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Introduction
Persistent headaches may sometimes get so annoying that many patients seek advice on how to get rid of it permanently. Some headaches are disabling but treatable (migraine, cluster headache) while others herald sinister diseases (brain tumors) or warrant immediate action (meningitis, subarachnoid hemorrhages, giant cell arteritis).
A classification system developed by the International Headache Society characterizes headache as primary or secondary.
Primary:
- Migraine (16%)
- Tension-type (69%)
- Cluster (0.1%)
- Idiopathic-stabbing (2%)
- Exertional (1%)
Secondary:
- Systemic infection (e.g. URTI, meningitis) (63%)
- Head injury (4%)
- Vascular Disorders (1%)
- Subarachnoid hemorrhages (<1%)
- Brain Tumor (0.1%)
- Glaucoma
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Danger signs of headache suggesting a serious underlying disorder
Worst headache ever
First severe headache
Gradual worsening over days or weeks
Abnormal neurologic examination
Fever or unexplained systemic signs
Vomiting that precedes headache
Pain induced by bending, lifting, cough
Pain that disturbs sleep or presents immediately upon awakening
Known systemic illness
Onset after age of 55 years
Pain associated with local tenderness e.g., region of temporal artery | |
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Based on duration headache can also be classified as
Acute single episode:
- Meningitis, encephalitis, cerebral malaria
- Subarachnoid hemorrhage
- Head injury
Acute recurrent attacks:
- Migraine
- Cluster headache
- Glaucoma
- Sinusitis
Subacute onset:
Chronic headache:
- Tension headache
- Raised intracranial pressure
- Low intracranial pressure
- Analgesic rebound headachex
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Investigations
A complete neurologic examination is an essential first step in the evaluation. In most cases, patients with an abnormal examination or a history of recent-onset headache should be evaluated by a CT or MRI study. In some circumstances a lumbar puncture (LP) is also required, unless a benign etiology can be otherwise established. A general evaluation of acute headache might include the investigation of cardiovascular and renal status by blood pressure monitoring and urine examination; eyes by fundoscopy, intraocular pressure measurement, and refraction; cranial arteries by palpation; and cervical spine by the effect of passive movement of the head and by imaging.
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References
- www.achenet.org, American Council for Headache Education
- Harrisons 17e
- John Patten, Neurological DD
- Oxford medicine
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