Headache overview

Suroto
Dept of Neurology, Fac of Medicine
Sebelas Maret University

suroto_dr@yahoo.com
 INTRODUCTION

Of all the painful states, Headache is the most frequent

reason for seeking medical help.
 95% of young women and 91% of young men
experienced headache during a 12-month period;
18% of these women and 15% of these men
consulted a physician because of their headache.
Headache is usually a benign symptom but occasionally it
is the manifestation of a serious illness.

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Defferentiating headache and vertigo

 Headache or Cephalalgia: A pain in the head with the

pain being above the eyes or the ears, behind the head
(occipital), or in the back of the upper neck.
 The word “cephalal” : head and “algesia”: ache

 Vertigo: is a feeling that you are dizzily turning around

or that things are dizzily turning about you.
 The word "vertigo" comes from the Latin "vertere", to
turn + the suffix "-igo", a condition = a condition of turning
about).
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 Headache can occur as a result of:

1. Distension, traction or dilatation of intra-cranial or extra-

cranial arteries,
E.g. - After taking nitrates.
-After eating monosodium glutamate.
- Extreme rise of BP.
- After ingestion of alcohol.

2. Traction or displacement of large intracranial veins or their

dural envelope.
3. Compression, traction or inflammation cranial or spinal
nerves.
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Contd..

4. Spasm, inflammation or trauma to cranial & cervical

muscles & apophyseal joints in the upper part of spine.
5. Meningeal irritation & raised ICP.
6. Headache of ocular origin:
eg. sustained contraction of extra ocular muscles, acute
glaucoma, and iridocyclitis.

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CLASSIFICATION OF HEADACHE

 Primary headaches  Secondary headaches

 OR Idiopathic headaches  OR Symptomatic
headaches
 THE HEADACHE IS ITSELF
THE DISEASE  THE HEADACHE IS ON LY A
 NO ORGANIC LESION IN SYMPTOM OF AN OTHER
THE BEACKGROUND UNDERLYING DISEASE
 TREAT THE HEADACHE!  TREAT THE UNDERLYING
DISEASE!

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Primary, Idiopathic Headache

1.Tension type headache

2. Migraine
3. Cluster headache
4. Miscellaneous primary headache:
Idiopathic stabbing headache.
Cold stimulus headache .
Headache associated with sexual activity .

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Secondary, Symptomatic Headache

5.Headache associated with head and/neck trauma.

6.Headache associated with vascular disorder.
7.Headache associated with non vascular intracranial disorder.
8.Headache associated with substances or its withdrawal
9.Headache associated with infection.
10. Headache associated with homeostasis disorder.
11.Headache or facial pain associated with disorders of cranial or
facial structures.
12.Headache attributed to psychiatric disorder

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 DIAGNOSTIC APPROACH
OF HEADACHE
HISTORY AND EXAMINATIONS SHOULD CLARIFY:

 THE PATIENT HAS PRIMARY OR SECONDARY

HEADACHE

 IS THERE ANY URGENCY

 IN CASE OF PRIMARY HEADACHE ONLY THE

HEADACHE ATTACKS SHOULD BE TREATED
(„ATTACK THERAPY”), OR PROPHYLACTIC THERAPY
IS ALSO NECESSARY („PREVENTIVE THERAPY,
INTERVAL THERAPY”)
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History Taking:

1.Age, sex:
 Migraine headache – more frequent in teenagers & young adults,
higher occurrence in female.
Cluster headache – almost exclusively in males.
Cranial arteritis – more frequently in late middle age & in elderly.

2.Quality of pain:
 Tension headache – pressing, squeezing, tight or heavy.
 Migraine headache – throbbing or pounding.
 Headache due to intracranial lesion – relatively mild.
 Acute SAH- pain tends to be explosive & intense.

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History Taking: Contd

3. Location of headache:
As a general rule localized headache is of greater significance than diffuse
headache.
 Tension headache – typically generalized, band like or bioccipital.
 Migraine with aura – often unilateral & frequently more prominent
interiorly.
 Migraine without aura – frequently bilateral.
 Cluster headache – invariably limited to the same side of the head in any
given attacks & usually periorbital.
 Sinusitis – fontal/ethmoidal, head position
 Cranial arteritis – manifested by localized temporal headache.

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History Taking: Contd

4. Associated symptoms:
 Tension headache – often associated with other psycho-
physiologic disturbances.
Cluster headache – typically associated with ipsilateral
lacrimation, conjuctival injection, rhinorrhoea, & facial
flushing.
 Intracranial mass lesion – associated symptoms are
more prominent than headache. Some intra-cerebral lesion
may exhibit seizure or vomiting.
Cranial arteritis – systemic symptoms as fever, anorexia &
rheumatic symptoms.

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History Taking: Contd

5. Precipitating & aggravating factors:

Tension headache & vascular headache – induced or
aggravated by emotional factors.

Intraventricular & posterior fossa tumour – may be

accentuated by change in the head position, coughing &
Valsalva maneuver.

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History Taking: Contd
6. Frequency, duration & diurnal variation:
 Tension headache – long duration -- often persist & may worsen
as the day progress.
 Migraine headache – the frequency is variable & unpredictable.
Although usual variation is from 4 - 72 hrs, they may persist for
days.
 Cluster headache – occur repetitively over a period of weeks or
months. Often there are 1 or 2 attacks daily. The headache typically
nocturnal & of brief duration (30 min to a few hours).
 Headache due to meningeal cause – acute in onset.

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PHYSICAL EXAMINATION:

1. General physical examination:

 Flushed face, lacrimation, and unilateral rhinorrhoea –
cluster headache.
 Systemic sign (fever, weight loss, anaemia) – infectious
disease, specific infection of CNS, metastatic disease of brain
&/or meninges.

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PHYSICAL EXAMINATION:

2. Neurological examination:
 No neurological abnormality – tension headache.
 Evidence of cerebral ischaemia – small percentage of
migraine (permanent residual damage).
 Horner’s syndrome – sometimes during migraine
headache (rarely permanent).
 Localizing sign – expanding IC-SOL.
 Papilledema -  ICP due to IC-SOL.
 Bruits over the eyes/cranium – vascular malformation.
 Sign of meningeal irritation – lesion affecting the
meninges.
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Investigations

 Blood Examination.
 Skull & Cervical Spine Imaging.
 CT Scan of the head.
 MRI & MRA of the brain.
 Eye & ENT evaluation.
 Cardiologic & renal evaluation.

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When to scan a patient with headache

 First or worst headache, particularly if of sudden onset.

 Headache of increasing frequency or severity.
 Increased frequency of vomiting and headache.
 Headache triggered by coughing, straining or postural
changes.
 Persistent physical symptoms or signs after attack.
 Meningism, confusion, impairment of consciousness or
seizures.
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Tx of Primary Headache

 Pharmacologic Treatment

 NonPharmacologic Treatment

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Acute Medical Treatment of
Migraine Headaches

 Ergot Preparations
 oral, sublingual and rectal formulations
 most effective if taken early in an attack
 may need adjunctive antiemetic
 potent vasoconstrictors
 contraindicated in patients with PVD, CAD,
thrombophlebitis, marked HTN, pregnant or
breast-feeding women or very elderly
patients
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Triptans
 Contraindications:
ischemic heart disease (angina, hx of MI,
documented silent ischemia or Prinzmetal’s
angina),
uncontrolled HTN
concomitant use of ergotamine preparations
pregnancy
 decreased dose of triptans recommended if
a MAO inhibitor is being taken

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Prophylactic Treatment of
Migraine Headaches

 Beta Blockers: propanolol, atenolol

 Calcium Channel Blockers: diltiazem
 Antidepressants: amitryptiline, fluoxetine
 Serotonin Antagonist: methysergide
 Anticonvulsants: valproic acid, topiramat

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Treatment of Cluster Headache

 Acute treatment:
 100% Oxygen via face mask at 8liters/min
given in a seated position
 SL ergotamine at onset of HA and repeated
once if needed
 Triptans shown effective in two RCTs
 Intranasal administration of a local
anesthetic (4% lidocaine) may be helpful

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Treatment of Cluster Headache
 Preventive Treatment
 Verapamil 80 mg qid
 Lithium 300 - 900 mg per day
 Prednisone 40 mg per day in divided
doses, tapered over 3 weeks
 Ergotamine 2 mg 2 hrs before bedtime to
prevent nocturnal attacks
 Divalproex sodium 600 - 2000 mg per day

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 Red flag for secondary headache -
Silberstein SD et al

Flag Descriptions/example
Systemic symptoms or secondary Fever,W-loss,or known cancer,HIV,
risk factors immunosupression or thrombotic risks
Neurological symptoms or signs Confusion,impaired alertness/drowsy,
persistent focal signs >1h
Onset First and worst headache,sudden abrupt
from sleep, or progressively worsening
Older New onset at age and progressive
(Giant cell arteritis)
Previous headache history Significant change in features, freq. or
severity
Triggered headache By valsalva, exertion,

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HEADACHE OF SOME SERIOUS ILLNESS:

Meningitis:
Acute severe headache – rapid evolution, minutes to hours.
Site - generalized or bi-occipital or bi-frontal.
Associated with fever, photophobia, nausea and vomiting.
Neck stiff on forward bending, Kernig and Brudzinski signs.
 LP- diagnostic.

 SAH:
 Acute severe headache – rapid evolution, minutes to hours.
 Site – generalized.
 Not associated with fever.
 Neck stiffness – on forward bending.
 LP – diagnostic.
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  Brain tumor:

 Site – unilateral or generalized headache.

 Worse in the early morning & improves during day.
 Worsen with exertion, change in position, bending,
lifting or coughing.
 Associated with nausea, vomiting.
 Impaired mentation, focal sign, seizures, and
papilloedema – present.

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Temporal arteritis/giant cell arteritis:

 Age – older patients (>50 yrs).

 Site – uni/bilateral & is located temporally in 50% patients.
Character – dull & boring with superimposed lancinating
 Appears gradually over a few hours before peak intensity
 Worse at night & is often aggravated by exposure to cold.
Associated with polymyalgia rheumatica, jaw claudication,
fever & weight loss.
Scalp tenderness . Temporal artery & less commonly
occipital artery may be tender.
 ESR - .
 Temporal artery biopsy – diagnostic.
 Treatment – prednisolone 80 mg daily for 4-6 wks.
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 Summary
 Headache is usually a benign symptom but occasionally
it is the manifestation of a serious illness.
 Primary headache: tension headache, migraine, cluster
headache
 Secondary headache: the headache is only a symptom
of an other underlying disease
 Accurate history taking is fundamental in making
diagnosis
 Need for further investigation: determined by red flag
symptoms
 Acute Tx vs Preventive Tx
 
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