Thunderclap headache (TCH) refers to a severe headache of sudden onset. Its explosive and unexpected nature is likened to a &quot;clap of thunder.”In addition, the term primary TCH is often used to refer to a benign, idiopathic, and potentially recurrent headache of sudden and severe intensity with a lack of underlying pathology. Sex headaches Coital Cephalgia (sef-hal-gia) are headaches brought on by sexual activity — especially an orgasm. You may notice a dull ache in your head and neck that builds up as sexual excitement increases. Or, more commonly, you may experience a sudden, severe headache just before or during orgasm. Obviously, sex raises the blood pressure. This in turn raises the pressure in the head. Also, sex causes muscle tightening and tension. Sex headaches are a combination of the blood pressure and muscle tension, for most people. Some cases have been found where there is low pressure of the fluid around the brain and spine. A cluster headache is one of the most painful types of headache. A striking feature of cluster headache is that the attacks occur in cyclical patterns, or clusters — which gives the condition its name. Bouts of frequent attacks — known as cluster periods — may last from weeks to months, usually followed by remission periods when the headache attacks stop completely. The pattern varies from one person to another, but most people have one or two cluster periods a year. During remission, no headaches occur for months, and sometimes even years. Fortunately, cluster headache is rare and not life-threatening. Treatments can help make the attacks shorter and less severe. In addition, preventive medications can help reduce the number of headaches. Cough headaches are an unusual type of headache triggered by coughing and other types of straining — such as from sneezing, blowing your nose, laughing, crying, singing, bending over or having a bowel movement. Doctors divide cough headaches into two categories. Primary cough headaches are usually harmless, occur in limited episodes and eventually improve on their own. Secondary cough headaches are more serious, as they&apos;re caused by structural problems within the brain, which may require surgery to correct A tension headache (renamed a tension-type headache by the International Headache Society in 1988) is the most common type of primary headache. The pain can radiate from the neck, back, eyes, or other muscle groups in the body. Tension-type headaches account for nearly 90% of all headaches. Approximately 3% of the population has chronic tension-type headaches. Various precipitating factors may cause TTH in susceptible individuals: 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 One half of patients with TTH identify stress or hunger as a precipitating factor. Tension headaches may be caused by muscle tension around the head and neck. One of the theories says that the main cause for tension type headaches and migraine is teeth clenching which causes a chronic contraction of the temporalis muscle. Unnamed &quot;experts&quot; cited by a staffer at the Mayo clinic express doubts with the role muscle tension plays, but no research is cited by the staffer.
Paroxysmal-short, sudden, frequent and stereotyped symptoms that can be observed in various clinical conditions
Sahar yusuf Alkadi
• Headaches Introduction
• Sensitive structures in the skull
• Headache ‘red flags’Diagnosis
• Classification of headaches
• History : Profile of HA
• Home care for headaches
• Material to read later-Case StudyMaterial to read later-Case Study
Pain or discomfort
from the level of
the brows to the
Sensitive structures in the skull
1. All the tissue covering the bone except
2. Cerebral arteries
3. Venous sinuses
4. Cranial nerves: 5,9,10 & upper 3 cervical
5. Meninges: especially the basal
N.B: the Brain itself is insensitive
Origins of Pain in the Head
Extra-cranial pain sensitive
Intra-cranial pain sensitive
Headache ‘red flags’
New onset headache in middle age or later
;and progressive headache, especially in middle-
age >50 (giant cell arteritis)
New or progressive headache that lasts for days
Headache with neurologic symptoms
Systemic symptoms (neck stiffness, fever, nausea,
Vomiting, weight loss ,blurry or double vision )
or Secondary risk factors (HIV, systemic cancer)
1) Vascular headache : (V.D.)
Hypertension & Hypoxia & Hypoglycemia
Arteritis & Aneurysm
Toxic: Caffeine withdrawal & Alcohol
renal and hepatic failure
2) Traction Headache: (Space occupying lesion )
due to stretch of Meninges as in brain tumors
3) Tension Headache: (Psychogenic headache )
Cap-like constriction (Ache pain)
Not localized & Not throbbing & Don’t increase
Usually associated with depression, neurosis &
4) Meningeal irritation:
5) Muscle contraction headache:
Prolonged contraction of the muscles of the head
and neck e.g: prolonged driving
6) Neuritis and neuralgia:
Of the sensory nerves of the scalp e.g.: trigeminal
7) Referred headache: may be very sever
Eye: iritis, glaucoma
Ear: middle ear diseases
Nasal sinuses diseases
Teeth diseases and Tongue diseases
Classification of headaches
OR Idiopathic headaches
THE HEADACHE IS ITSELF THE
NO ORGANIC LESION IN THE
TREAT THE HEADACHE!
OR Symptomatic headaches
THE HEADACHE IS ONLY A
SYMPTOM OF AN OTHER
TREAT THE UNDERLYING
The differentiation between 1° and 2° is critical as it dictates
diagostic approach and guides treatment and prognosis.
*Tension type of
Other, rare types of
deBruijn, SF, et al. Lancet. 1996; Lancet. 1998.
Episodic headache disorder characterised by combinations of
Neurological, Gastrointestinal, Autonomic
A neurologic disorder characterised by idiopathic,
paroxysmal, recurrent attacks of headache lasting from 2-72
Unilateral (sometimes bilateral)
mod or severe intensity
may be accompanied by either nausea & vomiting or
photophobia & phonophobia
aggravated by physical activity
may be preceded by an aura
Definition of Migraine headache
.The Most common type of 1ry headache, TTH accounts for
nearly 90% of all headaches. Approximately 3% of the
population has chronic tension-type headaches.
.lasting 30 min to 7 days.
.The pain not only occurs in the head and neck, but also
radiates around the face and scalp muscles.
.This is a type of muscle contraction pain.
.It is more in females than males.
- The exact cause of tension headache is
- it’s thought to occur due to stress, tension,
depression, bad posture, staying in one
position for long time, or caffeine.
. Adult or tightness pain around the
head , band like
. Pain radiates down to the neck.
. The pain is bilateral, vary in intensity.
. Not associated with aura, nausea, vomiting,
or light or sound sensitivity.
.sever in early part of the day and less as day
.continue for weeks or months without
..Tension headache is usually treated with the
help of over-the counter medications(pain-
killers) as: aspirin ,acetaminophen or naproxen .
..If these fail , other supportive ttt are available
as: massage & stress management.
..If recurrent headache , should seek for medical
Prophylactic treatment of the chronic
tension type of headache
• Start with low dose (10-25 mg) and increase the
dose if no beneficial effect after 1-2 weeks
• Maximal dose should not be more than 75
• Change to other tricyclic antidepressant only
after 6-8 weeks
• Ask the patient to use headache diary
• Use the tricyclic antidepressant for 6-9 months
• Decrease the dose gradually
Prophylactic treatment of the chronic
tension type of headache
First choice of drug:
Amitryptiline or Mirtazapine
1st week: 25 mg in the evening
2nd week: 50 mg in the evening
3rd week: 75 mg in the evening continuously
Change to other drug (e.g. clomipramine) if no
beneficial effect within 6 weeks
is one of the most painful types of headache..
- Is avascular headache that causes extreme
- Occur for several days or weeks at the same
time of the day.
- It’s more common in men, especially smokers.
- It begins in adolescence but can extend to
- There are 2 types of cluster headache:
Causes of cluster headache:
. the cause of cluster headache is unknown.
.it’s brought to occur due to:
1- dilation of blood vessels.
2- inflammation of the nerves present behind eyes.
3- bright sunlight, smoking, drinking alcohol and some
foods as: chocolate or foods high in nitrites like
smoked meats may trigger cluster headache.
4- tend to run in families& this suggest that there may
be areole for genetics.
5- may be due to changes in sleep patterns.
6- may be triggered by medication as: nitroglycerin
which used for heart disease.
Symptoms of cluster headache:
1- sever unilateral per orbital pain accompanied by: unilateral
lacrimation , nasal congestion..
(dull, steady pain ,some pt. describe the pain as feeling like a hot
poker in the eye, the affected eye may become red, inflamed and
watery ,also the nose of the affected side may become
congested and runny).
2- attack occur at the same time every day , lasting for 30 to 90
min , often awaken the pt. at night from a sleep.
3- once or twice daily or more than twice followed by respite for
months before another cluster occur — known as cluster periods .
4- tend to be restless which make the pt. to pace the floor or
bang their head against a wall.
5- nausea and vomiting rarely occur.
6-symptoms develop in early hours of morning
- There’s no specific ttt for cluster headache.
-- However ttt help in reliving the symptoms as well as
help prevent more attacks.
Some of these ttt include:
1. Inhalation of high concentration oxygen: the pt. is
required to wear an oxygen mask that help increase the
amount of oxygen in blood , thus relaxing the blood
vessels and providing pain relief.
2. Injection of triptan medication as, sumatriptan
which is common migraine medication.
3. Injection of lidocaine ,local anasthetic into the
Prevention of the next cluster headache
include the following:
1- calcium channel blocker as verapamil.
3- antidepressant medication.
5- antiseziure medication as valproic acid.
.also life style changes may help to
minimize the risk of cluster headache as
stop smoking and alcohol.
Prophylactic treatment of the episodic
form of cluster headache
Episodic form: prednisolone
1-5. days 40 mg
6-10. days daily 30 mg
10-15. days daily 20 mg
16-20. days daily 15 mg
21-25. days daily 10 mg
26-30. days daily 5 mg
Intravenous magnesium sulfate relieves cluster headaches in about 40%
of patients with low serum ionized magnesium levels. Melatonin has
also been demonstrated to bring significant improvement in
approximately half of episodic patients
Prophylactic treatment of the chronic
form of cluster headache
Daily 600-700 mg
Can be decreased after 2 weeks remission
Control of serum level is necessary
(0,4 - 0,8 mmol/l)
Methysergide (synthetic ergot alkaloid), and
the anticonvulsant topiramate are
DuboseDubose et alet al (1995); Goadsby (1999); Marks and Rapoport (1997)(1995); Goadsby (1999); Marks and Rapoport (1997)
Family historyFamily history YesYes
SexSex More femalesMore females
LocationLocation Usually unilateralUsually unilateral
in adultsin adults
Frequency/Frequency/ 2–72 h/attack2–72 h/attack
durationduration 1 attack/year to1 attack/year to
>8 per month>8 per month
AssociatedAssociated Visual auraVisual aura
Clinical featureClinical feature MigraineMigraine
More malesMore males
During sleepDuring sleep
one eyeone eye
15–90 min/attack15–90 min/attack
1–8 attacks/day1–8 attacks/day
for 3–16 weeksfor 3–16 weeks
1–2 bouts/year1–2 bouts/year
Facial flushingFacial flushing
Nasal congestionNasal congestion
Conjunctival injectionConjunctival injection
Pupillary changesPupillary changes
Cluster headacheCluster headache
More femalesMore females
Under stressUnder stress
Bilateral in bandBilateral in band
around headaround head
Persistent Tightening/pressingPersistent Tightening/pressing
30 min to 7 days30 min to 7 days
3–4 attacks/week3–4 attacks/week
to 1–2 attacks/yearto 1–2 attacks/year
Mild photophobiaMild photophobia
Mild phonophobiaMild phonophobia
Tension headacheTension headache
refers to a severe headache of
sudden onset. Its explosive and
unexpected nature is likened to a
"clap of thunder.”
- are headaches brought on by sexual activity.
- You may notice a dull ache in your head and neck
that builds up as sexual excitement increases
- you may experience a sudden, severe headache
just before or during orgasm.( Obviously, sex raises
the blood pressure. This in turn raises the pressure in
the head. Also, sex causes muscle tightening and
tension.) Sex headaches are a combination of the
blood pressure and muscle tension, for most people.
Lancinating pain in 2nd
of trigeminal nerve
Usually in pt. over the 50 yrs.
Sever, very brief but repetitive
Precipitated by touching trigger
zones within the trigeminal
territory by cold wind blowing on
the face or by eating
1-Carbamazepine more than
2-Gabapentin or pregabalin
Tend to occur in the elderly,
women>men. Occur particularly at night,
waking patient during REM stages of
sleep. Characterized by throbbing,
without autonomic features, may last
upto 1 hr and reoccur through the night.
Short, excruciating (15 min-3 hrs)
Usually occur in the middle of the night
unilateral pain behind eye
occur daily for 2-3mths then remit for months-years
Red, watering eyes, blocked nose
diffuse pain in tight head-band pattern
No nausea and vomiting
10 attacks lasting 30 min–7 days
2 of the following 4
Mild or moderate intensity
Not aggravated by routine physical activity
No nausea or vomiting
One or neither photophobia or phonophobia
Not attributable to another disorder
Evidence of purulent discharge from the nose
constant dull ache in cheek area accompanied by sinusitis
worsens with bending over or blowing nose
Differential diagnosis of primary headaches
SECONDARY – (structural or metabolic
• Extra-cranial: sinusitis, otitis media,
glaucoma, TMJ ds
• Intra-cranial: SAH, vasculitis,
dissection, central vein thrombosis,
tumor, abscess, meningitis
• Metabolic disorders: CO2 retention,
History : Profile of HA
time from onset to peak
usual time of onset (week
, month, season, hour of
frequency & duration
change over lifetime
description : pulsating,
location : unilateral or
bilateral or changing
factors that relieve the
pharmacological or non-
Giant cell arteritis syn Arteriitis
temporalis syn temporal arteritis
• Giant cell arteritis (GCA or temporal arteritis) is an autoimmune
disease, granulomatose inflammation of branches of External Carotid
Artery that supply the head eyes, and optic nerves . It is a form of
• The name (giant cell arteritis) reflects the type of inflammatory cell
that is involved (as seen on biopsy).
• The terms "giant cell arteritis" and "temporal arteritis" are
sometimes used interchangeably, because of the frequent involvement
of the temporal artery.
It is more common in females than males by a ratio of 3:1. The
mean age of onset is about 70 years, and it is rare in those
less than 50 years of age. The incidence is 24.2 per 100,000
women over 50 and 8.2 per 100,000 men over 50
•Unilateral headache, pulsating pain more sever at night
•Tenderness and sensitivity on the scalp
•Jaw claudication (pain in jaw when chewing)
inflammation of internal maxillary artery
•Tongue claudication (pain in tongue when chewing) and
•Reduced visual acuity (blurred vision)
•Acute visual loss (sudden blindness)
•Diplopia (double vision)
•Acute tinnitus (ringing in the ears)
•Approximately 50% of GCA patients also have
polymyalgia rhematica (PMR), which is characterized by
muscle pain and stiffness.
•The inflammation may affect blood supply to the eye
and blurred vision or sudden blindness may occur. In
76% of cases involving the eye, the ophthalmic artery is
involved causing anterior ischemic optic neuropathy.
Loss of vision in both eyes may occur very abruptly and
this disease is therefore a medical emergency.
Amaurosis fugax may precede the blindness
Corticosteroids, typically high-dose
prednisone (40–60 mg bd), must be
started as soon as the diagnosis is
suspected (even before the diagnosis is
confirmed by biopsy) to prevent
irreversible blindness secondary to
ophthalmic artery occlusion. The dose
of prednisone is lowered after a 2–4
weeks, and slowly tapered over the
course of 9–12 months. Oral steroids
are at least as effective as iv steroids,
except in the treatment of acute visual
loss where iv steroids appear to offer
significant benefit over oral steroids
Home care for headaches :
Headaches make life difficult , those who suffer from regular
headaches ,will agree with this statement .
.. When a headache strikes , one should follow some simple
home care tips that help relieve the symptoms to some extent .
These include :
- First and foremost , if possible , rest , it is very important that
you leave all works aside & rest in a quiet dark room .
- At times , a light sleep helps relieve the stress that causes
- You can place a light , cool cloth over the head as it helps you
- Use painkiller .
Material to read later-Case Study
17 yr old female
L-sided pulsatile headache recurring 3-4x monthly
headache preceded by loss of visual fields
headache is accompanied by nausea, vomiting and
headache lasts all day unless able to lie in a dark room &
affects ability to work/study
past medical history unremarkable - no other medical
general physical & neurologic exam -normal