Definition: Headache is defined as pain located in the head, neck, or jaw.
Etiology: Its etiology can be divided into two main types. Primary headache syndrome (Migraine headache, tension headache, cluster headache) and secondary headache syndrome (Intracranial heamorhages, meningitis, temporal arteritis, glaucoma and brain tumor) as shown in the above image.
Most important question to be asked from the patient in history. Wheather this is first episode of headache or recurrent. History of recurrent headache makes the diagnosis of primary headache. History of first time headache specially when severe speaks strongly for serious underlying pathology.
Specific characteristics of secondary headache. (1) Headache + nuchal rigidity +fever suggests meningitis. (2) Headache + nuchal rigidity without fever suggests an intracranial hemorrhage and patient will describe as the “worst headache of my life” or “thunderclap at onset”. (3) If the patient describes the headache as deep, dull, aching pain that disturb sleep suggests brain tumor. (4) If patient complain of unilateral pounding, dull with superimposed lancinating pain associated with visual changes suggest temporal arteritis. ( patient may also complain of difficulty in combing hair or lying on pillow). (5) Patient with glaucoma will usually give a history of eye pain preceding the onset of headache.
- Tension headache. No physical finding
- Migraine headache. No physical findings usually, but rare cases have aphasia, numbness, dysarthria, or weakness.
- Cluster headache. Red, tearing eye with rhinorrhea; (Evaluate for glaucoma with headache and a red eye)
- Giant cell arteritis. Visual loss, tenderness of the temporal area.
Diagnostic tests. Tension headache, migraine headache and cluster headache have no specific diagnostic tests. Head CT or MRI is done to exclude intracranial mass lesions if the diagnosis is unclear or the syndrome has recently started. There is no need to perform imaging if there is a clear history of headache of a particular type.Giant cell arteritis is associated with a markedly elevated ESR and the most accurate test is a biopsy.
Treatment. Treatment of secondary headache syndrome is usually the treatment of the cause.
- Tension headache: NSAIDs and other analgesics
- Migraine headache: triptans or ergotamine as abortive therapy
- Cluster headache: triptans, ergotamine, or 100% oxygen as abortive therapy.
- Giant cell arteritis: prednisone immediately, without waiting for the biopsy result.
Abortive therapy for Migraine and cluster headache. Both of these can be rapidly interrupted by either ergotamine or one of the triptans (eg. Sumatriptan, electriptan, almotriptan, zolmitriptan). The main difference is that 100% oxygen , prednisone and lithium are effective at interrupting cluster headache but not migraine.
Preventive therapy for migraine. Patient experiencing three or more migraine headaches per month should be started on treatment to prevent them. The best preventive therapy is propranolol. Other preventive medications are:
- Calcium channel blockers
- Tricyclic antidepressants (amitriptyline)
- SSRIs, topiramate
- Botulinum toxin injections
Since cluster headaches happen in short bursts (hence the name cluster) and then resolve for months to years, preventive therapy is not clear. Provide cluster prophylaxis with verapamil if needed.
Pseudotumor cerebri; another type of headache associated with obesity, venous sinus thrombosis, oral contraceptives and vitamin A toxicity. On examination papilledema with diplopia from sixth cranial nerve palsy. The diagnosis cannot be made without a CT or MRI to exclude an intracranial mass lesion and a lumbar puncture showing increase pressure. Only the pressure is abnormal, the CSF itself is normal. Weight loss and acetazolamide to decrease production of CSF can help.
Sinus headache; Your sinuses are air-filled spaces inside your forehead, cheekbones, and behind the bridge of your nose. When they get inflamed usually because of an allergic reaction or an infection they swell, make more mucus, and the channels that drain them can get blocked.The build-up of pressure in your sinuses causes pain that feels like a headache.Symptoms: You’ll feel a deep and constant pain in your cheekbones, forehead, or the bridge of your nose. The pain usually gets stronger when you move your head suddenly or strain