.1 Primary cough headache
4.2 Primary exercise headache
4.3 Primary headache associated with sexual activity
4.4 Primary thunderclap headache
4.5 Cold-stimulus headache
4.6 External pressure headache
4.7 Primary stabbing headache
4.8 Nummular headache
4.9 Hypnic headache
4.10 New daily persistent headache (NDPH)

18. EPIDEMIOLOGY AND COURSE
• Prevalence of headache is very common in the general population.
• About 70 percent of adults endorsing a history of headaches in a
given year.
• Average prevalence of definite migraine is 10.9 percent.
• The aggregate prevalence of probable migraine defined by ICHD-3
averages 7 percent.
• By contrast, chronic migraine is quite rare, with an aggregate estimate
of 0.5 percent.
• Prevalence of tension-type headache of 32 percent (30% and 78%).
• Tension-type headache is very common

19. EPIDEMIOLOGY AND COURSE
• Migraine with aura in males in the mid-teens.
• Females in whom the peak incidence is in early twenties.
• However, despite the high prevalence rates, about half of those with
migraine remit.
• About 35 percent continue to have intermittent headache.
• Only 20 percent continue to develop chronic migraine over time.

20. EPIDEMIOLOGY AND COURSE
• Aside from sex and age, a family history of migraine is one of the
most potent and consistent risk factors for migraine.
• The results of twin studies implicate genetic factors underlying
approximately one-third of the familial clustering of migraine.
• Patients should be encouraged to keep a headache diary.
• Assessment by Migraine disability score (MIDAS)

21. Precipitants of acute headache attacks
Hormonal changes
Stress or its cessation
Fasting fatigue
Over-sleeping
Particular foods and beverages
Drug intake
Chemical additives
Bright light
Weather changes
Exercise

22. Differential diagnosis and clinical evaluation
The following factors are important:
Onset
Frequency
Location
Duration
Quality
Severity
Precipitants
Precursors
Specific symptoms including visual changes, gastrointestinal symptoms, or neurologic
symptoms
Sensitivity to light, noise, sounds, or touch; mood changes
Cognitive changes

23. Headache Symptoms Indicating Further Diagnostic Workup
• First headache
• Worst headache
• Gradual worsening over days or weeks
• Vomiting prior to headache onset
• Abnormal neurologic examination
• Ongoing systemic illness
• Onset after age 50
• Accompanied by fever
• Occurs during sleep

24. • In addition to a history and physical examination, and laboratory studies are critical.
• Brain imaging:
CT Scan is indicated to rule out acute hemorrhage
Magnetic Resonance Imaging (MRI) is indicated when hydrocephalus, brain tumor,
sinusitis, vasculitis, or posterior fossa lesions are suspected.
• X-rays of the jaw and cervical spine are useful to rule out malocclusions and
degenerative changes of arthritis.
• Even if the results are negative and do not uncover a metabolic, endocrine, or
autoimmune etiology, this information may serve as a baseline for subsequent drug
therapy.
• Headache onset over age 50 is particularly threatening and requires careful
investigation.

25. Treatment of headache syndromes
Migraine:
1. Prophylactic treatment (medications that prevent future attacks)
2. Abortive treatment (interventions during the acute attack that
provide symptom relief)

26. Preventative Treatments for Episodic
Migraine
1. β-Blockers: Propranolol, metoprolol, timolol- Level A
2. Anticonvulsants
• Valproate- Level A
• Topiramate- Level A
• Gabapentin- Level U
3. Antidepressants
• Amitriptyline- Level B
• Venlafaxine- Level B
• Fluoxetine- Level U

27. Acute Management of Migraine
1. Pharmacologic Treatments
NSAIDs including ibuprofen, naproxen sodium, and indomethacin and
the analgesics ASA( acetylsalicylic acid) and acetaminophen were
commonly used as the first-line treatment of migraine.
2. Nonpharmacologic Treatments.
• Biofeedback, relaxation training, and cognitive behavioral therapy

28. Other drugs
• The seven triptans are 5HT1B/1D receptor agonists with vasoconstrictive effects on blood
vessels.
1. Almotriptan (12.5mg)
2. Eletriptan (80mg)
3. Frovatriptan
4. Naratriptan
5. Rizatriptan (10 mg)
6. Sumatriptan (50 mg)
7. Zolmitripta
• The choice of triptan depends on efficacy, side effects, duration of headache, and
coexistent vomiting and cost.
• Efficacy data at 2 hours favor eletriptan and rizatriptan

29. Cluster Headache
• First-line abortive therapy is subcutaneous sumatriptan with most
people obtaining relief quickly.
• Home oxygen can be very useful at high flow.
• Transitional treatments, such as oral steroids, can help the patient
through the acute phase while starting preventative strategies.
• Prophylactic medicine is almost always indicated for treating cluster
headache because of the extreme severity of pain induced by an acute
attack, which often occurs at night.

30. Medications that have been shown to be effective in preventing attacks
of cluster headache are:
• Lithium
• Corticosteroids
• Methysergide
• Calcium channel blockers
• β-blockers
• valproic acid

31. Reference:
KAPLAN and SADOCK’S Comprehensive Textbook of Psychiatry 10th
Edition