Headaches

• Headaches


  Aren't a disease state or condition, but rather a symptom, of which there are many causes
• Most people (more common in women) have headaches occasionally which resolve relatively quickly
• Primary headaches


  Have no underlying pathology and are more common, e.g. migraine, tension headaches, cluster headache
• Secondary headaches


  Are due to underlying pathology. Origin may be infectious, neoplastic (abnormal tissue growth), vascular or drug-induced
• Virtually everyone will have suffered from a headache at some time; it's probably the most common pain syndrome experienced by people
• Up to 80-90% of the population will experience one or more headaches per year
• Tension-type headache affects between 30% and 80% of people in Western countries, with age prevalence peaking between 20 to 40 years
• Migraine affects between 15% to 20% of women and is approximately two or three times more common than in men
• Cluster head is more common in men: episodic headache, which accounts of 90% of cases, is about four times more common and chronic cases fifteen times more common in men than women
• Migraine


  Thought to be caused by the abnormal dilation of blood vessels within or around the skull, but this vascular theory doesn't explain all migraine symptoms
• Migraine


  Likely a combo of vascular and neurochemical changes, i.e. the neurovascular hypothesis
• Migraine appears to have a genetic component
• Migraine attacks can last anywhere from 4 to 72 hours and the average length of an attack is 24 hours
• Migraine


  • Characterised by unilateral (one-sided), moderate to severe, throbbing pain and usually occurs every few weeks
• Phases of a Migraine

  1. Premonitory phase

  2. Headache with or without aura

  3. Resolution phase
• Migraine with Aura


  Accounts for less than 25% of migraine cases. The aura, which is fully reversible, develops over 5 to 20 minutes and can last for up to an hour
• Migraine with Aura


  • Visual or neurological auras, pain is unilateral, throbbing and moderate to severe, nausea affects almost all patients but less than as third will vomit, photophobia and phonophobia
• Migraine without Aura


  The remaining 75% of sufferers don't experience an aura but do suffer from all other symptoms that those with aura do
• Summary of Migraine Symptoms

  • Prodrome phase
  • Unilateral throbbing
  • Nausea and vomiting
  • Aura
  • Photophobia and phonophobia
• Tension Headache


  A tight band around the head that spreads to the top of the head, could be due to muscle spasm in the neck and scalp or tension in muscles resulting in constricted capillaries, reducing blood flow
• Types of Tension Headaches

  • Episodic (infrequent, frequent)
  • Chronic
• Episodic Tension Headache


  • Headaches last from 30 minutes to up to 7 days, pain is bifrontal or bioccipital, generalised and non-throbbing, gradual in onset and tends to worsen progressively throughout the day, mild to moderate pain, not aggravated by movement
• Chronic Tension Headache


  Occurs on at least 10 episodes per month and might be daily, lasting for at least 3 months, can severely affect the patient's quality of life
• Cluster Headache


  Severe, sharp, unilateral pain within and above eye and temporal region, associated with automatic symptoms, occurs once every other day 8 times a day often with circadian rhythm, duration is 15 mins to 3 hours
• Chronic Daily Headache


  Headache that occurs at the same time everyday that lasts for 15 days or more per month, pain appears to linger from morning to night and varies from an ache to a dull throb
• Causes of Secondary Headaches

  • Eye strain/glaucoma
  • Sinusitis
  • Referred jaw/dental pain
  • Muscle strain in neck/upper back
  • Hypertension (rarely)
  • Subarachnoid haemorrhage
• Medication Overuse Headache


  Type of secondary headache due to analgesic overuse which causes an increase in number of pain receptors that are switched on, first by pain itself then by increased sensitisation of receptors
• Traction Headache


  Pathology causes irritation and stretching of meninges, caused by inflammation, tumours, haematomas
• Space-occupying Lesion


  Tumours + cerebral abscesses compress brain tissue against skull, leading to increased intracranial pressure
• Location of Headache Pain

  • Frontal
  • Occipital (back of head)
  • Hemi-cranial (unilateral — one side)
  • Orbital (behind/around eyes)
  • Temporal (temples on sides of head)
• Description of Headache Pain

  • Sudden pain
  • Throbbing/pounding pain
  • Constant/nagging pain
  • Moderate-severe pain
• Questions to Ask About Headaches

  • Location of pain
  • Nature of pain
  • Duration
  • Speed of onset
  • Triggers
  • How often
  • Any history of headaches
  • What has worked before
  • Other meds
  • Other symptoms
  • Severity
  • Recent trauma or head injury
  • Underlying medical conditions
  • Aggravating or relieving factors
• Other Symptoms Associated with Headaches

  • Nausea and vomiting
  • Fever
  • Nasal congestion
  • Insomnia
  • Visual disturbances
  • Neck stiffness
  • Rash
  • Weight loss
  • CNS symptoms
• Management of Headache Pain

  1. Remove any causative factors

  2. Consider analgesics

  3. Non-drug therapy (relaxation)

  4. For medication overuse headache
• Non-Opioid Analgesics (first-line treatments)

  • Paracetamol
  • NSAIDs (ibuprofen, diclofenac, aspirin)
• Opioid Analgesics (second-line treatments)

  • Codeine & dihydrocodeine
  • Caffeine
• Anti-migraine Drugs


  Try simple analgesic first, such as ibuprofen and aspirin, paracetamol + codeine combination, some have antihistamine for nausea, 5HT1 agonist - sumatriptan
• Herbal Supplements


  • Feverfew
  • Valerian, hops, St John's Wort
• When to Refer


  • Headache in children 12 years old who have a stiff neck, high temp or skin rash
  • Headache after recent (3 months) trauma or injury
  • Nausea and/or vomiting in the absence of migraine symptoms
  • Neurological symptoms, if migraine is excluded
  • Very sudden and/or severe onset of headache
  • New or severe headache in patients 50 years
  • Progressive worsening of headache symptoms over time
  • Headache unresponsive to analgesics