HEADACHE

OBJECTIVES
define primary vs secondary
headache
Discuss some of the more common
types of each
Learn to take a history
Plan an appropriate work up and
therapy
 33 year old female presents to
PCP for headaches for the last 12
years.
Occur once or twice per month.
Accompanied by nausea,
vomiting, loss of vision.
Has not seen a doctor for these
in the past.
These usually make her go to
bed for the day.
Physical exam is normal
 HEADACHE
Lifetime prevalence 90% for men
95% for women
Primary vs Secondary
History and exam are crucial in
differentiating primary vs secondary
Clinical decision making required for
determining work up
 Primary Headaches
Tension-type
Migraine
Cluster
 Secondary Headaches
Vascular disorder: aneurysms, AVMs,
subarachnoid hemorrhage, arterial dissection,
arteritis
Intracranial disorder: mass lesions,
neoplastic, inflammatory, cystic
Abnormalities of CSF circulation:
hydrocephalus, low fluid pressure headache,
idiopathic intracranial hypertension
Substance or its withdrawal
Infection
 Secondary headache
Red flags:
Older age at onset (older person just starting to
have headache)
Associated systemic symptoms: fever, weight
loss
New or different headache
Sudden onset
History of trauma
Focal findings on exam
Comorbidities (immunosuppression, history of
cancer, coagulopathies)
 Tension-type
Most common, most easily treated
Result from muscular strain, stress,
overwork
Rapidly subside with rest or simple
analgesics
Throbbing pain, bilateral, lack of
associated GI symptoms
 Migraine
Derived from hemikranios half
head
Accompanied by nausea, vomiting,
photo-phonosensitivity, worse with
exertion, better with stillness
May occur with or without aura:
transient visual, sensory, motor, or
language disturbance, hallucinations
 Complications of migraine
Basilar migraine: involvement of
brainstem: bilateral numbness,
ataxia, impairment of consciousness,
occipital pain
Ophthalmoplegic migraine: paralysis
of cranial nerve III
Hemiparesis can be sporadic or
familial condition
 Pathogenesis of migraine
aura
Genesis is primarily neuronal, not
vascular.
Vascular theory no longer in favor.
Spreading oligemia not vascular in
distribution.
Instability of neuronal depolarization
 62 year old male smoker presents for
extreme headache pain for the last
three weeks.
Pain lasts for hours then resolves.
Returns during the course of the day.
Has had similar episodes in the past
which resolved after one or two
months.
Wake him from sleep
Eye gets red and teary with
headaches
Exam is normal
 Cluster Headache
Most painful recurrent headache, suicide
headache, frequently misdiagnosed and
inappropriately treated
Attacks of pain occur daily for days,
weeks, or months then remit. Last 45
minutes to 2 hours.
Mostly men, onset during sleep is
common, may correspond to onset of REM
Unilateral pain
 Cluster Headache
Restlessness, tendency to like cold
Ipsilateral eye tearing, facial flushing,
ptosis and miosis are common,
facial/palatal swelling
Tendency for heavy cigarette
smokers, drinkers
Physical characteristics: coarse facial
skin, hazel eye color (leonine facies)
May respond to high flow oxygen
Leonine facies
 66 year old male presents to the ED
for headache.
Has a previous history of headaches
but this is much worse.
Sudden onset.
Exam reveals obviously distressed
patient. Somewhat lethargic. Blood
pressure 170/100. Afebrile
 Vascular disorders:
aneurysm
Sentinel headaches may occur before
rupture, caused by non-catastrophic
leak of aneurysm
CT may be negative even in those
with aneurysms present.
LP indicated if suspicions high.
Evaluate for RBCs and
xanthochromia (yellow)
CTA may be done if available
 53 year old male presents to urgent
care for headache and neck pain
after MVA.
No previous history of headaches
Initially went to ED where CT brain
was negative
 Arterial dissection
May occur with very minimal trauma
or everyday activities
Carotid dissection may be associated
with ipsilateral Horners syndrome
May be associated with Marfans or
Ehlers-Danlos
 73 year old female presents to family
medicine for headaches for the last 2
months.
Has had some unexplained weight
loss, pain with chewing
One episode of curtain coming
down over vision in right eye
Exam is normal
CTA done urgently is normal
 Temporal Arteritis
Vasculitis of elderly persons
Unrecognized and untreated may
lead to blindness
Headache may be associated with
scalp tenderness, jaw claudication,
polymyalgia rheumatica
Amaurosis fugax should be treated
emergently with corticosteroids
 Temporal Arteritis
Check sed rate. Normal is 0-22
mm/hr. Mean sed rate in temporal
arteritis is 85 but may be normal in
3% of patients
Diagnosis rests on temporal artery
biopsy
 12 year old female presents to
pediatrician for headaches for the
last 3 months.
Associated with frequent vomiting
 Intracranial disorder: mass
lesion
Rapidly growing tumors more likely
to produce headache
When CSF is obstructed headache
results as a manifestation of raised
intracranial pressure
Compression of brainstem causes
cranial nerve palsies
Aggravated by coughing, straining.
 26 year old postpartum female
presents to OB for headache for the
last week after delivery.
Has a previous history of headaches
but these are different, more intense,
exacerbated by sitting or standing.
Had normal vaginal delivery
Exam is normal.
Low fluid pressure headache
Presents in upright position, relieved
by recumbency
Common after LP, but may be due to
spontaneous CSF leak or trauma
Brain normally floats in CSF, loss may
cause brain to sink and exert traction
on surrounding structures such as
bridging veins and sensory nerves
May require blood patch
 27 year old obese female presents to
ophthalmology for transient visual
obscurations, diplopia, and
headaches for the last 4 months.
Has history of migraines but these
are much worse and more persistent
Idiopathic intracranial hypertension
(Pseudotumor Cerebri)

Typically obese female

CSF pressure greater than 20 cm
water, diagnosed by LP. Remaining
CSF studies normal.
Associated with papilledema
Imaging studies are required to rule
out other pathology
 33 year old male presents to ED for
headache for last two days, gradually
worsening
Febrile on exam, lethargic & fever.
Exam reveals bilateral papilledema.
 Infections
Infections may be acute (bacterial or viral)
or chronic (due to fungal, tuberculous, or
granulomatous disease)
Meningitis vs encephalitis
LP gives definitive diagnosis but do not
delay treatment for LP or imaging
Imaging should be performed prior to LP if
there are signs of increased intracranial
pressure (can lead to brain herniation)
Try to obtain blood cultures first
 Substance or withdrawal
Medication overuse headaches:
analgesics, opioids, triptans
Usage greater than 15 times per
month
Causes chronic daily headache
Upregulation of serotonin receptors
causing hyperalgesic state
Caffeine withdrawal