Rehan Pradhan
Internal Medicine Resident
PAHS
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Headache is among the most common medical complaints and
accounts for 1% to 2% of emergency department evaluations
and up to 4% of medical office visits.
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Although most often a benign condition (especially when
chronic and recurrent), headache of new onset may be the
earliest or principal manifestation of serious systemic or
intracranial disease.
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Headache is caused by traction, displacement, inflammation, or
distention of the pain-sensitive structures in the head or neck.
A. Within Cranial Vault include venous sinuses; anterior and middle
meningeal arteries; dura at skull base; falx cerebri; CN V, IX & X;
proximal portions of ICA and its branches near circle of Willis;
periaqueductal gray matter and sensory nuclei of thalamus.
The ventricular ependyma, choroid plexus, pial veins, and much
of brain parenchyma are not pain producing.
B. Extracranial Structures include periosteum of skull; skin;
subcutaneous tissues, muscles, and arteries; neck muscles; C2 &
C3 cervical nerves; eyes, ears, teeth, sinuses, and oropharynx;
and mucous membranes of nasal cavity.
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The key structures involved in primary headache are:
◦ Large intracranial vessels and dura mater, and peripheral
terminals of trigeminal nerve that innervate these structures
◦ Caudal portion of trigeminal nucleus, which extends into dorsal
horns of upper cervical spinal cord and receives input from first
and second cervical nerve roots (Trigeminocervical complex)
◦ Rostral pain processing regions, such as ventroposteromedial
thalamus and cortex
◦ Pain modulatory systems such as hypothalamus and brainstem
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Trigeminovascular system innervates large intracranial vessels
and duramater via CN V and synapses in the trigeminocervical
complex.
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Trigeminal activation can mediate the cranial parasympathetic
responses via pterygopalatine ganglion, which are secondary
events in headache cascade.
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Cranial autonomic symptoms, such as lacrimation, conjunctival
injection, nasal congestion, rhinorrhea, periorbital swelling,
aural fullness, and ptosis, are prominent in trigeminal
autonomic cephalalgias, including cluster headache and
paroxysmal hemicrania, and may also be seen in migraine.
Site
Headache
Unilateral
Invariable feature of cluster headache and majority of migraine
Bilateral
Most tension-type headache
Ocular or retro
orbital pain
Acute iritis, glaucoma, optic neuritis, or retro-orbital
inflammation (eg, Tolosa–Hunt syndrome), also common in
migraine or cluster headache
Paranasal pain
Sinusitis
Bandlike
Tension-type headache
Pain within V1
Postherpetic neuralgia (Burning in quality)
V2 or V3
Trigeminal neuralgia or tic douloureux (Lancinating pain)
Pharynx, EAM
Glossopharyngeal neuralgia
Onset of pain
Character
Headache
Pulsating or throbbing pain
Migraine
Steady tightness or pressure
Tension-type headache
Dull and steady
Intracranial mass lesions
Sharp, lancinating, stabbing
Neuritic cause such as trigeminal neuralgia
Icepick-like pain
Migraine, cluster headache, or giant cell
arteritis
Burning pain
Postherpetic neuralgia
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Trigeminal nerve carries sensation from intracranial structures
in anterior and middle fossae of the skull (above the cerebellar
tentorium). Discrete intracranial lesions in these locations can
produce pain that radiates in trigeminal nerve distribution.
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Glossopharyngeal (IX) and vagus (X) nerves convey sensation
from part of posterior fossa; pain originating in this area may also
be referred to ear or throat, as in glossopharyngeal neuralgia.
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Upper cervical (C2-C3) nerves transmit stimuli from the infra
tentorial and cervical structures; therefore, pain from posterior
fossa lesions often projects to C2-C3 dermatomes.
Association
Headache
Recent wt loss
Cancer, giant cell arteritis, or depression
Fever or chills
Systemic infection or meningitis
Visual symptoms
Involving optic nerve or tract or central visual pathways
Nausea/Vomiting Migraine, posttraumatic headache and intracranial mass
Photophobia
Migraine, acute meningitis, or subarachnoid hemorrhage
Myalgias
Tension-type headache, systemic viral infns, giant cell arteritis
Rhinorrhea
Cluster headache (with lacrimation), Sinusitis
Transient loss of
consciousness
Basilar migraine and glossopharyngeal neuralgia (due to
cardiac syncope); Subdural hematoma.
Episodic and may be worse
during menses and may
occur at varying intervals.
May be present every day,
esp stressful situations and
are often maximal at the
end of a workday
Frequently awaken patients
from sleep; often recur at
same time each day or
night; in bouts separated by
symptom-free periods.
Severe with time
Precipitant
Headache
Stress or fatigue, menses, hunger, fasting,
consumption of ice cream or foods with
nitrite (hot dogs, salami, ham, and most
sausage), phenylethylamine (chocolate) or
tyramine (cheddar cheese), exposure to
bright lights, OCP, Nitrates
Migraine
Coughing or sneezing
Structural lesion in posterior fossa
Chewing and eating
Glossopharyngeal neuralgia and tic
douloureux
Alcohol
Cluster headache
Acute URTI or hay fever
Chronic sinusitis
Exacerbating
Headache
Relieving factors
Anger, excitement, irritation
Migraine and TTH
Rapid changes in head position
such as bending over or by
events that transiently raise ICP,
such as coughing and sneezing
Migraine
Darkness, sleep, vomiting,
or I/L temporal artery
pressure, may diminish
during pregnancy
Coughing and sneezing
Intracranial SOL
Less severe on standing
Postural headache (maximal
when upright, nearly absent
when lying down) occurs with
low CSF pressure
Post LP and low
Recumbency
pressure headache
Stooping, bending forward,
sneezing or blowing nose
Sinusitis
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General condition of patient
Vital signs: Temperature, Pulse, Blood pressure, Respiratory rate
Head to toe examination: Built, Cyanosis, skin lesions, Scalp
tenderness, Nodularity, erythema, or tenderness over temporal
artery, Sinus tenderness, Arterial bruit over orbit or skull, Tongue
laceration, Carotid bruits, cervical muscle spasm, Papilledema
Neurological examination: Higher mental functions, CNs, motor,
sensory, signs of meningeal irritations
Cardiovascular system: Murmur
Respiratory examination: Chronic lung disease
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Primary headaches are those in which headache and its associated
features are the disorder itself, whereas secondary headaches are
caused by exogenous disorders. Primary headache often results in
considerable disability and decrease in quality of life.
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It is a chronic head-pain syndrome with bilateral tight, band like
discomfort that builds slowly, fluctuates in severity, and may
persist continuously for many days. It may be episodic or chronic
without nausea, vomiting, photophobia, phonophobia.
Simple analgesics such as acetaminophen, aspirin, or NSAIDs.
Behavioral approaches including relaxation can also be effective.
For chronic TTH, amitriptyline is the proven treatment.
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Group of primary headaches that includes
◦ Cluster headache
◦ Paroxysmal hemicrania
◦ SUNCT (Short-lasting Unilateral Neuralgiform headache attacks
with Conjunctival injection and Tearing)
Short lasting attacks associated with cranial autonomic symptoms,
such as lacrimation, conjunctival injection or nasal congestion.
Pain is usually severe and may occur more than once a day.
Misdiagnosed with "sinus headache”
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CH is relatively uncommon affecting fewer than 1 in
1000 adults, affecting six men to each woman.
Most people developing CH are in their 20s or older.
It is characterized by frequently recurring (up to several
times a day), brief but extremely severe headache,
usually focused in or around one eye, with tearing and
redness of the eye, the nose runs or is blocked on the
affected side and the eyelid may droop.
CH has episodic and chronic forms.
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Migraine is one of the common causes of recurrent headaches
According to IHS, migraine constitutes 16% of primary
headaches
Migraine afflicts 10-20% of the general population.
15-20% of women and 10-15% of men suffer from migraine.
Adults – Female: Male ratio is 2 : 1.
In childhood migraine, boys and girls are affected equally until
puberty.
Migraine is underdiagnosed and undertreated.
WHO ranks migraine among the world’s most disabling medical
illnesses
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According to World Federation of Neurology; “Migraine is familial
disorder characterized by recurrent attacks of headache widely
variable in intensity, frequency and duration. Attacks are
commonly unilateral and are usually associated with anorexia,
nausea and vomiting”.
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Triggers: Food, Disturbed sleep pattern, Hormonal changes, Drugs,
Physical exertion, Visual stimuli, Auditory stimuli, Olfactory
stimuli, Weather changes, Hunger, Psychological factors
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Diagnosis: Medical History, Headache diary, Migraine triggers,
Investigations (only to exclude secondary causes): EEG, CT Brain,
MRI
MIDAS: Migraine Disability Assessment score
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According to Headache Classification Committee of International
Headache Society, Migraine has been classified as:
• Migraine without aura (common migraine)
• Migraine with aura (classic migraine)
• Complicated migraine
Migraine Without Aura
No aura or Prodrome
Migraine With Aura
Aura or prodrome is present
Unilateral throbbing headache may Unilateral throbbing headache and
be accompanied by N/V
later becomes generalised
Patient complains of phonophobia
and photophobia
Patient complains of visual
disturbances and may have mood
variations
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Non-pharmacological treatment
– Identification of triggers
– Meditation
– Relaxation training
– Psychotherapy
•
Pharmacotherapy
– Abortive therapy
Non-specific
Specific
– Preventive therapy
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Non specific treatment: Acetaminophen, Aspirin, Diclofenac,
Ibuprofen, Naproxen
Specific treatment
Drug
Dose
Route
Ergot alkaloids
Ergotamine
1-2 mg/d; max-6 g/d
Oral
Dihydroergotamine
0.75-1 mg
SC
5-HT receptor agonists (5HT1B & 5HT1D and some 5HT1F agonism)
Sumatriptan
25-300 mg
6 mg
Orally
SC
Rizatriptan
10 mg
Orally
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cGRP receptor antagonist, Gepants have been shown
to be effective in acute treatment of migraine and
monoclonal antibodies to cGRP have been shown to be
effective in 2 early phase clinical trials.
Ditans: 5HT1F agonists
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Patients who have very frequent headaches (>2 per week)
Attack duration is > 48 hours
Headache severity is extreme
Migraine attacks are accompanied by prolonged aura
Unacceptable adverse effects occur with acute migraine
treatment
Contraindication to acute treatment
Migraine substantially interferes with the patient’s daily routine,
despite acute treatment
Special circumstances such as hemiplegic migraine or attacks with
a risk of permanent neurologic injury
Patient preference
Drugs
Dose (mg/d)
Betablockers
Propranolol
40-320
Calcium Channel Blockers
Flunarizine
Verapamil
10-20
120-480
TCAs: Amitriptyline
10-20
SSRIs: Fluoxetine
20-60
Anticonvulsant: Sodium valproate
Antihistaminic: Cyproheptadine
600-1200
4-8
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Clinical Neurology 10th edition, Roger P. Simon, Michael
J. Aminoff, David A. Greenberg
Harrison’s Principles of Internal Medicine – 21st edition
Uptodate