Headache

Headache is one of the most common symptoms in

medicine and may account for up to 40% of
neurological consultations.

There is a great deal of overlap in the presentations

of headache, and although the characteristic features of
particular types of headache will be presented in this
class, it is important to bear in mind that, in practice,
symptoms are often not as clear-cut.
TENSION HEADACHE

Tension headache is the commonest form of

headache and is experienced by most people at some
point in their lives.
 There is a diffuse, “band like”, dull headache,
which may be accompanied by scalp tenderness and be
aggravated by noise and light. It may last hours to days.
It may be infrequent or daily, and is usually worse
towards the end of the day. There are no abnormal
physical signs.
 Treatment is with reassurance, analgesia,
physical treatment (massage, relaxation therapy),
and antidepressants when indicated. Paradoxically,
these headaches can be exacerbated by analgesic
overuse (analgesic abuse), especially codeine-
containing drugs, and thus stopping these drugs
may help.
MIGRAINE

Migraine is a common, often familial,

condition characterized by an episodic unilateral
throbbing headache lasting 1—24hours. It is much
more common in women, especially when young.
There is often a visual prodrome with fortification
spectra or flashing lights.
 The headache is thought to have a vascular
component and to be related to the release of
vasoactive substances. The level of serum 5-
hydroxytryptamine (5HT) rise with the prodromal
symptoms and falls during the headache.
 There are various subdivisions of
migraine, although classical and common
migraine are the most frequently encountered
forms.
Classical migraine

In classical migraine, an aura, which is

usually visual, precedes the headache. Typically,
the headache is unilateral and throbbing,
accompanied by nausea and vomiting, and
aggravated by light (photophobia) and relieved
by sleep in a darkened room.
Common migraine

In common migraine, there is no aura.

The headache is similar to a classical migraine,
but may be more indistinct and merge more
with tension headache.
Basilar migraine

In basilar migraine, the prodomal symptoms

result from dysfunction in the territory of the
posterior cerebral circulation, with bilateral visual
symptoms, ataxia, dysarthria, vertigo, limb
paraesthesiae, and even weakness. There may be loss
of consciousness prior to the onset of headache.
Hemiplegic migraine

Hemiplegic migraine is rare and

involves hemiplegia that can persist for days
after the headache has settled. In some cases
there is an autosomal dominant transmission.
Ophthalmoplegic migraine

Extraocular palsies, usually the third nerve,

occurring with a migraine constitute ophthalmoplegic
migraine. This is rare and difficult to differentiate
from other causes of third nerve palsy.
DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS

 The diagnosis is usually made from the history, as there are

usually no clinical findings in the commoner forms of
migraine.

 The headache needs to be differentiated from meningitis

and subarachnoid haemorrhage, as both these require
prompt treatment.

 Hemiplegic migraine must be differentiated from stroke or

transient ischaemic attacks.
MANAGEMENT

The patient needs to be reassured. Avoidance of

any precipitating dietary factors (e.g. chocolate cheese)
may be helpful. For patients taking oral contraceptives,
changing the brand or stopping the drug may be
required.
During an attack

 Antiemetics are often required to allow ingestion of other

drug such as simple analgesics (e.g. paracetamol) or stronger
analgesics (e.g. codeine-containing drugs).

 Attacks may be terminated by the use of 5-HT agonists.

Ergotamine is now rarely used , because of more frequent
side effects.
Prophylaxis

For frequent and severe attacks, regular daily

treatment may be required to prevent their onset.
Commonly used drugs includes:
 Propranolol (beta-adrenergic-receptor blockor)

 Antidepressants, especially tricyclics (e.g.

amitriptyline).

 Pizotifen (5-HT antagonist)

 Methysergide (5-HT antagonist)---rarely used now

as it causes retroperitoneal fibrosis.
 CLUSTER HEADACHE

Cluster headache is a characteristic

headache syndrome that occurs more commonly
in men, with an onset in early middle life.
Features

Features of cluster headache comprise severe

unilateral pain localized around the eye with unilateral.

 Conjunctival injection

 Lacrimation

 Rhinorrhoea

 With or without transient Horner’s syndrome

 The headache and associated features last
between 10 minutes and 2 hours, typically occurring
one to three times daily in clusters lasting weeks or a
few months at a time. Interval between clusters may
extend to several years. Onset of an attack is often in
the early hours of the morning, waking the patient
from sleep.
Treatment

Treatments used in migraine ,

particularly sumatriptan and ergotamine ,
can be helpful in cluster headache.
 Specific treatments include a course of
corticosteroids (e.g. 60mg of prednisolone for 5-10
days), inhaled oxygen, indomethacin and verapamil.
Methysergide can be used for resistant cases, but
under hospital supervision as it can cause
retroperitoneal fibrosis. Lithium can be useful if the
symptoms are more chronic, however levels need to be
monitored.
GIANT-CELL ARTERITIS

Giant-cell arteritis is a granulomatous arteritis,

usually affecting the superficial temporal artery in
those over 60 years old.

The majority of patients experience pain over

the thickened, tender, often non-pulsatile, temporal
artery. The headache is accompanied by:
 A raised ESR----often marked(60-100)

 Visual lost (25% of untreated cases): amaurosis fugax (a

transient ischaemic attack involving the retinal vessels).
Permanent visual loss due to inflammation or occlusion of
the ciliary or retinal vessels

 Jaw claudication
 Systemic feature : prximal muscle pain---
polymyalgia rheumatica (up to 50% of cases),
weight loss, lassitude.

 Rarer complications: brainstem ischaemia,

cortical blindness, cranial nerve lesions, aortitis,
involvement of coronary and mesenteric arteries.
Diagnosis

The diagnosis is made from the history and

a raised ESR. It is confirmed by a biopsy of the
temporal artery (at least 1cm, as the diseases
process may be patchy).
Treatment

The treatment is with high-dose

corticosteroids, e.g. prednislolone 60mg. There is a
risk of blindness if treatment is delayed, hence the
steroids should be started immediately, prior to the
biopsy.

The dose is reduced as the ESR falls. It is

usually possible to withdraw steroids slowly after
several months to years.