Headache

Definition

A headache or cephalagia is pain anywhere in the region of head or neck. It can be a symptom of a number of different conditions of head and neck. The brain tissue itself is not sensitive to pain because it lacks pain receptors. Rather, the pain is caused by disturbance of pain sensitive structures around the head and neck.

Types of headache

• Part I: The Primary Headaches
• Part II: The Secondary Headaches
• Part III: Cranial Neuralgias, Central and Primary Facial Pain And Other Headaches

PRIMARY HEADACHE

Primary headaches are benign, recurrent headaches not caused by underlying disease or structural problems. primary headaches may cause significant daily pain and disability but they are not dangerous. It includes

1. Migraine

2. Tension-type headache (TTH)

3. Cluster headache and other trigeminal autonomic cephalalgias (TAC)

4. Other primary headaches

SECONDARY HEADACHE

Secondary headaches are caused by an underlying disease, like an infection, head injury, vascular disorders, brain bleed or tumors. Secondary headaches can be harmless or dangerous. It includes

1. Post traumatic Headache

2. Vascular Headache of cranial or cervical origin

3. Non vascular headache intracranial origin

4. Post infective headache

5. Headache due to substance abuse/withdrawal

6. Headache due to disorder of homoeostasis

7. Headache due to non cranial causes

8. Headache attributed to psychiatric disorders

MIGRAINE WITH AURA

• Typical aura with migraine headache 
• Typical aura with non-migraine headache
• Typical aura without headache 
• Familial hemiplegic migraine (FHM)
• Sporadic hemiplegic migraine
• Basilar-type migraine

COMPLICATIONS OF MIGRAINE

• Chronic migraine
• Status migrainous
• Persistent aura without infarction
• Migrainous infarction
• Migraine-triggered seizure

Tension Headache

International Headache Society Diagnostic Criteria

• Duration

30 min to 7 days 

• Pain characteristics (at least 2)

      I) Pressing/tightening quality 

      II) Mild to moderate severity Bilateral location 

      III) No aggravation by routine physical activity 

• Associate symptoms (Must have both)

No vomiting

No more than one of: nausea, photophobia, phono-phobia H&P and diagnostic tests do not suggest underlying organic disease

Migraine Without Aura

International Headache Society Diagnostic Criteria

• At least 6 or more periodic attacks 
• Duration

   4-72 h if untreated or unsuccessfully treated 

• Pain characteristics (at least 2)

• Unilateral location 
• Pulsating quality 
• Moderate to severe intensity
• Aggravation by walking stairs or similar physical activity 

• Associated symptoms (at least 1)

• Nausea, vomiting, or both Photophobia or phono-phobia
• H&P and diagnostic tests do not suggest underlying organic disease

Migraine With Aura

International Headache Society Diagnostic Criteria

• At least 3 periodic attacks 
• Aura characertistics (At least 3 )

• One or more fully reversible aura symptoms indicating focal cerebral cortical or brain-stem dysfunction
• At least 1 aura symptom develops gradually over >4 minutes or 2 or more symptoms occur in succession
• No single aura symptom lasts > 60 minutes
• Headache begins within 60 minutes of aura onset
• History, physical, and diagnostic tests do not suggest underlying organic disease

Cluster headache

International Headache Society Diagnostic Criteria

• Duration

15 to 180 minutes untreated

• Pain characteristics

Severe unilateral orbital, supraorbital, or temporal pain

• Associated symptoms (at least 1, ipsilateral to pain)

• Conjunctival injection, Lacrimation 
• Nasal congestion, Rhinorrhea , Forehead and facial swelling 
• Miosis, Ptosis 
• Eyelid Edema 

• Frequency

between 1 every other day to 8/day

Secondary headache

• Intracranial hemorrhage

• Subarachnoid Hemorrhage
• Intracerebral hemorrhage
• Subdural/epidural hematoma

• Meningitis/encephalitis
• Hypertensive encephalopathy
• Ischemic stroke
• Venous sinus thrombosis
• Hypoxia, hypercarbia, carbon monoxide

Physical Exam

• Vital signs

fever, hypertension, hypoxia

• Head/face

trauma, bruits, tenderness

• Eyes

conjunctiva, cornea, pupils, fundi:papilledema

• Ears

OM or hemotympanum

• Mouth

Teeth, TMJ

• Neck

pain/stiffness/tenderness

Carotid and/or vertebral bruits

• Skin

rash

• Neurologic

Mental status

Pupils, EOM, Visual field

Focal deficits

Horner's syndrome

Ataxia

Diagnostic Alarms

   • Onset after age 50

   • Sudden onset

• Increased frequency and severity
• New onset with risk factors for HIV or cancer
• Associated with systemic illness (HT,DM,fever, meningismus, rash)
• Altered consciousness or focal neurologic deficits
• Papilledema 
• Significant trauma

Prophylaxis Treatment of Primary Headache

• Tension

Reassurance

Antidepressant &/or Anxiolytic drugs (Tricyclic antidepressant or/& SSRI) 

• Migraine

Betablockers: Proponolol 

Ca channel blocker: Verapamile 

Antidepressant: (Tricyclic antidepressant or/& SSRI) 

Anticonvulsant: Na valproate, topiramate,

Methysergid.

Pizotifine.

• Cluster 

Steroid

Lithium carbonate 

Verapamile

Subarachnoid hemorrhage

• Approximately 50% of have "sentinal bleed"

• 50% with "sentinal bleed" will rebleed within 2-6 wks

• Rebleed

• 50% mortality
• > 50% of survivors have significant neurologic deficits

• Head CT negative in 1-10% of cases

Sensitivity decreases with time from onset of sx

• LP if head CT negative (RBC’s 3 hrs, xanthochromia 12 hrs)

• Angiography if positive CT or LP

Temporal arteritis

• Rare before age 50

• Temporal artery tenderness, swelling, redness, nodularity

• Visual disturbance

Visual loss in 7-60% if untreated

• Jaw claudication

• Systemic symptoms

fever, wt loss, anorexia, malaise

• Polymyalgia rheumatica (prox muscle pain/tend./stiffness)

• ESR usually > 50 (mm/hr)

• Temporal artery biopsy

multi nucleated giant cells / inflammation

• Therapy: High dose steroids

ED treatment of primary headache

• Tension

Oral Analgesics (NSAIDS, Acetaminophen) 

• Migraine

Serotonin agonists (Sumitriptan 50 mg PO or 6.0 mg SQ)

Narcotics IV or IM

• Cluster

100% oxygen I Intranasal lidocaine ?

NSAIDS

Migraine specific therapies