Headache

primary headache disorders:

1. Migraine
   • Female predilection
   • Often commences in adolescence
   • Often a positive family history
   • Associated visual, sensory, motor or cortical symptoms
   • Unilateral throbbing headache
   • Associated gastrointestinal symptoms of nausea and vomiting
   • Associated light and sound sensitivity
   • Duration of days
   • Often recurrent, predictable triggers
2. Episodic tension type headache
   • Female predilection not so pronounced as in migraine
   • Often begins in young adulthood or later
   • No aura
   • Tight band-like pressing headache
   • No features of gastrointestinal disturbance, phono- or photo-phobia
   • Unusually not as incapacitating as migraine or cluster headache
3. Cluster headache
   • Male predilection
   • Severe, often excruciating pain
   • Unilateral with seldom side shift
   • Location of pain typically behind the affected eye
   • Shorter duration
   • Ipsilateral autonomic phenomena
   • Seldom triggers (except for alcohol during a cluster)
4. trigeminal autonomic cephalalgias

Primary frequent (chronic daily) headache disorders

1. Transformed migraine
2. Chronic tension type headache
3. New daily persistent headache
4. Hemicrania continua
5. Secondary headache disorders

secondary headache disorders

1. Headache secondary to disorders of the:
   – skull (eg. Paget disease, mastoiditis, secondary malignancy)
   – ears (eg. otitis media or externa)
   – eyes (eg. glaucoma, strabismus, ocular strain, iritis)
   – nose and nasal sinuses (eg. acute or chronic sinusitis)
   – teeth (eg. tooth abscess, malocclusion)
   – cervical spine (eg. cervical spondylosis)
   – cranial nerves (eg. herpes zoster, occipital neuralgia)
2. Headache secondary to:
   – intracranial vascular disorders (eg. venous sinus thrombosis, ruptured
   aneurysm, cerebral haemorrhage)
   – extracranial vascular disorders (eg. carotid artery dissection, cranial
   arteritis or carotidynia)
   – disorders of intracranial pressure (raised intracranial pressure or low
   cerebrospinal fluid pressure, eg. postlumbar puncture leak)
   – intracranial infections (eg. encephalitis or meningitis)
3. Headache attributable to:
   – generalised infection (eg influenza, typhoid or malaria)
   – medication (eg. vasodilators)
   – hypertension

Red flag headaches

• New onset, specific setting. New headache in the setting of :
  • cancer (metastases)
  • HIV infection (opportunistic infection)
  • postmanipulation or trauma of the neck, or associated with mild head trauma in the elderly
    (subdural haematoma)
• New headache that is persistent
• Focal signs or symptoms (other than the typical visual or sensory aura of migraine)
• Headache with focal neurological signs that precede or outlast the headache (the rare exception is hemiplegic migraine)
• Headache that is progressive (may suggest a mass lesion)
• Headache of sudden onset (may indicate a bleed either into the subarachnoid space or the cerebral parenchyma)
• Headache with rash (may indicate meningococcal meningitis or Lyme disease)
• Persistent unilateral temple headache in adult life (may indicate cranial arteritis)
• Headache with a raised erythrocyte sedimentation rate (ESR) (may be an indication of cranial arteritis, collagen disease or systemic infection)
• Headache with papilloedema (raises the suspicion of raised intracranial pressure due to a mass lesion or benign intracranial hypertension)
• Nonmigraine headaches in pregnancy or postpartum (cerebral vein thrombosis can occur during or just after pregnancy)
• Headache triggered by cough or straining (may be an indication of either a mass lesion or a subarachnoid bleed)
• Headache clearly triggered by changes in posture (may indicate low cerebrospinal fluid [CSF] pressure, for instance due to spontaneous CSF leak)
• Headache associated with pressing visual disturbances (may indicate conditions such as glaucoma or optic neuritis)
• Headaches that have primary characteristics, but with unusual features

Type of Medical Condition	Signs and Symptoms
metastases	New headache in the setting of cancer
opportunistic infection	New headache in the setting of HIV infection
Subdural haematoma	New headache postmanipulation or trauma of the neck, or associated with mild head trauma in the elderly
	Persistent headache
	Focal neurological signs (other than the typical visual or sensory aura of migraine)
Hemiplegic migraine (rare exception)	Headache with focal neurological signs that precede or outlast the headache
Mass lesion	Headache that is progressive
Bleed into subarachnoid space or cerebral parenchyma	Headache of sudden onset
Meningococcal meningitis or Lyme disease	Headache with rash
Cranial arteritis	Persistent unilateral temple headache in adult life
Cranial arteritis, collagen disease, or systemic infection	Headache with a raised erythrocyte sedimentation rate (ESR)
Raised intracranial pressure (mass lesion or benign intracranial hypertension)	Headache with papilloedema
Cerebral vein thrombosis	Nonmigraine headaches in pregnancy or postpartum
Mass lesion or subarachnoid bleed	Headache triggered by cough or straining
Low cerebrospinal fluid (CSF) pressure (e.g., spontaneous CSF leak)	Headache clearly triggered by changes in posture
Glaucoma or optic neuritis	Headache associated with pressing visual disturbances
Primary headaches with unusual features	Headaches that have primary characteristics, but with unusual features

Blue flag features :

indicate secondary headaches that do not require urgent investigation. Red flag features require urgent attention

• Headache that is mainly occipital, but sometimes radiates to the temple,
  exacerbated by examination of neck mobility (cervicogenic headache or
  cervical spondylosis)
• Headache temporally linked to whiplash injury of the neck
• Headache related to reading (eye strain)
• Headache clearly temporally linked to the ingestion of medications (eg.
  vasodilators)
• Headaches associated with systemic viral illness (eg. influenza)

Type	Site	Features	Causes	Management	Other
Tension Headache	Symmetrical, tight	Non-pulsating No nausea No vomiting	Stress, tension, cervical dysfunction	Relaxation, meditation Massage Simple analgesia	75% female
Cervical Dysfunction /Spondylosis	Occipital with radiation to parietal region, vertex, eye	Present on waking and settles Tender over C1-3 levels on side of headache	Abnormalities in C2/3 innervated structure, facet joint arthropathy	PhysiotherapySupportive neck pillowNSAIDsCorticosteroid injection	History of MVA/trauma
Cluster headache	Unilateral over or around eye	Wakes at same time, 1-3 times per day at same time in 6 week clusters	Vascular: dilation of blood vessels	100% O2 for acute attackPrevention: verapamil, lithium, methysergideSteroids rapidly suppress attacks	Alcohol aggravatingRetro-orbital headache +rhinorrhoea + lacrimation = cluster headache
Temporal arteritis	Temporal region and forehead	Severe burning pain, malaise, vague aches and painsESR elevatedJaw claudicationIntermittent blurred vision	Inflammation temporal artery Ophthalmic and post. Ciliary arteries can be involved leading to optic atrophy and blindness	Steroids: start immediately to prevent blindness Pred 60mg daily	50-70yo PMR 20% patients get TA May take 1-2 years to resolve
Raised intracranial pressure	Generalised, often occipital	Worse in mornings, intermittent Vomiting Vertigo Seizures drowsiness	Intracerebral tumour, subdural haematoma	Imaging and refer	Drowsiness + vomiting + seizure = raised ICP
Frontal sinusitis	Frontal or retro-orbital	Worse in mornings Focal facial tenderness Otitis media	Commonly post URTI	Steam inhalations Amoxil Analgesia
Subarachnoid Haemorrhage	Occipital	Sudden onset, neck pain and stiffnessVomiting, Kernig sign +Neurological deficit	Ruptured aneurysm	CT investigation and immediate referral	Occipital Headache + vomiting + neck stiffness =SAH