APPROACH TO HEADACHE

.Done by: Hani Abdeljawad

INTRODUCTION
This is the first time we discuss headache (or
Cephalalgia) as a separated subject.
Definition:
Headache is pain in any part of the head,
including the scalp, face (including the
orbitotemporal area), and interior of the head.
Headache is one of the top ten most common
complaints patients seek medical attention for.
Headache occurs due to activation of painsensitive structures in or around the brain, skull,
face, sinuses, or teeth.
Headache may occur as a primary disorder or
be secondary to another disorder.

 Most headaches dont represent a

serious medical condition, however;
has one of the longest lists of
differential diagnoses in all of
medicine.
The most important diagnostic tool is
a detailed history.

Pathophysiology

The brain tissue itself is not sensitive to pain because it lacks

pain receptors. Rather, the pain is caused by disturbance of the painsensitive structures around the brain. Several areas of the head and
neck have these pain-sensitive structures, which are divided in two
categories: within the cranium (blood vessels, meninges, and the
cranial nerves) and outside the cranium (the periosteum of the skull,
muscles, nerves, arteries and veins, subcutaneous tissues, eyes,
ears, sinuses and mucous membranes).
Headache often results from traction to or irritation of the meninges
and blood vessels. The nociceptors* may also be stimulated by other
factors than head trauma or tumors and cause headaches. Some of
these includestress, dilatedblood vesselsand muscular tension.
Once stimulated, a nociceptor sends a message up the length of the
nerve fiber to the nerve cells in the brain, signaling that a part of the
body hurts.
Endorphins rule.

(Anociceptoris asensory receptorthat responds to potentially damaging stimuli by sending nerve

signals to the spinal cord and brain. This process, callednociception, usually causes the
perception ofpain.)

 Pain sensitive structures include:

* Skin and its blood supply
* Muscles of the head and neck
* Great venous sinuses and tributaries
* Portions of the meninges including the dura mater at
the
* base of the skull
* Dural arteries
* Intracerebral arteries
* Cervical nerves
* Select cranial nerves
* Pain sensitive structures are affected by
tension,traction, distension, dilatation, and
inflammation.

 Within the skull, the dura and the

proximal large pial blood vissels are
the main structures sensitive to the
pain.
The pain sensitive structures are
mainly innerveted by the trigeminal
nerve.

 Headache may occur as a primary

disorder or be secondary to another
disorder.

Classification of headaches
Primary headaches OR Idiopathic
headaches
THE HEADACHE IS ITSELF THE DISEASE
NO ORGANIC LESION IN THE
BEACKGROUND
TREAT THE HEADACHE.

 The t basic categories of primary

headache are:
- Tension,
- Migraine,
- Cluster,
- and less commonly; Hemicrania
continua.

 Secondary headaches OR
Symptomatic headaches
THE HEADACHE IS ONLY A SYMPTOM OF
AN OTHER UNDERLYING DISEASE
TREAT THE UNDERLYING DISEASE!

 THE HEADACHE IS A SYMPTOM OF AN

UNDERLYING DISEASE, LIKE

Sinusitis
Glaucoma
Eye strain
Fever
Cervical spondylosis
Anaemia
Temporal arteriitis
Meningitis, encephalitis
Brain tumor, meningeal carcinomatosis
Haemorrhagic stroke

To summarize
"MM...IT ACHES"- this phrase gives us our
mnemonic for the majority of differential diagnoses for
a headache..
M-Migraine
M-Meningitis
I-Increased Intracranial Pressure
T-Tension Headache + Temporal Arteritis
A-AV Malformations
C-Cluster Headache
H-Hypertension
E-Eye Disorders (Refractory Errors + Glaucoma)
S-Sinusitis +Sub-Arachnoid Hemorrhage +
mostSystemic illnesses

Does hypertension cause

?headache
Currently, there is no concrete evidence to
establish a firm causal link between
hypertension and headache. There is, however,
an evidence that hypertension does not cause
headaches and in fact may be protective against
the development of headache. Despite
conflicting data in the medical literature, many
of the large trials that have examined this
relationship have found no association between
hypertension and the development of headache.
Hypertension increases risk of brain
hemorrhage, so may cause headache.

Red flags for headache

;complaint

Matching Red Flag Findings with a Cause for Headache

Suggestive Findings
Neurologic symptoms or
signs (eg, altered mental
status, confusion,
neurogenic weakness,
diplopia, papilledema,
focal neurologic deficits)

Causes
Encephalitis, subdural hematoma, subarachnoid or
intracerebral hemorrhage, tumor, other intracranial
mass, increased intracranial pressure

Immunosuppression or
cancer

Brain infection, metastases

Meningismus

Meningitis, subarachnoid hemorrhage, subdural

empyema

Onset of headache after

age 50

Increased risk of serious cause (eg, tumor, giant

cell arteritis)

Thunderclap headache
(severe headache that
peaks within a few
seconds)

Subarachnoid hemorrhage

Contd
Combination of fever,
weight loss, visual
disturbances, jaw
claudication, temporal
artery tenderness, and
proximal myalgias

Giant cell arteritis

Systemic symptoms
(eg, fever, weight loss)

Sepsis, thyrotoxicosis, cancer

Red eye and halos

around lights

Acute narrow-angle glaucoma

History of headache chief

.complaint
History:History of present illnessincludes
questions about headache location, duration,
severity, onset (eg, sudden, gradual), and quality
(eg, throbbing, constant, intermittent, pressurelike). Exacerbating and remitting factors (eg, head
position, time of day, sleep, light, sounds, physical
activity, odors, chewing) are noted. If the patient
has had previous or recurrent headaches, the
previous diagnosis (if any) needs to be identified,
and whether the current headache is similar or
different needs to be determined. For recurrent
headaches, age at onset, frequency of episodes,
temporal pattern (including any relationship to
phase of menstrual cycle), and response to
treatments (including OTC treatments) are noted.

Review of systemsshould seek symptoms suggesting a cause,

including
Vomiting: Migraine, increased intracranial pressure
Fever: Infection (eg, encephalitis, meningitis, sinusitis)
Red eye, visual symptoms (halos, blurring): Acute narrow-angle
glaucoma
Visual field deficits, diplopia, or blurring vision: Ocular migraine,
brain mass lesion, idiopathic intracranial hypertension
Lacrimation and facial flushing: Cluster headache
Rhinorrhea: Sinusitis
Pulsatile tinnitus: Idiopathic intracranial hypertension
Preceding aura: Migraine
Focal neurologic deficit: Encephalitis, meningitis, intracerebral
hemorrhage, subdural hematoma, tumor or other mass lesion
Seizures: Encephalitis, tumor or other mass lesion
Syncope at headache onset: Subarachnoid hemorrhage
Myalgias, vision changes (people > 55 yr): Giant cell arteritis

 Past medical historyshould identify risk factors

for headache, including exposure to drugs
(methapred), substances ( caffeine), and toxins,
recent lumbar puncture, immunosuppressive
disorders or IV drug use (risk of infection);
hypertension (risk of brain hemorrhage); cancer
(risk of brain metastases); and dementia, trauma,
coagulopathy, or use of anticoagulants or ethanol
(risk of subdural hematoma).
Family and social history should include any family
history of headaches, particularly because
migraine headache may be undiagnosed in family
members.

PRIMARY (IDIOPATHIC)
;HEADACHE
Tension headache (the most
common type of primaryheadache.)
Migraine
Cluster headache
Other, rare types of primary
headaches

BY HISTORY
Some Characteristics of Headache Disorders by Cause
Cause
Suggestive Findings
Primary headache disorders*
Cluster headache
Unilateral orbitotemporal attacks at the
same time of day
Deep, severe, lasting 30180 min; often
with lacrimation, facial flushing, or
Horner's syndrome; restlessness

Migraine headache

Frequently unilateral and pulsating,

lasting 472 h; occasionally with aura,
nausea, photophobia, or osmophobia
Worse with activity, preference to lie in
the dark, resolution with sleep

Tension-type headache

Frequent or continuous, mild, bilateral,

and viselike occipital or frontal pain that
spreads to entire head
Worse at end of day

Tension headache(tensiontype headache)

Tension-type headaches account for
nearly 90% of all headaches.
ension-type headache pain is often
described as a constant pressure, as
if the head were being squeezed.

 Frequency and duration:

- Tension-type headaches can be
episodicorchronic.
- Episodic tension-type headaches are
defined as tension-type headaches
occurring fewer than 15 days a month,
whereas chronic tension headaches
occur 15 days or more a month for at
least 6 months.

Causes. 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.
- Irregular meal time (hunger)
- Eyestrain
- Caffeinewithdrawal
- Dehydration

One half of patients with TTH identify stress or hunger as a

precipitating factor.
Tension headaches may be caused bymuscle tension
around the head and neck.

 TTH that occur 15 or more days a month for at

least three months, they're considered chronic.
TTH that occur fewer than 15 times in a
month, your headaches are considered
episodic.
Tension headaches can sometimes be difficult
to distinguish from migraines, but unlike some
forms of migraine, tension headache usually
isn't associated with visual disturbances (blind
spots or flashing lights), nausea, vomiting,
abdominal pain, weakness or numbness on one
side of the body, or slurred speech.

CRITERIA
A. At least 10 episodes occurring on <1 day/month on
average and fulfilling criteria B-D
B. Headache lasting from 30 minutes to 7 days
C. Headache has at least 2 of the following
characteristics:
Bilateral location
Pressing/tightening (non-pulsating) quality
Mild or moderate intensity
Not aggravated by routine physical activity such as
walking or climbing stairs
D. Both of the following:
No nausea or vomiting (anorexia may occur)
No more than one of photophobia or phonophobia
E. Not attributed to another disorder

Treatment of tension type of

headache
Episodic form: NSAID drugs.
Chronic, Tricyclic antidepressants.

MIGRAINE
Migraine is derived from the word hemicrania or half-a-head
Episodic, lasting 4-72 h, associated with nausea and/or
vomiting, photophobia and phonophobia .
Headache has a throbbing or pulsatile quality and is often
unilateral (2/3rds of patients) although may become
generalised
We have Migraine without aura (more common) , and, Migraine
with aura.
Aura: precedes the migraine with some sort of visual
disturbance known as an aura. Aura symptoms typically last
from 10 to 25 minutes. Visual changes can occur in one or both
eyes. They can include one or more of the following:

Zigzag lines
Flashing lights
auditory hallucinations
numbness or tingling on one side of the face or body
Weakness, unsteadiness.. etc

Migraine without aura (MO) diagnostic

criteria
A.At least five headache attacks lasting 4 - 72
hours (untreated or unsuccessfully treated), which has at
least two of the four following characteristics:
1. Unilateral location
2. Pulsating quality
3. Moderate or severe intensity (inhibits or prohibits
daily activities)
4. Aggravated by walking stairs or similar routine
physical activity
B.During headache at least one of the two
following symptoms occur:
1. Phonophobia and photophobia
2. Nausea and/or vomiting

Migraine with aura (MA) diagnostic

criteria
A.At least two attacks fulfilling with at least three of the
following:
1. One or more fully reversible aura symptoms indicating focal
cerebral cortical and/or brain stem functions
2. At least one aura symptom develops gradually over more than
four minutes, or two or more symptoms occur in succession
3. No aura symptom lasts more than 60 minutes; if more than one
aura symptom is present, accepted duration is proportionally
increased
4. Headache follows aura with free interval of at least 60 minutes
(it may also simultaneously begin with the aura
B.At least one of the following aura features establishes a
diagnosis of migraine with typical aura:
1. visual disturbance
2. Unilateral paresthesias and/or numbness
3. Unilateral weakness
4. Aphasia or unclassifiable speech difficulty

IMPORTANT TO KNOW! MIGRAINE WITH

AURA
IS A RISK FACTOR FOR ISCHAEMIC
STROKE
THEREFORE PATIENTS SUFFERING FROM
MIGRAINE WITH AURA
SHOULD NOT SMOKE!!!
SHOULD NOT USE ORAL CONTRACEPTIVE
DRUGS!!!

Drug therapy
Acute attacks analgesics, NSAIDS,
dopamine antagonists,
ergotamines(by inhibitingtrigeminal
neurotransmission).
Preventive therapy propranolol,
tricyclic antidepressants.

Cluster headache
Severe, unilateral pain, orbitally,
supraorbitally and/or temporally, lasting
15-180 minutes, occurring from once
every other day to 8 times a day.
Bouts may last weeks or months (scince
the name clusture) and then remit for
months or years (average 1/year)
80-90% are episodic (as above), 10-20%
are chronic

Cluster Headache criteria

A.At least five attacks of severe unilateral orbital,
supraorbital and/or temporal pain lasting 15 to 180
minutes untreated, with one or more of the following
signs occurring on the same side as the pain
1. Conjunctival injection
2. Lacrimation
3. Nasal congestion
4. Rhinorrhoea
5. Forehead and facial sweating
6. Miosis
7. Ptosis
8. Eyelid oedema
B. Frequency of attacks from one every other day
to eight per day

 Treatment acute: 100% oxygen,

ergotamines and triptans,
preventive: ergotamines,
corticosteroids, verapamil.

Hemicrania continua
Hemicrania continua(HC) is a
persistentunilateralheadachethat
responds toindomethacin (NSAID)
it's considered "diagnostic" if they
respond completely toindomethacin
because the cause and etiology are
not known.

Diagnostic criteria
* The following diagnostic criteria are given for hemicrania
continua[1]:
Headache for more than 3 months fulfilling other 3 criteria:
All of the following characteristics:
Unilateral pain without side-shift
Daily and continuous, without pain-free periods
Moderate intensity, but with exacerbations of severe pain

At least one of the following autonomic features occurs

during exacerbations and ipsilateral to the side of pain:
Conjunctival injectionand/orlacrimation
Nasal congestion and/orrhinorrhea
Ptosisand/ormiosis

Complete response to therapeutic doses of indomethacin

Secondary headache

Thunderclap headache
subarachnoid hemorrhage
Sinus Headaches
Arteriitis temporalis
Idiopathic intracranial hypertension
Meningitis
,,,, etc

Thunderclap headache
Is a headache that is acute and severe at onset
Originally used to describe the headache
associated with subarachnoid
hemorrhage(SAH).
If the work-up for SAH is negative, however,
there is a list of alternate possibilities for
etiology.
Diagnosis is made via a process of exclusion
with accompanying negativeCTand
lumbar punctureresults.

 Thunderclap headaches can be caused by

a number of different conditions including:
Subarachnoid hemorrhage
Cerebral venous thrombosis
Cervical artery dissection
Ischemic stroke
Meningitis
Primary thunderclap headache
Complicatedsinusitis

Subarachnoid hemorrhage
Most common cause of secondary
thunderclap headache and should be
the focus of the initial investigations
25% of patients presenting with
thunderclap headache have SAH
Etiology of SAH:
- Ruptured aneurysm 85%
- Non aneurysmal perimesencephalic
bleed 10%
- Other causes 5%

 Need to have maximal headache within

a few minutes
Typically the headache lasts at least a
few days
10-43% of patients with aneurysmal
SAH have a history of a sentinel
headache days to weeks before.
CT head: Sensitivity with new scanners
nears 100% within the first 12 hours.
Sensitivity falls to 50% by 1 week.

Sinus Headaches
Sinus headaches are headaches that may accompany
sinusitis, a condition in which the membranes lining the
sinuses become swollen and inflamed. patient may feel
pressure around his eyes, and forehead.
There are numerous factors that may predispose to
sinusitis and sinus headaches. If a patient suffers from
frequent colds and upper respiratory infections, he may
find that your sinuses are easily and often inflamed.
Some structural problems such as a deviated septum in
the nose can put you at a higher risk of sinus headaches.
Asthmatics may find that they experience frequent sinus
headaches due to a greater sensitivity to allergens.
So this headache is treated by mostly antibacterial and
decongestants drugs.

 Consult doctor if:

symptoms last longer than 10 days
have a severe headache, and overthe-counter pain medicine doesn't
help
have a fever greater than (38 C).

Arteriitis temporalis
is aninflammatorydisease ofblood vessels
(most commonly large and mediumarteriesof
the head). It is a form ofvasculitis.
The terms "giant cell arteritis" and "temporal
arteritis" are sometimes used interchangeably,
because of the frequent involvement of
thetemporal artery. However, it can involve
other large vessels.
It is more common in females than males by a
ratio of 3:1 with age>50y.
Corticosteroids, typically highdoseprednisone(4060mg ), must be started
as soon as the diagnosis is suspected.

 Patients present with:

1- fever
2-headache[4]
3 tenderness and sensitivity on thescalp
4- jawclaudication(pain in jaw when chewing)
5- tongueclaudication(pain in tongue when
chewing).
6- reducedvisual acuity(blurred vision)
7- acutevisual loss(sudden blindness)
8- diplopia.
9- acutetinnitus(ringing in the ears)

To summerize
Secondary headache
Acute narrow- Unilateral
angle
Halos around lights, decreased visual acuity,
glaucoma
conjunctival injection, vomiting
Encephalitis

Fever, altered mental status, seizures, focal neurologic

deficits

Giant cell
arteritis

Age > 55
Unilateral throbbing pain, pain when combing hair,
visual disturbances, jaw claudication, fever, weight loss,
sweats, temporal artery tenderness.

Idiopathic
intracranial
hypertension

Migraine-like headache, diplopia, pulsatile tinnitus, loss

of peripheral vision, papilledema

Intracerebral
hemorrhage

Sudden onset
Vomiting, focal neurologic deficits, altered mental
status

Meningitis
Sinusitis
Subarachnoid
hemorrhage

Tumor or mass

Fever, meningismus, altered mental

status
Positional facial or tooth pain, fever,
purulent rhinorrhea
Peak intensity a few seconds after
headache onset (thunderclap
headache)
Vomiting, syncope, obtundation,
meningismus
Eventually altered mental status,
seizures, vomiting, diplopia when
looking laterally, loss of spontaneous
venous pulsations or papilledema,
focal neurologic deficits

Thank you
..