Headache: Types, Diagnosis, Treatment and Complications

Headache is a pain or discomfort in the head or face region and it can be generalised over head or it can be localised to specific area. It is one of the common condition that people experience many times in their lives. Most of the headaches are not dangerous but there are certain signs which tells the seriousness of the causative condition of the headache.

Types of Headache

1. Primary Headache:
   • Tension Headache
   • Analgesic rebound headache
   • Cluster Headache
   • Migraine Headache
2. Secondary Headache:
   • Subarachnoid Hemorrhage
   • Tumor
   • Abscess 
   • Meningitis
   • Idiopathic intracranial hypertension

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Diagnosis Of Headache

First of all check for the red flags to rule out any dangerous condition. The red flags are:

• Fever
• Seizure
• Change of consciousness
• Trauma
• Focal neurological deficit
• New onset headache >50 years
• Thunderclap headache
• Progressive nausea and vomiting worse in morning
• The differences compared to prior headaches should be noted like if there are any changes in frequency, intensity and characteristics.
• If the differences are positive then it can be a secondary headache. The next step in management is: 
  • Do CT, LP and biopsy, The differentials diagnosis are- Tumor, abscess, meningitis, subarachnoid hemorrhage, idiopathic intracranial hypertension
• If negative then it is a primary headache then the physician should do history and physical examination. The differential diagnosis are - Tension headache, analgesic rebound, cluster and migraine.

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Tension Headache

• Most common headache
• Muscular type of headache

Clinical Features

• Bilateral vice-like pain starts in the front and radiates to the neck.
• Temporal and occipital regions
• Muscle tenderness over head and neck.

Diagnosis

Chronic tension headache >15 days/months for 3 months

Treatment

• Intermittent TTHs (<1 day/month): OTC medications and Acetaminophen
• More frequent TTHs (>10 episodes on 1-14 days/month for 3 months) and chronic headache: Amitriptyline or nortriptyline and CBT for stress-reduction techniques.

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Medication Overuse Headache

• Withdrawal from analgesics, acetaminophen or opioids or triptans.
• The main risk factor is the use of analgesics more than 10 times per month and it causes headaches when they stop medications

 Diagnosis

• Preexisting headache disorder plus symptoms present for 3 or more months.
• Headache present upon awakening.
• Treatment:  Withdrawal of the agent.

Cluster Headache

The main trigger is Alcohol

 Clinical Presentation

• Asymptomatic for months and then there are cluster of attacks.
• Duration is 8 to 10 days
• Unilateral eye pain
• Partial horner syndrome, no anhidrosis
• Rhinorrhea
• Lacrimation
• Suicidal thoughts

Treatment

• Abortive:
  • 100 % oxygen or the second line is subcutaneous sumatriptan.
  • Before giving sumatriptan— rule out contraindication such as ischemic heart disease and pregnancy.
• Prophylaxis: Verapamil or lithium
  • Severe resistant cases: deep brain stimulation.
  • A one-time CT imaging to rule out serious conditions

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Migraine Headache

The main  process of pathogenesis is abnormal neuronal activation of trigeminal ganglion afferents. 

Risk Factors

• Equal incidence in boys and girls until puberty.
• Risk increases in adolescent girls and women

Clinical Presentation

• Pulsatile
• Unilateral
• Debilitating: photophobia, phonophobia, hyperacusis, nausea and vomiting.
• Aura: scintillating scotoma or other visual disturbances.
• Associated with a trigger.
• Can last for 4 to 72 hours.

  Diagnosis: Neuroimaging  if there is an increase in headache frequency, neurological deficits and signs of increased ICP.

   Treatment

• Abortive: Sleep
  • Mild cases - NSAIDS
  • Moderate to severe or refractory to NSAIDS - triptans and ergots (causes coronary vasospasm) 
  • If Associated with vomiting- antiemetics (prochlorperazine or chlorpromazine)
• Prophylactic Treatment Indications
  • Frequent (>4/month)
  • Long-lasting (>12 hours)
  • Disabling symptoms
  • No relief to abortive medications
  • Overuse of abortive medications and have rebound headache        
• For Pregnancy Prophylaxis
  • Beta blockers are the first line due to safety profile.
  • Give lowest effective dose and frequent monitoring to avoid growth restriction
  • Avoid triptans and ergots.
  • Women with migraine, particularly those associated with aura are at an increased risk of ischemic stroke.
  • Risk increased with the use of OCPs, OCPs contraindicated in women with migraine and aura.

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Some Variants Of Migraine Are:

• Hemiplegic Migraine: migraine plus motor deficits.
• Basilar Migraines: cerebral vasospasm involving brainstem
• Basilar Aura (vertigo, dysarthria, tinnitus, diplopia)

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Idiopathic Intracranial Hypertension

Clinical Presentation

• Female
• Obese
• Signs of increased ICP-  papilledema, nausea and vomiting and focal neurological deficits.
• Facial nerve palsy
• Diplopia- palsy of the abducens nerve
• Pulsatile tinnitus

Associations

• Associated with OCPs
• Vitamin A excess
• Tetracycline
• Danazol
• Growth hormone
• Steroids

Diagnosis

• Ocular examinations and neuroimaging to exclude other causes such as cerebral venous thrombosis (MRI or MRV)- empty sella might be seen.
• Lumbar puncture; pressure more than 20 cm H2) in non obese patients.

Complications

Blindness due to optic nerve damage.

Treatment

• First line
  • Weight loss 
  • Acetazolamide (choroid plexus carbonic anhydrase inhibitor)
  • Furosemide can be added for those who do not respond.
• Refractory
  • Optic nerve sheath decompression
  • LP shunting
  • Bridging while awaiting for definitive surgical management–serial LP or steroids.

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