Headache

common medical problem.

Often a symptom associated with a
disease and not a diagnosis itself.
Most headaches are due to benign
causes
important to exclude more sinister
possibilities.

Red flags for headache

Progressively worsening headache
Sudden onset headache
Precipitated by exertion, cough
,sneezing
First episode after the age of 50 yrs
Disturbing Sleep
Systemic symptoms
Abnormal neurological examination-

Scenario 1
25 y female was admitted to NFTH
with a severe headache as she got
up from the bed in the early hours of
the morning. The headache was
mainly occipital. On admission she
vomited twice and was in severe
pain.

 She had been having episodes of

headache over the last 3 years.
Some of the episodes were following
soon after her periods.

Examination
normal

Scenario 2
25 year female was admitted with a
severe headache as she got up from
the bed in the early hours of the
morning. The headache was mainly
occipital and radiating down the
neck. On admission she vomited
twice and was in severe pain.
Past history - trauma to the neck last
year and was wearing collar.

EXAMINATION
Appeared drowsy
GCS 15/15
Neck stiffness ++

Causes
Primary
Secondary

Primary headache
migraine
Cluster
tension

Secondary headache
cranial
Extra-cranial

cranial
infection- meningitis, abscess
vascular- ICH,SAH
SOL- tumour, SDH

extracranial
toxic- viral, typhoid, leptospirosis
Hypertension
Referred from eye, ear, teeth,
sinuses, neck
Face-trigeminal neuralgia
Giant cell arteritis
Substance withdrawal
Psychiatric disorder

Headache due to Infection

Headaches presenting as a symptom of either
intracranial or systemic infections such as:
- Meningitis
- Encephalitis
- Brain abscess and empyema
- Sinusitis- 11 Oclock headache
- Dengue fever
- Malaria
- Leptospirosis

Types of Headache

Acute
Recurrent
Gradual
Chronic

Acute single episode

Meningitis
Encephalitis
Sub Arachnoid haemorrhage
Head injury
Referred pain from sinuses ,ear,
teeth etc

Sub Acute Headache

Giant cell arteritis

Recurrent Headache
Migraine
Cluster Headache.

Gradual Headache
Space occupying lesion

Chronic Headache
Tension Headache
Hypertension
Increase Intracranial pressure.
(Benign/SOL)
Analgesic rebound headache.
Trigeminal neuralgia.

Migraine

very common.
3 phases
premonitory symptom- mood changes, anorexia
aura visual symptoms
Headache

Migraine
Unilateral, Pulsatile quality,
associated with Nausea, Vomiting.
Moderate to severe pain.
Photophobia
Phonophobia
Lasts for about 48 72hrs

Migraine
Ranked as the third most prevalent disorder and
seventh-highest specific cause of disability
worldwide.
Migraine has two major subtypes:
Migraine without aura- Recurrent headache
manifesting in attacks lasting 4-72 hours.
Typical characteristics of the headache are
unilateral
location,
pulsating
quality,
moderate or severe intensity,
aggravation by routine physical activity and
association with nausea and/or photophobia and
phonophobia.

aura
recurrent attacks,
lasting minutes, unilateral fully
reversible visual, sensory or other
central nervous system symptoms
that usually develop gradually
usually followed by headache and
associated migraine symptoms.
*

Common triggering factors

Alcohol, particularly red wine
Certain foods, such as processed
meats that contain nitrates
Changes in sleep or lack of sleep
Poor posture
Skipped meals
Stress

Pathophysiology
Not clearly identified.
Related to serotonin mechanism.
Decrease in serotonin results in
deficit in the pain inhibiting system.
Precipitating factors.
Emotions, Menstruation, Hypoglycemia,
Weather, Sleep, Alcohol,food

Treatment
Acute attack

Paracetamol
Ibuprofen
Diclofenac
Metocloprmide

Treatment
Ergot Alkaloids
Triptans - considered to be specific
treatment for migraine.
Serotonin (5-HT)agonists.
Inhibit the release of vasoactive peptides.
promotes vasoconstriction.

Blocks pain pathways in brain stem.

Sumatriptan, Rizotriptan, Almotriptan,
Narotriptan, They are safe and
effective.

triptans
The serotonin 1b/1d agonists
effective for the acute treatment of
migraine
"specific" therapies for acute
migraine -in contrast to analgesics,
they act at the pathophysiologic
mechanism of the headache

mechanism
inhibit the release of vasoactive
peptides
promote vasoconstriction
block pain pathways in the brainstem

Preparations
sumatriptan, zolmitriptan,
naratriptan, rizatriptan, almotriptan,
eletriptan, and
Sumatriptan s.c injection
(autoinjector in the thigh), nasal
spray, oral
Zolmitriptan -both nasal and oral use

 The highest likelihood of consistent

success was found with rizatriptan
(10 mg), eletriptan (80 mg), and
almotriptan (12.5 mg).

avoid
in patients with familial hemiplegic
migraine, basilar migraine
ischemic stroke
ischemic heart disease
uncontrolled hypertension
pregnancy

Prevention
Give prophylaxis if patient is having
more than 4attacks per month.
Propanolol.
Flunarazine.
Amytriptyline.
Use HCT during menstruation.

Tension Type headache

Episodes of headache, typically
bilateral, pressing or tightening
in quality and of mild to moderate
intensity, lasting minutes to days
The pain does not worsen with
routine physical activity and is not
associated
with
nausea,
but
photophobia or phonophobia may be
present.

Tension Headache
Most frequent headache.
B/L Tightening pain.
No associated Nausea.
Treatment
NSAIDS
Prevention Tri Cyclic Antidepressants

Cluster headaches
Attacks of severe, strictly unilateral pain
which is orbital, supraorbital, temporal or in any
combination of these sites,
lasting 15180 minutes
occurring from once every other day to eight
times a day.
associated with ipsilateral conjunctival
injection, lacrimation, nasal congestion,
rhinorrhoea, forehead and facial sweating,
miosis, ptosis and/or eyelid oedema,
and/or with restlessness or agitation.

Cluster Headache

Unilateral
Severe pain
Usually Orbital or Supra orbital.
Lasts for 15mins 3hours.
Associated with lacrimation, Nasal
congestion.
Occurs in series of clusters weeks
to months.

Trigeminal neuralgia

Paroxysms of pain.
Pain is Stabbing or shocking in nature.
Lasts for seconds.
Common >50
triggering areas in the skin usually
ophthalmic or maxillary areas.
triggered by eating, talking, washing
face.
treatment: Carbamazapine

Giant cell Arteritis

Seen in elderly- may be a medical
emergency
Pain Over the Temporal artery.
Throbbing in nature
Jaw claudication
Increased ESR,biopsy
Treatment Prednisolone
Complication visual loss

Idiopathic Intracranial Hypertension

Increase CSF pressure with no
evidence of Intracranial pathology.

Intracranial Neoplasm

Intracranial Neoplasm.
Primary
Secondary

Tumors superficially located in

Frontal and Temporal Hemispheres.

Clinical features
Headache feature of increased
Intracranial pressure.
Progressive neurological deficit.
Seizures.
Disturbance of the level of
consciousness.
Cognitive and behavioral
impairment.

Features of Increased intracranial

pressure

Headache.
Vomiting.
Waking at night due to headache.
Headache worse on waking.
Papilloedema.

Progressive neurological
deficit
Hemisphere contra lateral
weakness, sensory disturbance,
vision loss, dysphasia.
Posterior fossa - Ataxia, Cranial
nerve palsy ( cranial nerve III & IV )
Cerebello pontine angle Deafness,
Ataxia, Facial sensory loss
Pituitary tumors Hyper or Hypo
secretion of hormones.

 Seizures commonly focal fits.

May lead to secondary
generalization.
90% of Gliomas may present with
fits.

Malignant tumors
Type

Site

Age

Glioma
(Astrocytoma)

Cerebral
Hemisphere

Adult

Oligodendroglioma Cerebral
Hemisphere

Adult

Medulloblastoma

Childhood

Posterior fossa

Benign tumors
Type

Site

Age

Meningioma

Cortical dura
Parasaggital
Sphenoidal ridge

Adult

Neurofibroma

Acoustic Neuroma

Adult

Craniopharyngioma

Supra sella

Childhood

Pituitary adenoma

Pituitary

Adult

Colloid Cyst

3 rd Ventricle

Any age

Investigation
CT scan.
MRI scan.
MRI Particular value in Brain Stem
and posterior fossa tumors.

Management
Medical management Relieve
raised ICP by Dexamethasone.
Surgery is the mainstay of treatment.
Radiotherapy & Chemotherapy

Brain metastasis
Site

cerebellum,
cerebral
hemispheres.
Commonly from malignant tumors of
Bronchus, Breast, Colon and Renal
cell carcinoma.
Clinical features will depend on the
site of metastasis.

 Management
Dexamethasone to reduce cerebral edema.
Surgical removal.

Paraneoplastic neurological
syndromes
Presents as a complication of cancer.
Symptoms may present before the
symptoms of malignancy.
Not due to direct or metastatic
invasion of the tumor.
Commonly associated cancers.
Small cell carcinoma of the lung, Breast
carcinoma, Gynocological cancers.

Presentation
Sensory neuropathy.
Lambert- Eaton Myasthenic
syndrome.
Polymyosities.
Dermatomyosities.
Cerebellar degeneration.

Subarachnoid hemorrhage

SAH
Blood in the subarachnoid space.
Can be due to
Traumatic
Spontaneous

Spontaneous SAH
Rupture of a berrys aneurysm of
circle of willis.
Commonly seen in the anterior
circulation of the circle of willis.
Commonly seen in anterior
communicating artery.

 Others
AV malformations.
Ingestion of cocaine and Amphetamines.

Risk factors
Hypertension
Smoking
Alcohol

Clinical features
Sudden onset severe headache.
( Thunder clap headache ).
Lasts for hours or days.
Associated vomiting.
Loss of consciousness
Photophobia
Irritability
Physical exertion and sexual excitement
are preceding factors.

Signs
Neck stiffness
Kernigs sign + ve
III cranial nerve palsy due to
posterior communicating artery
aneurysm.
Subhyloid haemorrhages in fundus
examination

Management

Recurrence in 40% in first 4 weeks.

Urgent referral to a neurosurgeon.
Non contrast CT brain
If negative do lumbar puncture after
12 hours.
Look for xanthochromia.
Traumatic LP no xanthochromia.
If LP is negative after 12 hours SAH
excluded.

Complications
Obstructive hydrocephalus.
Recurrent bleeding.
Cerebral ischemia due to vasospasm.

Treatment
Medical
Nimodipine

Surgical
Clipping of the aneurysm.
Inserting platinum coils to the aneurysm.