Headache

Headache. 1

Classification. 1

Pathogenesis. 2

Clinical manifestations. 2

Diagnosis. 2

Tension Type Headaches. 2

Treatment 2

Medication Overuse Headache. 3

Classification

ICHD-3

Primary Headaches

• Migraine

• Tension-type headache

• Trigeminal autonomic cephalgias

• Other primary headaches

Secondary Headaches

Headaches attributed to:

• Trauma or injury to head or neck

• Cranial or cervical vascular disease

• Non-vascular intracranial disorder

• A substance or its withdrawal

• Infection

• Disorder of homeostasis

• Disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cervical structure

• Psychiatric disorder

Neuropathies and Facial pains and other headaches

• Painful lesions of the cranial nerves and other facial pain

• Other headache disorders

Primary	%
Migraine	16
Tension	70
Trigeminal Autonomic Cephalgias	0.1
Cluster
Paroxysmal hemicrania
SUNCT/SUNA
Other
Cough headache
Exertional headache
Sexual activity associated
Hypnic
Thunderclap
Hemicrania continua
New daily-persistent headache
Secondary
Trauma	4
Vascular disorder (GCA, SAH)	1
Non-vascular intracranial disease - Idiopathic intracranial HTN - Tumour	0.1
Substance use or withdrawal - Medication overuse headache
Related to infection - systemic infection - intracranial infection	63
Disorders of haemostasis
Related to extracranial structure - sinus, teeth, eyes etc.
Secondary to psychiatric disorder

Chronic Daily Headache

• Frequently used term, now classified in HIS scheme as either of the entities
• Chronic Migraines
• Chronic tension type headaches
• Medication overuse headache
• Hemicrania continua
• New daily persistent headache

Pathogenesis

• Pain producing structures of the cranium
• Scalp
• Middle meningeal artery
• Dural sinuses
• Falx cerebri
• Proximal segments of large pial arteries

Clinical manifestations

• Red flags
• Worst headache ever
• First severe headache
• Subacute – worsening over days or weeks
• Abnormal neurology
• Fever
• Vomiting that precedes headache
• Pain induced by bending, lifting, coughing
• Pain that disturbs sleep
• Pain on awakening
• Onset after age 55
• Temporal artery tenderness
• History of systemic illness
• Elements of examination
• IOP
• Cervical spine mobility

Diagnosis

• For screening CT or MRI are probably equally sensitive.

Primary Headaches

Migraine

Tension-type headache

Trigeminal autonomic cephalgias

• Cluster

• Paroxysmal hemicrania

• Short-lasting unilateral neuralgiform headache attacks

• Hemicrania continua

Other primary headaches

• Primary cough headache

• Primary exercise headache

• Primary headache associated with sexual activity

• Primary thunderclap headache

• Cold-stimulus headache

• External-pressure headache

• Primary stabbing headache

• Nummular headache

• Hypnic headache

• New daily persistent headache

Migraine

See

Tension-Type Heacache

Prevention

• Medications
• TCAs/Amitriptyline – has best evidence
• Reduces length and number of headaches
• Start low dose – trial used 75mg daily
• SNRI
• Mirtazepine and venlafaxine – some evidence
• SSRI - no evidence of benefit over placebo
• Topiramate and gabapentin may help

• Behavioural therapy
• CBT, relaxation and combinations “stress management” have been investigated to some extent
• Some evidence of effectiveness
• May get a small additive effect from TCA plus stress management

Other Primary Headaches

Primary stabbing headache

Treatment:

• May respond to Indomethacin 75-150mg daily

o 30-50% response in some series

• Other agents that have been trialled:

Nummular headache

• “Coin-shaped headache”

• ?A terminal branch neuralgia

• Pain in a small, circumscribed area of the scalp

• Usual features:

o Sharply contoured

o Fixed size and shape

o Round or elliptical

o 1-6cm diameter

• Usually parietal region

• Can be multifocal

• Usually mil-moderat pain

• Variable duration (75% >3 months)

• Hypaesthesia, dysaesthesia, paraesthesia, allodynia, tenderness

Treatment:

• Try neuropathic pain medication, such as gabapentin.

Hypnic headache

• “Alarm clock headache”

• Rare

Clinical

• Recurring headache attack developing only during sleep, causing awakening

• Dull, tension type headache – usually mild-moderate, occasionally severe

• Last 15min to 4 hours

• >10 days/month for >3 months

• Usual onset >50 yrs

• Can have some (but not multiple) migraine features – e.g. nausea, photophobia, phonophobia

• Must be distinguished from TACs

• Must rule out other headaches occurring in sleep (OSA, raised ICP)

Treatment

• Lithium as a prevenative

• Caffeine (100mg) prior to sleeping

• Melatonin

• Indomethacin

Medication Overuse Headache

• Most frequently implicated mediations (one study)
• Analgesics
• Ergots
• Opioids
• Triptans
• Combinations
• Main message is that analgesics are most frequently associated
• Cause and effect difficult to distinguish

Thunderclap

Aetiology

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