Headaches

Introduction

Headache is defined as pain or discomfort in the head and the surrounding structures.
They may be:

  1. Primary (idiopathic)
  2. Secondary

Primary headache types

  1. Tension type
  2. Migraine with or without aura
  3. Cluster headache

Secondary causes

  1. Intracranial space-occupying lesions like brain tumours, subdural haematoma
  2. Vascular lesions: strokes
  3. Infections
  4. Following generalized convulsions
  5. Metabolic derangements
  6. Alcohol hangover
  7. Drugs
  8. Irritation of sensory cranial nerves
  9. Inflammation or diseases of structures/organs in the head region: eyes, nose, sinuses, ears, cervical vertebrae.

Atypical headache

  1. Sleep disorders (hypoxia)
  2. Brain stem malformations
  3. HIV infection

Clinical features

This depends on the underlying type/cause(s):

Tension type

  • Heaviness in the head
  • Crawling sensation
  • “Peppery sensation”.Tight-band sensation.Disturbed concentration
  • Poor sleep

Cluster type

  • Recurrent, frequent, brief attacks of disturbing pain in the head
  • Redness of the eyes
  • Pain around the eyes and forehead
  • Drooping of the eyelids
  • Nasal stuffiness

Migraine headache

Read about migraine headache here

Secondary headaches: presence of additional symptoms:

  • Fever
  • Vomiting
  • Neck stiffness
  • Alteration in level of consciousness
  • Convulsions
  • Cranial nerve deficits
  • Limb weakness (hemiparesis, quadriparesis)
  • Papilloedema as evidence of raised intracranial pressure
  • Evidence of disease in other organs
  • Evidence of drug or alcohol abuse.
  • Persistent daily Headache
    • daily attacks of pain on the head
    • mimics tension-type pain and could have pulsating quality
    • associated with chronic use of analgesic drugs which then sets up a vicious cycle
    • may point to underlying stress or emotional disturbance

Differential diagnoses

  • Meningitis
  • Hysteria
  • Refractive error
  • Cervical spondylosis
  • Brain tumour
  • Haemorrhagic stroke

Complications

Depend on the cause and type

  • Some are benign with no sequelae apart from reduced economic productivity/wastage of medications
  • Coning (depending on cause)
  • Blindness (following temporal arteritis, unrelieved raised intracranial pressure)

Investigations

  • Neuro-imaging: skull X-ray, computerized tomographic scan,
  • MRI
  • Cerebrospinal fluid examination for pressure, cells and chemistry
  • Erythrocyte sedimentation rate
  • Electroencephalography

Treatment objectives

  • Eliminate pain
  • Treat the precipitating factor or disease
  • Prevent recurrent attacks

Non-drug treatment

  • Psychotherapy
  • Physiotherapy/biofeedback

Drug treatment

Primary headaches

  • Simple analgesics and non-steroidal anti inflammatory agents
  • Tricyclic antidepressants:
    • Amitriptyline 10-25 mg daily at night
  • Anxiolytics
    • Lorazepam 1-2.5 mg at night. Use lower doses for the elderly patient
    • Stop analgesic use in individuals with persistent daily headaches

Secondary headaches

  • Medical or surgical management of identified causes
  • Antibiotics for infections like meningitis, sinusitis
  • Steroids for vasculitis

Notable adverse drug reactions, caution

  • Aspirin and other NSAIDs: use with caution in patients with history of dyspepsia, and asthma
  • Tricyclic antidepressants: use with caution in respiratory diseases, cardiac symptoms, muscle weakness and myasthenia gravis, organic brain damages, history of drug or alcoholic dependence, personality disorder, may increase risk of dependence, avoid prolonged use or abrupt withdrawal thereafter. Drowsiness may affect performance of skilled tasks(e.g. driving), effects of alcohol enhanced anticholinergic effects e.g. urinary retention in the elderly

Prevention

  • Reduce stress levels
  • Prophylactic medications if attacks last more than 15 days a month, or are severely incapacitating (in the absence of other causes)
  • Early detection and correction of refractive errors, sinusitis, oto-rhino-laryngologic and dental problems.