GENERAL INTRODUCTION TO HEADACHE. INCLUDES ITS TYPES, ETIOLOGY, PATHOPHYSIOLOGY

1. INTRODUCTION TO
HEADACHE
DR. UMAR MUSHIR
M.B.B.S., M.D. (PSYCHIATRY)
SENIOR RESIDENT, CIMS&H, LUCKNOW

2. HEADACHE
 HEADACHE is the MOST COMMON reason for which
patients seek medical attention
 Diagnosis and management are based on a careful
clinical approach augmented by an understanding of
Anatomy, Physiology and Pharmacology of nervous
system pathways mediating various headache
syndromes
 It is a painful and disabling feature and is the most
common disorder of the nervous system

3. PREVALENCE
 90% OF POPULATION in the world experiences
headache in any given year
 Prevalence among adults of any headache is 47%
 About 15% of the reported headache is migraine
 1.7-4% of world’s adult population experiences
headache on 15 or more days every month

4. Origins OF PAIN
 EXTRACRANIAL PAIN SENSITIVE STRUCTURES:
o Sinuses
o Eyes
o Teeth
o Ears
o TMJ
o Blood vessels
5, 6, 9, 10 cranial nerves carry pain from these
structures

5.  INTRACRANIAL PAIN SENSITIVE STRUCTURES:
o Arteries of circle of Willis and proximal Dural arteries
o Dural venous sinuses, veins
o Meninges
o Dura
Contd…

6. HEADACHE SYMPTOMS THAT SUGGEST A
SERIOUS UNDERLYING DISORDER (RED FLAG
SIGNS)
 “ WORST” headache ever
 First severe headache
 Subacute worsening over days or weeks
 Abnormal neurologic examination
 Fever or unexplained systemic signs

7. Contd…
 Vomiting precedes headache
 Induced by bending, lifting, cough
 Disturbs sleep or present immediately
upon awakening
 Known systemic illness
 Onset after age 55

8. PATHOPHYSIOLOGY
 The brain tissue itself is not sensitive to
pain as it lacks pain receptors
 But the pain-sensitive structures that
are around brain causes the sensation
of pain

9. PATHOPHYSIOLOGY
CAUSATIVE FACTORS
STIMULATION OF NOCIOCEPTORS
TRANSMISSION OF PAIN IMPULSE
BY SMALL MYELINATED FIBERS

10. CONTD…
FIBERS ARE TERMINATED IN DORSAL
HORN OF SPINAL CORD
DORSAL HORN INITIATES SECONDARY
NEURONS
SECONDARY NEURONS REACHES THE
THALAMUS THROUGH SPINAL THALAMIC
PATHWAY

13. MECHANISM
The most important mechanism underlying
headaches are:
o Vasodilatation
o Traction on intracranial structures
o Inflammation
o Muscle spasm
o Referred pain
o Psychogenic headache

14. VASCULAR HEADACHE
 Dilatation of intracranial vessels is the responsible
mechanism for vascular headache
 Abrupt elevation of blood pressure may cause headache
 Vascular headache is typically throbbing in nature
 On the other hand, the headache of migraine and chronic
hypotension is due to dilatation of extracranial arteries

15. Traction on intracranial structures
 In addition to distension, traction on the great vessels
and dura at the base of brain causes headache
 Pain is momentarily increased by sudden
movement of the head
 Sometimes pain of this nature indicates the location
of the cerebral tumour
 The value of headache as a localising sign is reduced
by the fact that pain may be referred to another part
of the head but if unilateral it does help to indicate
the side of the tumour

16. HEADACHE DUE TO INFLAMMATION
 MENINGEAL IRRITATION due to:
o Meningitis
o Haemorrhage
o Other cause
 Produces generalised headache which is increased by
head movement, coughing or straining
 Involvement of the roots of the cranial nerves
contributes to headache by causing spasm of
occipital and nuchal muscles

17. CONTD….
 Neck rigidity is an important sign of meningeal
inflammation
 Extra cranial inflammation usually causes more
localised headache
 Cranial arteries is also characterised by localised
throbbing pain in the head, sometimes associated
with arteritis in the other parts of the body

18. HEADACHE DUE TO MUSCLE SPASM
 This is the one of the most common mechanisms of headache
 Intensity vary from a feeling of tightness to a true aching
pain
 It may be unilateral but is usually bilateral
 Nodular areas and points of tenderness may be palpable in
the painful muscles or along the occipital and supra orbital
ridges

19. CONTD…
 Secondary muscle spasm may contribute to a
prolonged pain referred from other structures
 It may also be caused by irritation of cervical
nerve roots by cervical spondylosis

20. REFERRED HEADACHE
 Disease of structure in the head may cause pain referred to the
cranium
 Eye disease such as glaucoma and iritis cause frontal
headache
 Ciliary spasm induced by some errors of refraction may cause
pain
 Nasal and sinus disease causes pain in the molar, nasal,
frontal areas
 Dental, aural and temporo-mandibular joint diseases may
cause pain spreading far beyond the area of primary pain
 Pain may even be referred to the head in angina pectoris

21. PSYCHOGENIC HEADACHE
 By far the most common cause of headache is emotional
upset
 It is often vascular or tension type but there is usually an
underlying personality defect
 It is often a sense of pressure at the vertex or a tight band
round the head, constant day and night and completely
resistant to analgesic drugs

22. CLASSIFICATION OF HEADACHE
 The INTERNATIONAL CLASSIFICATION OF HEADACHE
DISORDER(ICHD) is an in-depth hierarchical classification of
headaches published by the international headache society
 Headache are classified as:
 PRIMARY HEADACHE
(no structural or metabolic abnormality)
o Tension-type headache
o Migraine headache
o Cluster headache
o Exertion headache

23. CONTD…
 SECONDARY HEADACHE:
(structural or metabolic abnormality)
o Extracranial: sinusitis, otitis media, glaucoma, TMJ
ds
o Intracranial: SAH, vasculitis, dissection, central vein
thrombosis, tumour, abscess, meningitis
o Metabolic disorders:CO2 retention, CO poisoning

24. EPIDEMIOLOGY
PRIMARY HEADACHE
o Tension-type 69%
o Migraine 16%
o Idiopathic stabbing 2%
o Exertional 1%
o Cluster 0.1%

25. CONTD…
SECONDARY HEADACHE
o Systemic infection 63%
o Head injury 4%
o Vascular disorders 1%
o Subarachnoid haemorrhage <1%
o Brain tumour 0.1%

26. PRIMARY HEADACHE
 PRIMARY headache are those in which headache and its
associated features are the disorder in itself or occurs in
absence of any exogenous cause
 They often result in considerable disability and a decrease
in patient’s quality of life
 The most common are Migraine, Tension-type, Trigeminal
autonomic cephalagias, and cluster headache
 The less common are stabbing headache, headache due to
cough, exertion and sexual activity(coital cephalagia)

27. PRIMARY HEADACHE TYPES
MIGRAINE TENSION CLUSTER
PAIN
DESCRIPTION
Throbbing, moderate
to severe, worse
Pressure, tightness,
waxes and wanes
Abrupt onset, deep,
continuous,
excruciating
explosive
ASSOCIATING
SYMPTOMS
Photophobia, aura None Tearing, congestion,
rhinorrhoea, pallor,
sweating
LOCATION 60-70% unilateral bilateral Unilateral
DURATION 4-72 hours variable 0.5-3 hours, many
per day
PATIENT
APPERANCE
Resting in quiet dark
room, young female
Remains active or
prefers to rest
Remains active,
prefers hot shower,
male , smoker

28. SECONDARY HEADACHE
 SECONADRY HEADCAHE occurs due to
underlying structure problem in the head or
neck
 It is classified based on their aetiology and
not on their symptoms

29. CONTD…
 Headache attributed to head or neck trauma
 Headache attributed to cranial or cervical vascular disorder
 Headache attributed to non-vascular intracranial disorder
 Headache attributed to a substance or its withdrawal
 Headache attributed to infection
 Headache attributed to disorder of homoeostasis
 Headache or facial pain attributed to disorder of cranium,
neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial
or cranial structures
 Headache attributed to psychiatric disorder

30. NIH CLASSIFICATION
It outlines five types of headache:
o Vascular
o Myogenic(muscle tension)
o Cervicogenic
o Traction
o Inflammatory

31. VASCULAR
 The MOST COMMON type of vascular headache
is migraine
 After migraine, the most common type of vascular
headache is the “toxic” headache produced by
fever
 Other kinds of vascular headaches include
cluster headaches

32. MUSCULAR/MYOGENIC
 When strained or irritated neck muscles cause the pain,
the headaches are myogenic
 When dysfunctional or irritated spinal joints cause the
pain, the headaches are vertebrogenic
 Caused by trauma to the head and neck from injuries
such as:
o Whiplash
o Poor posture
o Occupational or recreational stresses(extended phone use
and other activities that keep the neck in awkward
positions for prolonged periods)

33. CONTD…
 Mild to severe discomfort or pain
 Unilateral/sometimes bilateral
 Starts in the involved muscles and spread to the
temples and possibly a combination of the ears, eyes
and top of the head
 Aggravated by awkward or uncomfortable postures
and certain neck movements like turning or bending
your neck can make the pain worse
 The muscles around your neck may also be tight and
abnormally tender

34. CERVICOGENIC
 Cervicogenic headache is a syndrome characterized
by chronic hemicranial pain that is referred to the
head from either bony structures or soft tissues of the
neck
 Occurrence among females is twice that of males
 Headache are unilateral dominant side headache,
associated with neck pain and aggravated by neck
movements
 Movements stresses of the cervical spine are
associated with the headache complaint

35. THANK YOU