Medical Causes of Headache

8/14/2019 Medical Causes of Headache

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Medical causes of headache


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Headache - Epidemiology

Most frequent presenting symptom - outpatient clinic

1-2.5% of emergency visits

>95% of population experience atleast one episode during

lifetime

-Primary care physicians to speciality doctors

one of the top ten complaints in any speciality

Longest list of differential diagnosis in medicine

Underestimating headache to over investigating headache

remains a concern.


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Classification of headache

International Classification Of Headache Disorders

ICHD (revised in 2004 )

1.Primary

2.Secondary

The primary headaches( no identifiable cause)

1.Migraine

2.Tension-type headache

3.Cluster headache and other

4.Trigeminal-autonomic cephalalgias

5.Other primary headache disorders


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Other primary headache disorders

Primary stabbing headachePrimary cough headache

Primary exertional headache

Primary headache associated with sexual

activity

Primary thunderclap headache

Hemicrania continua

New daily persistent headache


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Diagnostic criteria for migraine

At least 5 attack f ulfilling criteria

Headache attacks lasting 4-72 hours (untreated or

unsuccessfully treated)

Headache has at least two of the following characteristics:

unilateral location

pulsating quality

moderate or severe pain intensityaggravation by routine physical activity (eg,

walking or climbing stairs)

During headache at least one of the following:

nausea and/or vomiting

photophobia and phonophobia

Not attributed to another disorder

Treatment Acute ergotamine, sumatriptan

Prophylaxis verapamil, propanalol


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Tension headache

1.Episodic

2.Chronic

Episodic 1.Frequent

2.Infrequent

Bilateral, non throbbing

Non pulsatile

Band likeTreatment Acetaminophen, relaxation

therapy


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Cluster headache

1.Common in males 7 : 1 ratio2.Occurs in specific time period of a day,

daily, specific month of year

3.Associated with lacrimation, conjuctival

injection, autonomic disturbance4.Usually retro orbital, supra orbital

5.Treatment with steroids, verapamil

SUNCT Sudden Unilateral Neuralgiaform

heaache with Conjectival injection and

Tearing


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The secondary headaches( with identifiable cause)

Headache attributed to head trauma and or neck trauma

Headache attributed to non-vascular, non-infectious, intracranial disorder

Headache attributed to substances or their withdrawal

Headache attributed to infection

Headache attributed to disturbance 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 neuralgias, and central causes of facial

pain disorder

Headache associated with metabolic disorders

Trigeminal, glossopharyngeal neuralgia


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Theories of headache

1.Vasogenic

Intracranial vasoconstiction followed byrebound vasodilatation

2. Neurogenic

brain is the centre point of headache

3.Others

Stimulation of trigeminovascular fibres

around the pial vessels

Emotional triggers modulate activity ofvessels near meninges..


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Cardiological conditions

1.Nitrate related

2.Hypertension

Nephrology related

1.Acute glomerulonephritis

2.Pyelonephritis

3.Dialysis related

Rheumatological conditions

1.Temporal arteritis

2.SLE

3.Antiphospholipid antibody

syndrome

Others

1.Anaemia

2.Hypoxia

3.Hypercapnia

4.Sleep apnea

5.Hypothyroidism


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Acute severe new- onset headache (first

or worst)

Crash migraine

Cluster headache

Systemic lupus erythematosus

Temporal arteritis

Accelerated hypertension

Phaeochromocytoma

Acute intoxicationsAcute febrile illness

Acute pyelonephritis

Acute mountain sickness


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Gold standard in the management of headache

Good clinical history and

general and neurological examination

including fundoscopy

When and Who to investigate?????


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Red flag signs

Head or neck injury

New onset of headache first/ worst ever

headache

Onset of new headache type,

Change for worse in pattern of existingheadache.

Progressively worsening headache

Age > 50 years

Neurological signs or symptoms

Systemic signs or symptoms

Secondary risk factors such as a history of

cancer or human immunodeficiency virus

infection


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Yellow flags

Wakes patient from sleep at night

Headache always occurs on the same side

Prominent effect of change in posture on pain


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All primary headache blood investigations are normal

Reasons to consider blood tests to evaluate headaches

Inflammatory disease

Infectious disease

Prolactin level

Complete haemogram

TSH, serum calcium

BUN,Creatinine


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When to consider neuroimaging

Temporal profile and headache features:

1. The first or worst headache (thunderclap

headache)2. Subacute headache with increasing frequency

or severity

3. Progressive or new daily persistent headache

4. Chronic daily headache

5. Side-locked

6. Headache not responding to treatment

Demographics:

1. New headache in patient with cancer or HIV

2. New headache age > 50

3. Headache and seizures

Associated symptoms and signs:

1. Fever, stiff neck, nausea and vomiting

2. Focal neurological symptoms or signs

3. Papilledema, cognitive impairment or

personality change


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MOST IMPORTANT INDICATION IS.

REASSURANCE , REASSURANCE, REASSURANCE


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Carry home message

1.Spare time on history

it solves the puzzle

2.Ascertain whether its primary or secondary

3.Investigate as and when needed

Nothing routine here

4.Never miss a red flag/ yellow flag sign..


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Documents

Medical Causes of Headache