• Hemoglobin – Low hemoglobin in anemia secondary bleeding or autoimmune disease.
• White Blood Cell Count – Increased in infection e.g. meningitis, encephalitis.
• Thrombocytopenia – Decrease platelet count in bleeding disorder causing headache.
• ESR and CRP – Level increased in temporal arteritis or systemic disease.^[1]
• Creatinine – Kidney disease and kidney failure associated with headache.
• Hypercalcemia – Increased calcium level in blood associated with headache.
• Thyroid Function Test – Low thyroid hormone in hypothyroidism causing headache.^[2]
• Liver Function Test – Abnormal liver function test may be associated with primary or metastatic tumor of liver and brain.
• VDRL and ESR – Increased in tuberculosis and veneral diseases associated with headache.
• HIV – Patient with positive HIV may be suffering with headache.

CT scan of brain – Useful in diagnosis of hemorrhage, brain tumor or brain metastasis.

Magnetic Resonance Imaging (MRI) of The Brain– Assist in evaluation and diagnosis of multiple diseases causing headache:

• Brain hemorrhage.
• Brain tumor and metastasis.
• Stroke.
• Aneurysm.
• Blood clots.
• Hydrocephalus.
• Pituitary gland hypertrophy.
• Brain abscess.
• Head injury – Skull fracture, hemorrhage and bleeding.
• Brain disease – Multiple sclerosis, Huntington’s disease.
• Parkinson’s disease.^[3]

• Pregnancy.
• Kidney problem.
• Sickle cell disease.
• Devices – Arterial stent, pacemaker, mitral heart valve, spinal cord stimulator, intrathecal catheter and programmable pain pump, brain stimulator, limb prosthesis, IUD.
• Remove metal object – jewelry, watches, Denture, hearing aids, hairpins, coins and credit cards.^[4]

Sinus infection such as frontal and maxillary sinusitis can cause sever headache. X-ray is used to diagnosed sinusitis.^[5]

Used in seizure disorder associated with headache.^[6]

Eye examination with ophthalmoscope by eye specialist – rule out glaucoma and optic neuropathy.

Spinal tap procedure is performed in operating room under sterile conditions. Cerebrospinal fluid is collected and studied for infection and autoimmune diseases.^[7]

References:

Also Read:

• What is Headache or Cephalalgia
• Diagnosis of Headache
• Pathophysiology of Headache
• Signs and Symptoms of Headache
• Treatment for Headache

Most individuals suffer from mild to severe headache at some point in their life. Headache is classified as tension headache, cluster headache, and migraine. Migraine is the most debilitating symptom and is observed in 4.4% of the patient visiting the office of General Practitioner.¹ The tension headache is the most common type of headache and lasts for a few minutes to several hours.² Most patients use over the counter medication to treat a tension headache. Most headaches are treated with NSAIDs and Tylenol. Occasionally lower dosage of opioids are prescribed for a headache that is resistant to most anti-headache medication. Among headaches, migraine resists most medication but frequently responds to triptans and ergotamine. The better therapeutic outcome is observed following treatment using triptan than ergots.³

Sumatriptan is also known as a triptan. Triptan is prescribed for migraine and cluster headache. Triptans are prescribed as a nasal spray and intravenous therapy. Sumatriptan injection is very effective in the treatment of migraines and cluster headaches and works within 15 minutes. The nasal route of sumatriptan is effective in 30 minutes. In most of the cases, the effect of the nasal treatment lasts less than 45 minutes. Quality of pain relief is better with intravenous therapy than nasal spray treatment.³ Newer triptans with fewer side effects used are zolmitriptan (Zomig) in oral or nasal spray forms.

• Nausea.
• Dizziness.
• Muscle weakness.
• Heaviness or pressure in the chest.
• Tingling and numbness in the toes.
• Rapid heart rate.

• Cardiac arrhythmia and tachycardia observed over EKG that suggest conduction changes.
• Muscle weakness
• Peripheral neuropathy
• Hallucination
• Nausea and vomiting

Dehydroergotamine (DHE) is prescribed for migraine and cluster headache. Most of the patients suffering from cluster headache respond within 5 minutes with no pain. Ergotamine can be prescribed as tablets, suppositories, and nasal spray.

• Tachycardia.
• Nausea and vomiting.
• Diarrhea.
• Dizziness.
• Muscle weakness.
• Heaviness or pressure in the chest.
• Tingling and numbness in the toes.

• Stroke secondary to vasoconstriction of cerebral arterial blood vessels.
• Heart attack and angina secondary to vasoconstriction of the coronary artery.
• Hypertension caused by vasoconstriction of the peripheral arterial system.

Serotonin syndrome is a life-threatening condition. Sumatriptan increases the overall concentration of serotonin in the brain. Symptoms observed are tachycardia, nausea, vomiting, diarrhea, hallucination, anxiety, tremors, and restlessness.

Lidocaine– is a local anesthetic and used in resistant cases to treat a cluster headache. Lidocaine nasal drops or nasal spray is recommended for optimum effects.4 A group of patients with a history of cluster headache may not respond to lidocaine treatment. Reports suggest that it is helpful for most patients within about 40 minutes.

• Unpleasant taste.
• Numbness of area treated.

Capsicum originated from hot pepper, and it is used for tension and cluster headache. Capsicum is applied over occipital skin and also inside the nose. It is a safe medication and available as over the counter product in pharmacy.

• Burning sensation over skin and nose,
• Sneezing and watery eyes,
• Stomach upset,
• Sweating,
• Flushing and running nose and
• Dermatitis.

• Liver and kidney damage and
• Bleeding disorder.
• It is recommended to discontinue medications for two weeks to prevent post-op bleeding if a patient is scheduled for surgery

Calcium channel blockers influence the calcium channel of the smooth muscle of blood vessels. A calcium channel blocker is effective in treating hypertension and coronary vascular disease. Migraine or sinus headache and cluster headache is secondary to changes in the diameter of cerebral blood vessels. Calcium channel blocker causes changes in the width of a cerebral blood vessel resulting in a reduction of headache symptoms. Verapamil is a preferred calcium channel blocker used for preventive treatment of cluster and migraine headache.5, 6 Medication should be taken for 2 to 3 weeks to build maximum effects.

• Constipation.
• Severe Hypertension – If discontinued abruptly.
• Bradycardia and Hypertension – If overdose.
• Heart Failure – History of congestive heart failure.

Lithium (Eskalith, Lithane, Lithobid, Lethonate, Lithotabs), commonly used for bipolar disorder, may also help prevent cluster headaches. The patient usually receives benefit within two weeks of starting to take the drug, often within the first week. Lithium may be used alone or with other medications. Lithium can have many side effects, including trembling of hands, nausea, and increased thirst. Weight gain is a common side effect with long-term use.

• Thinning of the hair and hair loss.
• Mild tremor.
• Loss of appetite.
• Tiredness.
• Nausea.
• Severe allergic reactions.
• Skin – Rash, hives, itching.
• Respiratory system – Bronchospasm, dyspnea and tightness in the chest.
• Cardiovascular system – Slow or irregular heartbeat.
• Central nervous system – Confusion, restlessness, tremor, dizziness, faintness, bladder and bowel incontinence, numbness of the skin, ringing in the ear, restlessness, seizures and severe or persistent headache.
• Musculoskeletal system – Tremors, involuntary muscle twitching, decrease muscle tone, and coordination.
• Gastrointestinal system – Edema of oral cavity and tongue, nausea, and diarrhea.

Anti-seizure medications are used for the prevention and treatment of headache.⁷ Anti-seizure medications thought to reduce the occurrence of migraines by calming inflamed blood vessels in the brain, which may lead to migraine pain or sinus headache. However, none of these medications is a cure for migraines. Antiepileptics are a diverse group of medications used as antiseizure. Some of the medication within this large group is being used to treat a headache. In research, there were areas of hyper activities in the brain that were recognized in epilepsy and headache patients. Antiepileptic medications reduced the area of irritability by its molecular action at the voltage-gated sodium channel. The most common used antiepileptic in headache treatment is Topamax, Depakote, and Neurontin.

Topamax – The oral tablet is taken every day as prescribed, even if headache symptoms are absent.

• Tachycardia.
• Dyspnea – breathlessness or shortness of breath.
• Chest pain.
• Urine – bloody or cloudy.
• Cognitive symptoms – thoughts of suicide or aggressive behavior.
• Depression.
• Depakote – Depakote (valproic acid) is available as capsule, tablet and syrup.

• Liver damage.
• Pancreatitis.
• Neurontin (Gabapentin) used in post-herpetic neuralgia, diabetic neuropathy, and fibromyalgia.

Nausea.

• Skin – Rash, hives, itching.
• Respiratory System – Bronchospasm, dyspnea and tightness in the chest.
• Central Nervous System – Seizures and Tremors.
• Musculoskeletal System – Tremors.

Corticosteroid drugs (also called steroids) are used in allergic reaction and autoimmune diseases anti-inflammatory medications. Corticosteroids are membrane stabilizing agents, prescribed for the headache to prevent irritability of cortical and subcortical centers. It enhances the effect of verapamil in the treatment of headaches and often prescribed with verapamil. Prednisone is being tried as short term breakthrough pain meds for cluster headache. It is usually prescribed as a tablet form prednisone and injection form decadron.

• Symptoms like diabetes increase blood sugar levels.
• General Symptoms – Dry mouth, fatigue, weakness, blurred vision, facial swelling, infection, avascular necrosis and glaucoma.
• Central Nervous System – Anxious, depression, confusion, insomnia, mania, psychosis.
• Gastrointestinal System – Stomach bloating feeling, increase appetite, weight gain, abdominal pain, diarrhea and peptic ulcer.
• Urination – Frequent urination.

• NSAIDs are anti-inflammatory medication abbreviated as NSAIDs. NSAIDs are used for the treatment of headache in combination with other medications. Mild headaches are often treated by NSAIDs alone.
• Analgesics – NSAIDs are not effective in severe pain and also pain caused by non-inflammatory etiology.
• Most Prescribed NSAIDs – Aspirin, Ibuprofen (Motrin, Advil) and Naproxen (Aleve).
• Side Effects – Complications caused by NSAIDs can be devastating if continued for a prolonged period.
• Dose-dependent Side Effects – Dyspepsia, ulcer, perforation, upper gastrointestinal bleeding, and severe blood loss. A combination of aspirin and COX 2 inhibitor (Celebrex) may block the cardioprotective effects of aspirin.
• Myocardial Infarction and Stroke – NSAIDs with COX2 inhibitor may increase risk. A combination of NSAIDs and COX 2 are not recommended in-patient with a history of myocardial infarction and heart attack.

Most acute attacks of tension-type headaches get better without any treatment. Over-the-counter pain relievers such as acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs) can treat mild symptoms. Aspirin or ibuprofen (generic, Advil, other brands) are usually the first choices, followed by naproxen (generic, Aleve). Some patients may also find helpful medications that combine a pain reliever with caffeine.

• Ibuprofen. (Advil, Motrin)
• Naproxen. (Aleve, Naprelan, Naprosyn, Anaprox)
• Acetaminophen/butalbital. (Bupap, Cephradine, Phrenilin)
• Acetaminophen/butalbital/caffeine. (Esgic, Fioricet)
• Aspirin/butalbital/caffeine. (Fiorinal)
• Acetaminophen/butalbital/caffeine/codeine. (Fioricet with Codeine)
• Acetaminophen/Dichloralphenazone/Sometheptene Mucate. (Midrin)
• Acetaminophen/Phenyltoloxamine. (Percogesic)
• Acetaminophen/Isometheptene mucate. (Prodrin)

Sedatives are prescribed for selective cases of headache. The most common indication to use sedatives or anti-anxiety medications are Tension headache and prevent a recurrent episode. Buspirone (Buspar) and Alprazolam are prescribed as anti-anxiety medications.

• Drowsiness.
• Irritability.
• Fatigue.
• Low blood pressure.
• Amnesia.

Opioids are used for treating tension headaches, which are not responding to NSAIDs and other medications. Acute and brief attack of headache most of the time gets better without any treatment. Patients may develop resistance and tolerance to opioid medication. Patients are advised to consider relaxation treatment, cognitive behavioral therapy, and lifestyle changes if failed to get pain relief with opioids. Daily attacks of headaches are treated with preventive medication such as NSAIDs, and NSAIDs combined with opiates or opioids. All other options of medications should be tried before introducing opioid prescriptions. Patients dependent on opioids for pain relief consume frequent pills for rapid pain relief and at the time may behave like a drug addict. Opioid dependence some time needs a higher dosage and frequent need for pain medications. These symptoms are because of opioid dependence to achieve pain relief and classified as Pseudoaddiction. Opioids do cause addiction in a few patients, and treatment of headache with opioids become difficult.

• Nausea.
• Vomiting.
• Constipation.
• Dry mouth.
• Itching.
• Miosis.

• Skin – Itching, urticaria, hypothermia, and histamine-induced flushing.
• Eyes – Miosis.
• Gastrointestinal – Nausea, vomiting, dry mouth, constipation, and biliary spasm (colicky pain).
• CNS – Depression, confusion, hallucination, delirium and dizziness.
• Respiratory System.
• Depression
• CVS – Bradycardia and occasional may be tachycardia.
• Orthostatic hypotension.
• Kidney, Ureter, and Bladder (KUB) – Urinary retention and ureteric spasm.
• Musculoskeletal – Muscle spasm.

Botulinum toxin A (Botox) injections are typically used to smooth wrinkles in the practice of plastic surgery. Botox is used for the treatment of headaches, including the prevention of cluster headaches.8 Research is still preliminary, and there is no sufficient evidence to support its efficacy. Botox is the treatment of choice for headache localized over frontal, occipital and cervical (neck) region. Headache over parietal (top of head), temporal area (side of head above the ear), between eyes and behind the ear does not respond to botox injection.

• General Symptoms – Irritated eyes, facial pain, flu-like symptoms, inability to focus the eyes, neck pain, redness, swelling, tenderness at the injection site; sensitivity to light, sweating, and tiredness.
• CNS – Anxiety, arm or leg pain, back pain, dizziness, drowsiness, and headache.
• Gastrointestinal System – Nausea, constipation, dry mouth, dry, and indigestion.
• Respiratory System – Increased cough, mild sore throat, and runny nose.
• Musculoskeletal – Stiff or weak muscles at or near the injection site.

• Skin – Swelling of the mouth, face, lips, or tongue; fever and chills.
• Respiratory system – Unusual hoarseness, wheezing, chest pain, difficulty swallowing or breathing, persistent sore throat and shortness of breath.
• Kidney Ureter Bladder – Blood in the urine; burning, numbness, or tingling; burning with urination; difficult, frequent, or painful urination, loss of bladder control, eyes-double or blurred vision, or other vision changes; drooping of the upper eyelid and eyelid swelling.
• Central Nervous System – Fainting; seizures, headache, dizziness speech changes or problems and worsening migraines.
• Cardiovascular System – Irregular heartbeat.
• Musculoskeletal System – Loss of strength, paralysis, and severe or persistent muscle weakness.

Melatonin is found in animals, plants, and microbes. Melatonin is sold over the counter in the USA. In an animal research, melatonin was investigated against carcinogens. Melatonin prevents the initiation of the impairment of DNA by carcinogens. Impaired DNA otherwise would have initiated cancer growth.

Melatonin is being prescribed for migraines, as well as tension headache.9 Melatonin is widely used as an antioxidant in diseases such as immunodeficiency syndrome, autism, aging, Alzheimer disease, delirium mood disorder, alternative medicine, tinnitus, cancer and gallstone.

Oxygen therapy – Oxygen percentage in the atmosphere is 21%. Oxygen therapy can provide from 30% to 100% oxygen. Nasal oxygen therapy using nasal cannula offers 30 to 40% oxygen. A tight-fitting face mask or endotracheal tube can deliver up to 100% oxygen. Oxygen therapy has been used in congestive heart failure, chronic obstructive lung disease (COPD), and allergic reaction causing shortness of breath, convulsion, and hemorrhagic shock. Oxygen therapy up to 100% is used in cluster and tension headache on and often. The patient is advised to inhale oxygen for 15 minutes several times a day.

• Occipital Neuralgia- Pain over the back of the head (occipital area of a skull) is caused by irritation of the lesser and greater occipital nerve. Such pain is treated with radiofrequency ablation of bother lesser and greater occipital nerve.¹⁰
• Deep Brain Stimulation: Chronic cluster and migraine headaches in a few patients are resistant to all treatments. These patients are imprisoned in the house suffering from an intense headache and unable to perform any regular activities. Severe pain may bring multiple thoughts of suicide. These patients are given a trial of deep brain stimulation as a last option of treatment. The published studies suggest that implants of the hypothalamic stimulator have a better outcome in treating a cluster headache.¹¹
• Gasserian (Trigeminal) Ganglion Radiofrequency Rhizotomy: Headache associated with trigeminal nerve irritation or pinch is treated with Gasserian ganglion neurotomy. Gasserian or trigeminal ganglion ablation is performed by using radiofrequency heat¹² or glycerol. The trigeminal ganglion is identified during the procedure by sensory nerve stimulation. The trigeminal ganglion is treated with heat that is produced by radiofrequency waves. Pain carrying fibers are also often destroyed in few cases using glycerol as a chemical rhizotomy.
• Microvascular Decompression of Trigeminal Nerve: Trigeminal nerve pain is observed in patients suffering from postherpetic neuralgia and traumatic injury of the trigeminal nerve. Chronic headache pain secondary to trigeminal neuralgia is treated with microvascular decompression of the trigeminal nerve.¹³ Blood vessels surrounding the trigeminal nerve are selectively ligated or cauterized. Such treatment eliminates the pressure over the trigeminal ganglion.

A craniotomy is a surgical procedure performed to the exposed brain and subcortical part of the brain. It is a highly skilled procedure, which involves the removal of part of the skull bone and reattached at the end of surgery. Surgery is performed under the guidance of a CT scan. MRI images are studied before surgery as well as during operation.

• Tumor and Metastasis – Excision.
• Aneurysm – Clipping and reanastomosis.
• Blood Clot – Evacuation and stoppage of bleeding.
• Brain Abscess – Excision and drainage.
• Skull Fracture – Repair.
• Ischemic Brain Tissue – Excision.

• Infection.
• Bleeding.
• Seizures.
• Dural tear – CSF leak.
• Neurological Deficit – sensory and motor nerve deficiency, paralysis.
• The blood clot, thrombosis, and embolism.
• Cognitive Deficiency – memory, emotional expression.

Cognitive Behavior Therapy (CBT) is useful to assist change or modify behavior problems in patients suffering from chronic headaches or sinus headaches.

Following modification of behavior helps to reduce or eliminate headache:

Behavioral Treatment Is Classified As Follows:

• Cognitively Oriented.
• Behaviorally Oriented.
• Imaginary Exposure Therapy Combines Both Approaches.
• Principle of Behavioral Treatment:
• Points out over generalizing of symptoms.
• Magnifying negative feelings.
• Minimizing positive thoughts.
• Guiding to more realistic, effective concepts.
• Assess, reconceptualized, and acquisition of positive skills.

Modify Undesired Behavior – The treatment is targetted to eliminate and reinforced the changed behavior. Such therapy is performed as individuals or as a group.

Therapy as a Treatment – CBT has also been used to treat a primary and secondary headache that is causing severe pain and not responding to any alternative treatment. CBT is an active treatment inpatient suffering from headaches and insomnia.

Combination of Behavioral Therapy with Cognitive Therapy- Several centers have tried simultaneous behavior and cognitive therapy that has provided better results.

Maladaptive Thinking- Maladaptive thinking causes stress to induce a headache. Behavioral therapy helps to modify or eliminate maladaptive thinking.

Systematic desensitization involves gradually exposing a patient to anxiety-provoking stimuli until the anxiety response was extinguished, or eliminated.

Positive reinforcement improves behavior when compare with conditioning therapy. The therapy recommends punishment for repetitive harmful behavior and rewards for improvement in behavior.

Behavioral therapies can be a helpful accompaniment to drug treatment. These approaches can help with pain management and enable patients to feel more in control of their condition.

References:  

Also Read:

• What is Headache or Cephalalgia
• Diagnosis of Headache
• Pathophysiology of Headache
• Signs and Symptoms of Headache
• Tests to Diagnose Headache

Attacks are usually short, lasting from 15 – 180 minutes, and the excruciating pain may have subsided by the time a patient reaches a doctor’s office or emergency room. Because it can be difficult to treat attacks when they occur, treatment efforts focus on the prevention of attacks during cluster cycles.^[1] Although certain drugs are standard, preventive therapy needs to be individually tailored for each patient. The doctor may prescribe a combination of drugs.

Verapamil (Calan), a calcium-channel blocker drug, is the mainstay preventive treatment for cluster headaches. However, it can take 2 to 3 weeks for this drug to take effect. During this period, corticosteroids (typically prednisone) may be used as an initial transitional therapy. For long-term treatment of chronic cluster headaches, lithium may be used as an alternative to verapamil.^[2]

Although they are not approved for cluster headache, anti-seizure drugs such as valproate (Depakote), topiramate (Topamax), and gabapentin (Neurontin), are sometimes used for preventive treatment.

Several medications are used for prevention of migraine.

• Beta Blockers – Inderol and Toprol, which relax blood vessels.
• Calcium channel blockers – Cardizem and Procardia, vasodilator and relaxes blood vessels causing migraine headache.
• Tricyclic antidepressants – Amitriptyline.
• Anticonvulsants – Depakote and Topamax.^[3]

Avoid anxiety, fatigue, and hypoglycemia which triggers tension headache. Preventive medications used in tension headaches are:

• Tricyclic antidepressants – Amitriptyline.
• Anticonvulsants – Depakote and Topamax.
• NSAIDs – Advil and Aleve.^[4]

References:

Also Read:

• What is Headache or Cephalalgia?
• Treatment for Headache: Medications, NSAIDs, Opioids, Oxygen Therapy, Surgery
• Diagnosis of Headache: Migraine, Tension, Cluster, Stroke and TIA
• Preventive Treatment for Headache: Cluster, Migraine, Tension Headaches
• Splitting Headache, Is It Migraine?
• Exertional Headaches or Exercise Headaches: Causes, Symptoms, Treatment, Prevention

Migraine headache is severe intense throbbing pain with pulsating character mostly localized on one side of head. Patient may suffer with nausea and vomiting during the episode of headache. Patients are sensitive to light and sound. Pain may last for hours or days. Migraine headache may precede or accompany aura. Auras are sensory symptoms such as light flashing, blind spot or feeling of tingling and numbness.^[1] Aura may precede migraine and considered as warning symptoms. Physical activities increase intensity of headache.

Tension headache may be acute in nature or rarely become chronic with daily pain lasting more than 3 to 6 months. Tension headache may be once or few times a week or continuous for a several days. If tension headache last for 15 days or more in one month it is considered chronic tension headache.^[2] Headache is mild to moderate in intensity compared to migraine or cluster headache. Tension headache is not preceded or accompanied by aura like symptoms. Physical activities do not increase intensity of headache. Headache is either unilateral or bilateral.

Cluster headaches are one of the most painful cyclical headaches. Pain is often around the eyes and patient may wake up often in the middle of the night. Headache is unilateral like migraine headache. Cluster period of attack may last from weeks to months. In between attacks patient may pass through remission period of months to year. It is one of the rare types of headache.^[3]

Migraine patients with a history of frequent auras or cluster headaches may exhibit history of aura in 14% cases.

TIA is transient lack of blood supply to brain for very short period of time and may not induced brain damage or serious ischemia. But, if sustained for longer time may cause brain injury or stroke because of lack of blood supply (ischemia) to brain tissue. Persistent and frequent TIA may result in brain injury or stroke. TIA symptoms are brief and similar to those of stroke.^[4] TIA is often a warning sign indicating a person is at risk for severe stroke. Headaches with auras may also increase the risk for eye retinal damage (retinopathy). Aura-related headaches may affect the small blood vessels in the brain and the eyes, thereby increasing the risks for stroke and retinopathy.^[5] Cluster headaches are rare, affecting less than 1% of the population.

Pathophysiology causing these events and how they relate to cluster headaches are still unclear.

References:

Also Read:

• What is Headache or Cephalalgia
• Pathophysiology of Headache
• Signs and Symptoms of Headache
• Tests to Diagnose Headache
• Treatment for Headache

Pain in the forehead region and the scalp are the common symptoms of headache. Most cases of headache and its accompanying symptoms do not require immediate medical attention but if the frequency of headache is more accompanied by severe pain in the head, or after a trauma to the head and neck region or is accompanied with SOB, stiff neck, fever then it is better get yourself evaluated by an headache specialist at the earliest.

Pain Intensity Evaluation of Headache Based on the Symptoms:

• Symptoms of Mild Intensity Headache – Barely noticeable.
• Symptoms of Moderate Intensity Headache- Does not interfere with work or activities.
• Symptoms of Severe Headache- Distracts from work or activities.
• Symptoms of Very Severe Headache- Difficult to maintain normal activities.
• Symptoms of Incapacitating Headache- Unable to concentrate, needs to go to emergency room or see physician immediately.^[1]

Frequency of Headache Symptoms:

1. Symptoms of low frequency headaches last less than 15 days in a month.
2. Symptoms of high frequency headaches last more than 15 days.^[2]

Duration of Headache Symptoms:

1. Short duration headache symptoms last less than 4 hours.
2. Symptoms of long duration headache last more than 4 hours.

1. Migraine
2. Episodic Tension Type Headache.

• Chronic Migraine.
• Chronic Tension-Type Headache.
• New Daily Persistent Headache.
• Hemicrania Continua.

1. Episodic Cluster Headache (not triggered by cough or exercises)
2. Valsalva or Headache Triggered By Cough, Exercises or Valsalva

1. Chronic Cluster Headache.
2. Chronic Paroxysmal Hemicrania.
3. Hypnic Headache.
4. SUNCT Syndrome.
5. Valsalva or Headache Triggered by Cough, Exercises or Valsalva.^[3]

• Headache in young adults of age around 40 is more often a sign of cluster headache.
• Men are more likely to suffer from more common cluster headaches, it is 2 to 3 times more often than women.
• Headache in women aged 60 or more, is more likely a sign of Migraine headaches.^[4] This type of headache is influenced by fluctuations in estrogen and other female hormones in females.

• Symptoms of Headache in Nicotine Dependent (smoker) can be a sign of Cluster Headache.
• Symptoms of Headache in Alcohol Abuser can also be a sign of Cluster Headache.
• Professional Stress – Sign of Tension Headache and Cluster Headache.
• Symptoms of headache after drinking red wine can be indicative of Cluster headache.
• Discontinuation of smoking or drinking alcohol does not eliminate attacks of headache once it is established.

• Headache accompanied with Swollen Eyes and Lacrimation can be a sign of Cluster headache.
• Headache accompanied with running nose and lacrimation – Cluster headache.
• Headaches accompanied with Aura can be a Migraine.
• Headache after Physical Activities can also be indicative of Migraine.
• Bilateral Headache – Tension headache.

Cluster and migraine headaches tend to run in families, suggesting a genetic component may be involved in some cases. About half of people with migraine headache have a personal or family history of migraine. Studies have reported that about 15% of patients have both kinds of headache.^[5]

• Primary Headache – Cluster headache.
• Secondary Headache – Bleeding: epidural, subdural or cerebral bleeding, fracture skull.

Cluster headaches have been observed during specific sleep stages. Sleep disorders such as sleep apnea and narcolepsy tend to be followed by cluster headache or migraine headache. Patients who are unable to sleep (insomnia), commonly tend to suffer with cluster or migraine headache.^[6] Sleep hypoxia secondary to sleep apnea may trigger physiological events causing cluster headache during sleep. Sleep hypoxia triggered cluster headache may continue its symptom behavior during daytime mostly during late afternoon. Most of the patient with history of sleep apnea causing cluster headache have responded well to the treatments like CPAP (continuous positive airway pressure ventilation). Sleep study is extremely important investigation in patient with history of cluster headache that is not responding to medication treatment.

References:

Also Read:

• What is Headache or Cephalalgia
• Diagnosis of Headache
• Pathophysiology of Headache
• Tests to Diagnose Headache
• Treatment for Headache

Primary headaches are migraine, cluster and tension headache. Primary headaches are benign, chronic and not life threatening. Headache is considered primary when a disease or other medical condition does not cause the headache. Most primary headaches fall into three main types: tension-type, migraine, and cluster headaches. Tension headache is the most common primary headache and accounts for 90% of all headaches. After tension headache, the second most frequently occurring primary headaches are Migraine. Migraine is referred to as a neurovascular headache because it is most likely caused by an interaction between blood vessel and nerve abnormalities. Cluster headache is a less common type of primary headache. Cluster headache sometimes referred to as a neurovascular headache, evidence now suggests that its cause may lie in the hypothalamus, a region deep in the brain that regulates, among other functions, the biologic rhythms of the body.^[1]

Secondary headaches are sometimes life threatening, may be secondary to metastasis or malignant cancer and cerebral bleeding. Early diagnosis of secondary headache is essential to avoid life-threatening complications. Secondary headache may be resulting from life threatening disease such as brain tumor, brain hemorrhage or head injury. Secondary headaches are classified based on etiology, not on symptom profile. Recent origin headache in a patient with history of disease known to cause intracerebral complications must be further investigated. Patients with pre-existing primary headaches sometimes experience exacerbations, which may follow further expensive investigations to rule out life threatening secondary headaches. In this circumstance, the known cause of headache may have worsened the pre-existing primary headache. Alternatively, it may have caused a new type of secondary headache. Secondary headaches are caused by other medical conditions, such as sinus infections, neck injuries, and strokes. About 2% of headaches are secondary to abnormalities or infections in the nasal or sinus passages, and they are commonly referred to as sinus headaches.

Traumatic injury to head and neck may cause headache which is classified as secondary headache. Head injury may cause subdural or epidural hematoma if ignored can lead to cerebral herniation and critical outcome of complications. Neck injury following work accident or auto accident causes occipital neuralgia and occipital headache. Intracranial arterial aneurysm or cerebral arterial swelling can cause severe throbbing headache. Infection such as meningitis or encephalitis can cause pain mostly in frontal and occipital area of head. In few cases of inflammatory disease of eye, ear, nose and sinuses pain simulating headache referred to temporal, frontal or occipital region. Shingles or post herpetic neuralgic pain of trigeminal nerve or facial nerve can also cause severe headache in frontal or temporal dermatome.^[2]

References:

Also Read:

• What is Headache or Cephalalgia
• Diagnosis of Headache
• Signs and Symptoms of Headache
• Tests to Diagnose Headache
• Treatment for Headache

International Headache Society (IHS) first classified different types of headache in 1988. Headache classification were modified and improved in 2004 by International Headache Society. ICHD-2 classification of 2004 has simplified symptomatic descriptions and causation of headaches in to several subgroups, which were overlapping in the previous classifications.

• ICHD has included almost all causes and symptomatic presentation of headache as symptoms.
• Like its predecessor, the ICHD-2 separates headache into primary and secondary disorders.
• ICHD-2 classification helps to achieve methodical approach to investigate and rule out symptoms with red flags causing secondary headache.^[1]

1. Primary Headache.
2. Secondary Headache.

• Primary headaches are benign, chronic and not life threatening.
• Headache is considered primary when a disease or other medical condition does not cause the headache.
• Most primary headaches fall into three main types: Tension-type, Migraine, and Cluster Headaches.
• Tension headache is the most common primary headache and accounts for 90% of all headaches.
• After tension headache, the second most frequently occurring primary headaches are Migraine.
• Migraine is referred to as a neurovascular headache because it is most likely caused by an interaction between blood vessel and nerve abnormalities.
• Cluster headache is a less common type of primary headache.
• Cluster headache is sometimes referred to as a neurovascular headache, evidence now suggests that its cause may lie in the hypothalamus, a region deep in the brain that regulates, among other functions, the biologic rhythms of the body.^[2,3]

1. Migraine Headache.
2. Tension Headache
3. Cluster Headache.

• Secondary headaches are sometimes life threatening, may be secondary to metastasis or malignant cancer and cerebral bleeding.
• Early diagnosis of secondary headache is essential to avoid life-threatening complications.
• Secondary headache may be resulting from life threatening disease such as brain tumor, brain hemorrhage or head injury.
• Secondary headaches are classified based on etiology, not on symptom profile.
• Recent origin headache in a patient with history of disease known to cause intracerebral complications must be further investigated.
• Patients with pre-existing primary headaches sometimes experience exacerbations, which may follow further expensive investigations to rule out life threatening secondary headaches. In this circumstance, the known cause of headache may have worsened the pre-existing primary headache.
• Alternatively, it may have caused a new type of secondary headache.
• Secondary headaches are caused by other medical conditions such as sinus infections, neck injuries, and strokes.
• About 2% of headaches are secondary to abnormalities or infections in the nasal or sinus passages, and they are commonly referred to as sinus headaches.^[3]
• Traumatic injury to head and neck may cause headache, which is classified as secondary headache.
• Head injury may cause subdural or epidural hematoma and if ignored can lead to cerebral herniation and critical outcome of complications.
• Neck injury following work accident or auto accident causes occipital neuralgia and occipital headache.
• Intracranial arterial aneurysm or cerebral arterial swelling can cause severe throbbing headache.
• Infection such as meningitis or encephalitis can cause pain mostly in frontal and occipital area of head.
• In few cases of inflammatory disease of eye, ear, nose and sinus pain simulating headache is referred to temporal, frontal or occipital region.
• Shingles or post herpetic neuralgic pain of trigeminal nerve or facial nerve can also cause severe headache in frontal or temporal dermatome.^[4]

• Skull Fracture– Fracture Of Skull And Facial Bones.
• Bleeding: Intracerebral or Subdural Hematoma.
• Upper Neck Injury– Fractured Neck^[5]

• Cranial or cervical aneurysm.

• Malignant tumor
• Metastatic brain tumor
• Brain abscess
• Brain hemorrhage and blood clots^[6]

• Opioid Withdrawal
• Alcohol Withdrawal.

• Meningitis
• Encephalitis
• Sinusitis
• Post-herpetic trigeminal neuralgia
• Ear Infection
• Eye Infection

• Embolism of cerebral blood vessels causes stroke and secondary headache.
• Arterial spasm causes Transient Ischemic Attack or TIA.^[7]

• Depression may be associated with headache
• Anxiety is often followed by headache.

• Occipital headache is caused by vision problems.
• Cataract or retinopathy may cause occipital headache.
• Diplopia or vision problems results in severe headache.

References:

Also Read:

• What is Headache or Cephalalgia
• Pathophysiology of Headache
• Signs and Symptoms of Headache
• Tests to Diagnose Headache
• Treatment for Headache

Headache or Cephalalgia is a symptom of pain observed in head, face and upper cervical dermatome. Headache or Cephalalgia is a complaint of discomfort originating from tissue covering brain such as meninges, skull, periosteum and structures of the skull base. In addition, pain also originates from blood vessels and muscles around brain, scalp, face, and neck. Cerebral cortex, cerebellum, midbrain, blood vessels and nerves occupy space within the skull.^[1] Brain tissue is insensitive to pain since pain receptors are not detected in brain tissue.

Headache or Cephalalgia is broadly classified as primary and secondary headache.^[2]

Migraine, cluster and tension headache are primary headache.

Space occupying lesion within skull causes secondary headache. Stretching of meninges by tumor, abscess and blood clot results in tension type secondary headache.

Secondary tension headache may incur because bony skull cannot expand with space occupying lesions. Increased tissue mass either tumor, abscess or blood clot within skull will cause increased pressure or compression of nerves and blood vessels. Occasional symptom of tension headache may be a warning sign of life threatening internal bleeding within compact bony skull.

Bleeding could be mild, moderate or severe and result in blood clot of variable size depending on blood volume. Initial symptoms of mild to moderate headache or Cephalalgia secondary to mild hemorrhage if ignored may result in continuation of internal bleeding and developing into massive blood clot. Massive blood clot will cause shift of cerebral vital centers towards the skull base and mid brain to the base of the skull.

Increased pressure and ischemia of vital brain centers will lead to life threatening symptoms such as slow breathing, slow heart rate, low blood pressure and respiratory apnea. Bleeding within brain tissue during initial phase may indicate mild to moderate headache or Cephalalgia.^[3] Later with time, continuous slow bleeding may cause severe headache with substantial increase in size of clot. In a few cases, time is essential and important to save life.

References:

Also Read:

• Diagnosis of Headache
• Pathophysiology of Headache
• Signs and Symptoms of Headache
• Tests to Diagnose Headache
• Treatment for Headache
• What is Ice Cream Headache & How is it Treated?