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C. Rivera, MD

- The most frequent painful state that affects humans
- Most common reason for seeking help
- The face and scalp are richly supplied with pain receptors
- Nasal & oral passages, eyes, ears delicate and highly
sensitive structures are in the head
- There is great concern about what happens to the head
because it houses the brain
- Headache raises the suspicion of brain tumor or other
cerebral disease
- Not more than 1 or 2 patients out of every 1,000 with tension
headache will be found to harbor an intracranial tumor
- Only 2/3 of patients with brain tumors present with
significant headache

Pain-sensitive Structures in the Head
A. Intracranial Structures
a. Cranial sinuses and afferent veins
b. Arteries of the dura mater
c. Arteries of the brain and other major branches
d. Parts of the dura mater near the large vessels
e. Periosteum
B. Extracranial Structures
a. Skin, scalp, fascia, muscle
b. Mucosa (nasal cavities & sinuses)
c. Arteries
C. Nerves
a. Optic, trigeminal, facial, vagus, glossopharyngeal
cranial nerves
b. Upper 3 cervical nerves

*The brain parenchyma is not sensitive to pain.

Mechanisms of Pain in Headache
1. Traction of the Circle of Willis & its branches
2. Dilation of intra & extracranial vessels
3. Induced spasm of intra & extracranial vessels
4. Inflammation o intra & extracranial structures including
5. Inflammation involving vessels
6. Sustained contraction of neck & scalp muscles
7. Changes in intracranial pressure & intracraniatory pressure
within nasal or paranasal sinuses, orbits, ears & teeth
8. Direct pressure on nerves containing pain fibers

Primary Headache vs Secondary Headache
Primary Headache
- Is the primary manifestation & no underlying disease process
is present
Secondary Headache
- Is a manifestation caused by an underlying disease process

*Patients often assume that the word headache should have conveyed
enough information about the nature of the discomfort.

Evaluation of Headache
1. Quality
2. Severity
3. Location
4. Onset / duration / time-intensity course
5. Conditions that produce, exacerbate or relieve
6. Auscultation of the skull, palpation

- Most headaches tend to be dull, aching and sharply localized
- Tightness, pressure, bursting, sharp, stabbing
- Most important: Throbs vascular sensitivity
- Authentic pulsatile throbbing, especially if hemicranial, is
characteristic of migraine

- Indices of Severity
o Degree to which the pain has incapacitated the
o Propensity to awaken the patient from sleep or
prevent sleep
- The most intense are in cases of meningitis, subarachnoid
hemorrhage (worst headache of my life), migraine, cluster
headache, tic doloreaux


Age of Onset
- Primary headache childhood to young adulthood
- Onset at an age greater than 50yrs is particularly suspicious
or secondary headache

- If unilateral, the pathology is usually the side of the headache
- Pain from the supratentorial structures is referred to the
anterior 2/3 of the head; pain from the inratentorial
structures is referred to the vertex & back of the head & neck
- Bifrontal & bioccipital headaches, coming after unilateral
headaches, signify the development of increased ICP

Relationship to Biologic Events, Precipitating & Relieving Factors
- Relationship to menstruation
- Headaches may follow periods of inactivity
- Headaches may follow prolonged use o the eyes
- Alcohol, straining, coughing, sexual intercourse, anger, stress
- Relieving factors: compression of the carotids, superficial
temporal arteries, lying supine, standing, rest

Factors that Trigger Headache
Physical Factors
- Menstruation, ovulation, pregnancy
- Birth control pills, hormone replacement (progesterone)
- Illness
- Strenuous activity / exercise
- Too much or too little sleep (jet lag)
- Fasting, missing meals
- Bright or flickering lights
- Excessive or repetitive noises
- Odors / fragrances / tobacco smoke
- Weather / seasonal changes
- High altitudes
- Medications

Dietary Factors
- Sour cream, yoghurt
- Cheese
- Sausage, bologna, salami, pepperoni
- Chocolate
- Chicken liver
- Pickled or dry herring
- Pickled food, fermented or maintained
- Freshly baked yeast products
- Nuts or nut butters
- Beans
- Onions
- Figs, raisins, papaya, avocado, red plums
- Citrus foods, bananas
- Caffeine, alcoholic beverages

1. Evidence of cranial trauma
2. Tenderness to palpation
3. Purulent discharges
4. Diminished temporal artery pulse
5. Auscultation of the head
6. Meningeal sign
7. Neurocutaneous disorders

Classification of Headaches by the International Headache Society
1. Migraine
2. Tension-type headache
3. Cluster headache & Chronic Paroxysmal Hemicrania
4. Miscellaneous headaches not associated with structural
5. Headache associated with head trauma
6. Headache associated with vascular disorders
7. Headache associated with non-vascular disorders
8. Headache associated with substances or their withdrawal
9. Headache associated with non-cephalic infection
10. Headache associated with metabolic disorders
11. Headache or facial pain associated with disorder of cranium,
neck, eye, ear, nose, sinuses, teeth, mouth or other facial or
cranial structures
12. Cranial neuralgia, nerve trunk pain and
13. Headache non classifiable

- Familial
- Periodic, unilateral, pulsatile
- Begins in childhood, adolescence or early in life. In >80%,
onset is before 30yrs of age. Diminishes in frequency during
advancing years
- Migraine with aura: Migraine without aura
o 1:5
- Genetic nature of migraine with aura = 60-80%
- 4-6% among men and 13-18% among women
- Related to intake of chocolates, cheese, fatty foods, oranges,
tomatoes, onions, tyramine, alcohol, exposure to glare,
jarring of the head, rapid changes in barometric pressure
- AURA: Usually visual, may be in the form o focal numbness,
tingling, weakness, dysarthria, confusion, dizziness. Lasts 1-
15mins then followed by headache

Phases of Migraine
1. Prodrome mood changes, food cravings
2. Aura reflects the spreading wave of cortical depression
3. Headache
4. Postdrome malaise, mood changes, impaired
concentration, scalp & muscle tenderness

Migraine Variants
- Basilar migraine
- Opthalmoplegic or retinal migraine
- Migraine following head injury
- Abdominal igraine
- Hemiplegic migraine
- Status migranosus
- Complicated migraine or migranous infarction
o Stroke and TIA with migraine

- More common in young adult men (20-50yrs old), M:F = 5:1
- Consistent unilateral orbital localization. Deep pain & around
the eye. Intense and non-throbbing
- Radiates to the forehead, temple & cheek. Implies
involvement of the ophthalmic division of the trigeminal
- Occurs nightly, between 1&2 hrs after the onset of sleep.
Lasts 45mins
- Lasts for 8-12 weeks followed by complete freedom from
- Associated features: blocked nostril, rhinorrhea, injected
conjunctivum, lacrimation, miosis, ptosis, flush & edema of
the cheek

Mechanisms of Pain in Cluster Headache
- Paroxysmal parasympathetic discharge mediated through the
greater superficial petrosal nerve & sphenopalatine ganglion
- Narrowing of the ipsilateral ICA due to swelling of the arterial
wall. This would compromise the pericarotid sympathetic
- Parasympathetic overactivity & sympathetic dysfunction
probably due to inflammation of the cavernous sinus
- The cyclic nature of the attacks has been linked to the
hypothalamic mechanis that governs circadian rhythm

- Most common variety of headache
- Bilateral, wit occipitofrontal, temporal or frontal
predominance or diffuse extension over the top of the
- Dull & aching, fullness, tightness or pressure, head is
surrounded by a band or is clamped
- Lacks the persistent throbbing. Does not seriously interfere
with daily activities
- The only type of headache that may be present throughout
the day, day after day, or long periods of time
- More common in women. Coincides with anxiety, fatigue,
- Infrequently begins in childhood or adolescence

Mechanism of Pain
- Excessive contraction of craniocervical muscles and
constriction of scalp arteries
- Abnormal neuronal sensitivity & pain facilitation
- Hypothesis: Migraine and tension-type headaches are part of
a continuum of headache syndromes where the
predominating mechanism for head pain defines what type of
headache is experienced

Symptomatic Treatment
- GOAL: to stop a headache
o For headaches <3x/month
o Should not exceed 3 days week

Preventive Therapy
- GOAL: to reduce the frequency, severity and duration of
o For frequent attacks of headache >4x / month


Headache danger signals in Adults
Danger signals on history
1. Sudden onset of new severe headache
2. First headache in an adult
3. Progressively worsening headache
4. Onset with exertion, coughing, straining &/or sexual activity
5. Associated symptoms such as: drowsiness, confusion,
memory loss, chronic malaise, myalgia, arthralgia, fever

Danger signals on Examination
1. Abnormal vital signs esp fever and HPN
2. Altered sensoriu
3. Unequal or poorly reactive pupils
4. Papilledema or retinal hemorrhages
5. Signs of meningeal irritation
6. Lateralized weakness or sensory deficit
7. Asymmetrical reflexes / abnormal plantar response
8. Ataxia of gait &/or movements
9. Tender and poorly pulsating cranial arteries

I. Patients with serious headache (secondary headache)
a. Increased ICP
b. CNS infection
c. SAH
d. Cranial arteritis
e. Metabolic causes
f. Pheochromocytoma, malignant HPN
g. Acute glaucoma
h. Head trauma
i. CNS ischemia / hemorrhage
II. Patients with painful but benign headache (primary
a. Migraine
b. Cluster headache
c. Tension-type headache
d. Benign exertional headache
e. Orgasmic headache

Full evaluation of the patients needs:
1. Detailed history
2. Complete PE
3. Complete Neuro exam

*Take note of the HEADACHE DANGER SIGNALS that may suggest the
probability if ominous disease as the cause of headache.

For Secondary headache:
a. CBC with platelet count, ESR, ABG, blood chemistry
b. Imaging studies: CT scan / RI of the head, cervical spine Xray
c. CSF studies if no contraindication based on the CT scan of the
d. Ocular pressure measurement

For Primary headache: no further work-up is necessary

Indications for Neuroimaging
1. To rule out a structural disorder
2. For recurring & progressive headache
3. First worst headache
4. Changing headache patters with focal neurological deficits
5. Focal slowing on EEG
6. Comorbid seizures
7. Persistent unilateral headaches
8. To assure an anxious patient or his relatives

Giant Cell Arteritis
- In patients >50yrs
- Unilateral, intense, sharp, throbbing or non-throbbing
- Thickened and tender temporal & scalp arteries. Without
- High ESR & CRP
- Danger of blindness
- Biopsy is needed
- Treated with Prednisone

*If the cause of the headache cannot be determined, admit the
patient for further observation and work-up.

For Secondary Headache specific treatment on etiology
For Primary Headache
1. Migraine
a. Reassurance
b. Hydration, anti-emetics
c. SQ or oral Triptan
d. IM Ketorolac
e. IV Nalbuphine
f. IV Neuroleptics
g. One dose of IV Dexamethasone 4mg
2. Cluster Headache
a. O2 inhalation at 6-8L/min for 20mins
b. SQ Sumatriptan 3mg. May repeat in 20mins if
c. Oral Sumatriptan, 50mg
d. Intranasal Lignocaine
e. Perineural injection of Lignocaine 1%, 4-5ml at the
greater occipital nerve
f. IV Narcotics
3. Tension-type Headache
a. IV mild sedative
4. Mixed headache syndrome symptomatic treatment

- Cold compress
- Shield your eyes from light
- Pay attention to diet
- Regular sleeping schedule
- Regular exercise
- Stress management, psychotherapy
- Control environmental factors
- Acupuncture, physical therapy, massage, TENS
- Meditation, relaxation