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Chapter56Headache
Whentheheadaches,allthebodyisoutoftune.
Cervantes15471616
Headache,oneofthecardinalsymptomsknowntohumanbeings,isaverycommoncomplaintingeneral
practice.Whenapatientpresentswithheadacheweneedtohaveasounddiagnosticandmanagement
strategyastheproblemcanbeconfusing.Thekeytoanalysingthesymptomofheadacheistoknowand
understandthecause,foroneonlyseeswhattheyknow.
Thepatient'smannerofpresentationcanconfuseusbecausemanytendtoinfluenceuswith
preconceivedideasthattheywillverbaliseIthinkIneedmybloodpressurecheckedorMyeyesneed
testingortheymaynotmentiontheiranxietyaboutacerebraltumouroranimpendingstroke.
Hypertensionissuchararecauseofheadachethatoneistemptedtostresstheadagehypertension
doesnotcauseheadache,butwedoencountertheoccasionalpatientwhoseheadacheappearstobe
causedbyhypertensionanditismandatorytomeasurethebloodpressureofpatientspresentingwith
headache.Patientsexpectthisroutineandreassuranceisdifficultwithouttheappropriatephysical
examination.Whereheadachesandhypertensioncoexist,assumethattheheadachesarenotdueto
hypertension.
Thediagnosisofseriouscausesofheadachedependsonacarefulhistory,ahighindexofsuspicionof
thedifferentpresentationsandthejudicioususeofCTscanning.

Keyfactsandcheckpoints
85%ofthepopulationwillhaveexperiencedheadachewithin1yearand38%ofadultswillhave
hadaheadachewithin2weeks.1
40%ofchildrenwillhaveexperiencedoneormoreheadachesbytheageof7and75%bytheage
of15.2
Migraineaffectsatleast10%oftheadultpopulationandonequarterofthesepatientsrequire
medicalattentionfortheirattacksatsomestage.3Itisunderrecognisedandpoorlymanagedin
thecommunity.4
5%ofchildrensufferfrommigrainebytheageof11years.3
70%ofsufferershaveapositivefamilyhistoryofmigraine.
Manyheadachespreviouslyconsideredtobetensionaresecondarytodisordersoftheneck,
eyes,teeth,temporomandibularjointsorotherstructures.3
Druginducedheadachesarecommonandmustbeconsideredinthehistory.
Inchildrenthetriadofsymptomsdizziness,headacheandvomitingindicatesmedulloblastoma
oftheposteriorfossauntilprovedotherwise.
Atypicaltriadofsymptomsinanadultwithacerebraltumour(advanced)isheadache,vomiting
andconvulsions.
Eyestrainisnotacommoncause.
Bronchialcarcinomaisthecommonestcauseofintracerebralmalignancy.

Adiagnosticapproach
AsummaryofthesafetydiagnosticmodelispresentedinTable56.1.
Table56.1Headache:diagnosticstrategymodel
Q.Probabilitydiagnosis
A.Acute:respiratoryinfection
Chronic:tensiontypeheadache
combinationheadache
migraine
transformedmigraine
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Q.Seriousdisordersnottobemissed
A.Cardiovascular
subarachnoidhaemorrhage
intracranialhaemorrhage
carotidorvertebralarterydissection
temporalarteritis
cerebralvenousthrombosis
Neoplasia
cerebraltumour
pituitarytumour
Severeinfections
meningitis,esp.fungal
encephalitis
intracranialabscess
Haematoma:extradural/subdural
Glaucoma
Benignintracranialhypertension
Q.Pitfalls(oftenmissed)
A.Cervicalspondylosis/dysfunction
Dentaldisorders
Refractiveerrorsofeye
Sinusitis
Ophthalmicherpeszoster(preeruption)
Exertionalheadache
Hypoglycaemia
Posttraumaticheadache
Postspinalprocedure(e.g.epidural,lumbarpuncture)
Sleepapnoea
Rarities
Paget'sdisease
Postsexualintercourse
Cushing'ssyndrome
Conn'ssyndrome
Addison'sdisease(p.224)
Dysautonomiccephalgia
Q.Sevenmasqueradeschecklist
A.Depression
Diabetes
Drugs
Anaemia
Thyroiddisorder
Spinaldysfunction

cervicogenic

UTI
Q.Isthepatienttryingtotellmesomething?
A.Quitelikelyifthereisanunderlyingpsychogenicdisorder.

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Probabilitydiagnosis
Thecommonestcauseofheadachepresentingingeneralpracticeisrespiratoryinfection.1Themost
commoncausesofchronicrecurrentheadachearesocalledtransformedmigraine,tensiontype
headacheandcombinationheadaches.Combinationheadaches,typifiedbyrelativelyconstantpain
lastingformanydays,haveamixofcomponentssuchastension,depression,cervicaldysfunction,
vascularheadacheanddrugdependence.Neurologistsmayrefertotheseheadachesastension
vascularheadache.Tensionheadacheislesscommonthanpreviouslypromulgated.3
Transformedmigraine5
Thisdescribestheprogressiveincreaseinfrequencyofmigraineattacksuntiltheheadacherecursdaily.
Thetypicalmigrainefeaturesbecomemodifiedsothatthepatternresemblesthatoftensionheadache
butwiththeunilateralsituationofmigraine.Analgesicabusecantransformepisodicmigraineintochronic
dailyheadache.

Seriousdisordersnottobemissed
Fortheacuteonsetofheadacheitisvitalnottomisssubarachnoidhaemorrhage(SAH)ormeningitis.
Intracranialhaemorrhage,especiallyinvolvingcerebellar,intraventricularandfrontallobeareas,needsto
beconsidered.
Acutethunderclapheadache5
Thisisasuddensevereheadachethatcanbecausedbythefollowing:
enlarginganeurysmanenlarginganeurysmorvascularmalformationcancauseacuteheadache
SAHthepainistypicallyoccipital,localisedatfirstthengeneralisedandmayvaryinintensity
meningitismustbeconsiderediftheheadacheisgeneralised,especiallyinthepresenceof
malaise,feverandneckstiffness:theache,whichisconstantandsevere,maybeginabruptly
Forchronicheadache,spaceoccupyinglesionsincludingsubduralhaematomasmustbeconsidered.
Sinceheadachestendtodecreasewithage,headachesdevelopingintheelderlyshouldbeviewedwith
suspicionandthisincludesconsideringtemporalarteritis(TA).Benignintracranialhypertensionshouldbe
considered,especiallyinyoungobesewomen.Thedangerouscryptococcalmeningitiscanbedifficultas
theCTscanmaybenormal.
Tipsonsinistercausesofheadache4
Themostimportantindicatoristimecourse:bewareofacuteorsubacutetempo.
Besuspiciousofanyfocalsymptomsorsigns(exceptfortypicalmigraineaura).
Bewareoffever,confusion,alteredmentalstateorneckstiffness.

Pitfalls
Thelist(Table56.1)containssomecontroversialcausesofheadache,althoughsomeshouldbeobvious
ifacarefulhistoryiselucidated.Theseincludeposttraumaticheadache,postproceduralheadache(e.g.
lumbarpunctureandspinalanaesthesia)andexertionalheadache.Sinusitiscanbeoverlookedinthe
absenceofrespiratorysigns.Refractiveerrorsoftheeye,althoughanuncommoncauseofheadache,do
warrantconsideration.
Generalpitfalls
Overinvestigatingthepatientwithheadache,especiallyasasubstituteforacarefulhistoryand
examination
Failingtoappreciatethatacombinationoffactorsandcervicaldysfunctionarecommoncausesof
headache
Omittingtomeasurethebloodpressureinthepatientcomplainingofheadache
Rushinginwithantibioticsforapatient(especiallychildren)withfeverandheadachebacterial
meningitismaybemasked
Attributingtheearlyheadacheofaspaceoccupyinglesiontotensionorhypertension

Sevenmasqueradeschecklist
Ofthemasquerades,depressionanddrugsareimportantcausesofheadache.Cervicaldysfunctionis
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certainlyanimportantcauseandtendstobeignoredbysomedoctors.Australianfiguresaremisleading
becausemanyofthesepatientstendtogravitatetoalternativehealthprofessionals.
AUKstudyplacedheadachefromcervicalspondylosisonalmostequaltermswithmigraine.1
Theexplanationforreferralofpainfromdisordersoftheuppercervicalspinetotheheadandeyeisthat
someafferentfibresfromtheupperthreecervicalnerverootsconvergeoncellsintheposteriorhornof
thespinalcord(whichcanalsobeexcitedbytrigeminalafferentfibres),thusconveyingtothepatientthe
impressionofheadpainthroughthissharedpathway(Figure56.1).

Figure56.1Typicalheadachereferralpatternsfordysfunctionoftheuppercervicalspinalsegments
SignificantdrugcausesarelistedinTable56.2.Anaemiacancauseheadache,usuallyifthe
haemoglobinlevelfallsbelow100g/L.5Hypoandhyperthyroidismmayalsocauseheadache,andin
diabeticshypoglycaemiaisoftenresponsible.
Table56.2Drugsthatcancauseheadache
Alcohol
Analgesics(rebound)aspirin
codeine
Antibioticsandantifungals
Antihypertensivesmethyldopa
betablockers(e.g.atenolol)
hydralazine
reserpine
calciumchannelblockers(e.g.nifedipine)
Caffeine
Corticosteriods
Cyclosporin
Dipyridamole
Ergotamine(rebound)
H2receptorantagonists(e.g.cimetidine,ranitidine)
MAOinhibitors
Nicotine
Nitrazepam
NitrousOxide
NSAIDs(e.g.indomethacin)
Oralcontraceptives
PDEsinhibitors(e.g.sildanafil,tadelafil)
Retinoids
Sympathomimetics
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Theophylline
Vasodilators(e.g.calciumchannelblockers,nitrates)

Psychogenicconsiderations
Headache,liketiredness,isoneofthosesymptomsthatmayreflectahiddenagenda.Ofcourse,the
patientmaybedepressed(overtormasked)ormayhaveatrueanxietystate.Themostcharacteristic
featureofpsychogenicheadacheisthattheheadacheispresentvirtuallyeveryminuteofthedayfor
weeksormonthsonend.However,itiscommonforpatientstodenythattheyareanxious,depressedor
undulystressed.Forthisreasonadetailedhistoryisimportanttoidentifylifestylefactorsandhistorical
eventsthatcanbeassociatedwithheadache.
Somepatientsarefearfuloftheirheadachelestitrepresentsacerebraltumour,strokeorhypertension
andneedappropriatereassurance.
Conversionreactionsandotheraspectsofcompensationrewards,especiallyfollowinganaccident(e.g.
rearendcollision),maymakethesymptomofheadachedifficulttomanage.Headache,likebackache,is
oneoftheprimesymptomsperpetuatedorexaggeratedforsecondarygain.
Severeheadaches,especiallysimulatedmigraine,arecommonticketsofentryfordrugaddictsseeking
narcoticsfromempathicpractitioners.Suchpatientsrequireveryskilledmanagement.

Diurnalpatternsofpain
Plottingthefluctuationofheadacheduringthedayprovidesvitalcluestothediagnosis(Figure56.2).The
patientwhowakesupwithheadachecouldhavevascularheadache(migraine),cervicalspondylosis,
depressiveillness,hypertensionoraspaceoccupyinglesion.Itisusualformigrainetolasthours,not
days,whichismorecharacteristicoftensionheadache.Thepainoffrontalsinusitisfollowsatypical
pattern,namelyonsetaround9am,buildingtoamaximumbyabout1pm,andthensubsidingoverthe
nextfewhours.Intheabsenceofrespiratorysymptomsitislikelytobemisdiagnosedastension
headache.Thepainfromcombinationheadachetendstofollowamostconstantpatternthroughoutthe
dayanddoesnotusuallyinterruptsleep.

Figure56.2Typicaldiurnalpatternsofvariouscausesofheadachetherelativeintensityofpainisplotted
ontheverticalaxis

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Theclinicalapproach
History
Afulldescriptionofthepainincludingapainanalysisshouldbeobtained.Thisincludes:
site
radiation
quality
severity
frequency
duration
onsetandoffset
precipitatingfactors
aggravatingandrelievingfactors
associatedsymptoms
Itisusefultogetthepatienttoplotonapreparedgridtherelativeintensityofthepainandthetimesof
day(andnight)thatthepainispresent.Thehistory,especiallyofthetempoofthecondition,shouldhelp
diagnoseheadachessecondarytospecificpathology.
Keyquestions6
Canyoudescribeyourheadaches?
Howoftendoyougetthem?
Canyoupointtoexactlywhereintheheadyougetthem?
Doyouhaveanypaininthebackofyourheadorneck?
Whattimeofthedaydoyougetthepain?
Doyounoticeanyothersymptomswhenyouhavetheheadache?
Doyoufeelnauseatedanddoyouvomit?
Doyouexperienceanyunusualsensationsinyoureyes,suchasflashinglights?
Doyougetdizzy,weakorhaveanystrangesensations?
Doeslighthurtyoureyes?
Doyougetanyblurredvision?
Doyounoticewateringorrednessofoneorbothofyoureyes?
Doyougetpainortendernessoncombingyourhair?
Areyouunderalotofstressortension?
Doesyournoserunwhenyougettheheadache?
Whattabletsdoyoutake?
Doyougetahightemperature,sweatsorshivers?
Haveyouhadaheavycoldrecently?
Haveyoueverhadtroublewithyoursinuses?
Haveyouhadaknockonyourheadrecently?
Whatdoyouthinkcausestheheadaches?
DifferencesbetweentheclinicalfeaturesofmigraineandtensionheadachearepresentedinTable56.3.
Redflagindicatorsofaseriouscauseofheadacheareoutlinedinthebox.
Table56.3Acomparisonoftypicalclinicalfeaturesofmigraineandtensionheadache7

Migraine

Tensionheadache

Familyhistory

Onsetbefore20

Prodromata

Bilateral
Unilateral
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Throbbing
Constant

Lessthan1perweek
Continuousdaily

Lastslessthan24h

Vomiting

Aggravatedbythepill

Aggravatedbyalcohol

Relievedbyalcohol

Redflagpointersforheadache
Suddenonset
Severeanddebilitatingpain
Fever
Vomiting
Disturbedconsciousness
Worsewithbendingorcoughing
Maximuminmorning
Neurologicalsymptoms/signs
Youngobesefemale:?on
medication
Newinelderly,especially>50
years

Physicalexamination
Forthephysicalexaminationitisappropriatetousethebasictoolsoftrade,namelythethermometer,
sphygmomanometer,pentorch,anddiagnosticset,includingtheophthalmoscopeandthestethoscope.
Inspectthehead,temporalarteriesandeyes.Areastopalpateincludethetemporalarteries,thefacial
andneckmuscles,thecervicalspineandsinuses,theteethandtemporomandibularjoints.Search
especiallyforsignsofmeningealirritationandpapilloedema.
Amentalstateexaminationismandatoryandincludeslookingforalteredconsciousnessorcognitionand
assessmentofmood,anxietytensiondepression,andanymentalchanges.Neurologicalexamination
includesassessmentofvisualfieldsandacuity,reactionsofthepupilsandeyemovementsinadditionto
sensationandmotorpowerinthefaceandlimbsandreflexes,includingtheplantarresponse.Redflag
indicatorsfromtheexaminationaregivenintheboxbelow.
Specialsigns
Uppercervicalpainsign.PalpateovertheC2andC3areasofthecervicalspine,especiallytwo
fingerbreadthsoutfromthespinousprocessofC2.Ifthisisverytenderandevenprovokesthe
headacheitindicatesheadacheofcervicalorigin.

Redflagpointers:fromphysical
examination
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Alteredconsciousnessorcognition
Meningism
Abnormalvitalsigns:BP,
temperature,respiration
Focalneurologicalsigns,including
pupils,fundi,eyemovement
Tender,poorlypulsatilecranial
arteries

Ewing'ssignforfrotalsinusitis.Pressyourfingergentlyupwardsandinwardsagainsttheorbital
roofmedialtothesupraorbitalnerve.Painonpressureisapositivefindingandindicatesfrontal
sinusitis.
Theinvisiblepillowsign.Thepatientliesontheexaminationtablewithheadonapillow.The
examinerthensupportstheheadwithhisorherhandsasthepillowisremoved.Thepatientis
instructedtorelaxtheneckmusclesandtheexaminerremovesthesupportinghands.Apositive
testindicatingtensionfromcontractingneckmusclesiswhenthepatient'sheaddoesnotreadily
changeposition.Thisisuncommon.

Investigations
Investigationscanbeselectedfrom:
haemoglobin:?anaemia
WCC:leucocytosiswithbacterialinfection
ESR:?temporalarteritis
radiography
chestXray,ifsuspectedintracerebralmalignancy
cervicalspine
skullXray,ifsuspectedbraintumour,Paget'sdisease,depositsinskull
sinusXray,ifsuspectedsinusitis
CTscan
detectionofbraintumour(mosteffective)
cerebrovascularaccidents(valuable)
SAH
radioisotopescan(technetium99m)tolocalisespecifictumoursandhaematoma
MRI:veryeffectiveforintracerebralpathologybutexpensiveproducesbetterdefinitionof
intracerebralstructuresthanCTscanningbutnotassensitivefordetectingbleedingdetects
intracranialvasculitisintemporalarteries
lumbarpuncture
diagnosisofmeningitis
suspectedSAH(onlyifCTscannormal)
Note:Dangerousifraisedintracranialpressure.

Headacheinchildren
Respiratoryinfectionsandfebrileillnessesareacommoncauseofheadacheinchildrenbutthereare
othercausesthatreflectthecommoncausesinadults.Manychildhoodheadachesareisolatedbutare
chronicinasignificantnumber.Migraineisrelativelycommonbeforeadolescence,whiletensionor
musclecontractionheadacheismorecommonafteradolescence.
Consideroftenoverlookedcausessuchashairtraction,eyestrain(measureandrecordvision)and
hypoglycaemia.Childrenwhohavelongperiodswithoutregulareatingarepronetoheadacheincluding
exacerbationsofmigraine.Theyshouldnotskipbreakfast.8
Youngchildrenrarelyexperiencesinusheadacheandthisshouldnotreallybeconsidereduntilthe
sinusesdevelop,around5yearsforthefrontalsinuses.
From1%of7yearoldsto5%ormoreof15yearoldchildrensufferfrommigraine,withgirlsdevelopingit
atahigherrate2withincreasingage.Thereisastrongfamilyhistory.Asaruletheprognosisisgoodas
themajoritywillhavenomigrainesinthelongterm.Thetypeismainlycommonmigrainewithsymptoms
suchasmalaiseornausea:classicmigrainewiththetypicalauraisnotafeatureofchildhoodmigraine.
Theratherdramaticmigraine,suchasvertebrobasilarmigraine,isfrequentinadolescentgirlsand
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hemiplegiaoccursininfantsandchildren,especiallywiththeirfirstmigraineattack.9Vomitingisnot
necessarilyanassociatedsymptominchildren.
Thepossibilityofcerebralspaceoccupyinglesionsrequiresdueconsideration,especiallyifthe
headachesareprogressive.Thesearepresenttypicallyinthemorningandareassociatedwith
symptomssuchasvomiting,dizziness,diplopia,ataxiapersonalitychangesanddeteriorationofschool
performance.SymptomsthatindicateacerebraltumourorotherseriousproblemareoutlinedinTable
56.4.
Table56.4Pointerstoseriouscausesofheadacheinchildren
Headachefeatures
Persistent
Presentfirstthinginmorning
Wakeschildatnight
Nopasthistory
Nofamilyhistory
Associatedpoorhealth
Associatedneurologicalsymptoms
Unilaterallocalisation
Source:AfterWright2
Neonatesandchildrenaged6l2monthsareatthegreatestriskfrommeningitisanditisimportantto
keepthisinmind.
Managementofthenonseriouscausesofheadacheincludesreassurance(especiallyofparents),
discouragementofexcessiveemphasisonthesymptomandsimplemedications,suchasparacetamol
fortheyoungerchildandaspirinfortheadolescent.Patientswithundiagnosedand/orproblematic
headacheshouldbereferred.

Headachesintheelderly
Therecentonsetofheadacheintheelderlyhastobetreatedwithcautionbecauseitcouldheralda
seriousproblem,suchasaspaceoccupyinglesion(e.g.neoplasm,subduralhaematoma),TA,trigeminal
neuralgiaorvertebrobasilarinsufficiency.Cervicalspondylosisisagerelatedandmaybeanimportant
factorintheageingpatient.AgerelatedheadachesaresummarisedinTable56.5.
Table56.5Agerelatedcausesofheadache
Children

Adults,includingmiddleage

Elderly

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Intercurrentinfections
Psychogenic
Migraine
Meningitis
Posttraumatic
Migraine
Clusterheadache
Tension
Cervicaldysfunction
Subarachnoidhaemorrhage
Combination
Cervicaldysfunction
Cerebraltumour
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Neuralgias
Paget'sdisease
Glaucoma
Cervicalspondylosis
Subduralhaemorrhage

Latelifemigrainecanbemistakenforcerebrovasculardisease,especiallyinthepresenceofpreceding
neurologicalsymptoms.Itisthesequenceofthevisualandsensorysymptomswiththespreadfromface
totonguetohandoversomeminutes,withclearinginoneareaasitappearsthathelpsdistinguish
migrainefromtransientischaemicattacks(TIAs).AlthoughsomepatientsexperienceheadachewithTIAs
itisnotadistinguishingfeature.Vomitingissuggestiveofmigraineratherthancerebrovasculardisease.9

Tensiontypeheadache
Tensionormusclecontractionheadachesaretypicallyasymmetrical(bilateral)tightness.Theytendto
lastforhoursandrecureachday.Theyareoftenassociatedwithcervicaldysfunctionandstressor
tension,althoughthepatientusuallydoesnotrealisetheheadachesareassociatedwithtensionuntilitis
pointedout.Seventyfivepercentofpatientsarefemales.3

Typicalclinicalfeatures
Site:
Radiation:
Quality:

frontal,overforeheadandtemples(Figure56.3)
occiput
dullache,likeatightpressurefeeling,heavyweightontopofhead,tightbandaround
headmaybetightnessorvicelikefeelingratherthanpain
Frequency: almostdaily
Duration:
hours(canlastdays)
Onset:
afterrising,getsworseduringday
Aggravating stress,overworkwithskippingmeals
factors:
Relieving
alcohol
factors:
Associated lightheadedness,fatigue,neckacheorstiffness(occiputtoshoulders),perfectionist
features:
personality,anxiety/depression
Physical
muscletension(e.g.frowning),scalpoftentendertotouch,invisiblepillowsignmaybe
examination: positive

Figure56.3Typicaldistributionofpainintensiontypeheadache

IHScriteriafortensiontypeheadache
TheInternationalHeadacheSociety(IHS)criteriaforepisodictensiontypeheadachesinvolvethe
following:
1. Thepatientshouldhavehadatleasttenoftheseheadaches.
2. Theheadacheslastfrom30minutesto7days.
3. Theheadachesmusthaveatleasttwoofthefollowingfour:
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a. nonpulsatingquality
b. mildormoderateintensity
c. bilaterallocation
d. noaggravationwithroutinephysicalactivity
4. Theheadachesmusthavebothofthefollowing:
a. nonauseaorvomiting
b. photophobiaandphonophobiaareabsent,oronebutnottheotherispresent
5. Thereshouldbelessthan15daysofheadachepermonthandlessthan180daysperyear.
6. Secondarycausesareexcluded.

Management10
Carefulpatienteducation:explainthatthescalpmusclesgettightlikethecalfmuscleswhen
climbingupstairs.
Counsellingandrelevantadvice:
Learntorelaxyourmindandbody.
Duringanattack,relaxbylyingdowninahotbathandpractisemeditation.
Belessofaperfectionist:donotbeaslavetotheclock.
Don'tbottlethingsup,stopfeelingguilty,approveofyourself,expressyourselfandyouranger.
Adviseanddemonstratemassageoftheaffectedareawithasoothinganalgesicrub.
Advisestressreduction,relaxationtherapyandyogaormeditationclasses.
Medicationusemildanalgesicssuchasaspirinorparacetamol.Discouragestrongeranalgesics.
Avoidtranquillisersandantidepressantsifpossible,butconsiderthesedrugsifsymptomswarrant
medication(e.g.amitriptyline1075mg(o)nocteincreasingto150mgifnecessary).Diazepam
(shorttermuse)appearstobeveryeffectiveinmiddleagedmenitispronetocausedepression
inwomen(bewareofhabituation).
Specialnotes:
Thegeneralaimistodirectpatientstomodifytheirlifestyleandavoidtranquillisersand
analgesics.
Itisunusualtobeawokenfromsleep.
Bewareofdepression.
Considermuscleenergytherapyand/ormobilisationoftheneckfollowedbyexercisesifthereis
evidenceofcervicaldysfunction.
Recommendameditationprogram.

Migraine
Migraine,orthesickheadache,isderivedfromtheGreekwordmeaningpaininvolvinghalfthehead.It
affectsatleast1personin10,ismorecommoninfemales(18%ofwomen,6%men)andpeaksbetween
20and50years.Therearevarioustypesofmigraine(Table56.6),withclassicmigraine(headache,
vomitingandaura)andcommonmigraine(withouttheaura)beingthebestknown.Themostcommon
triggerfactorisstress.3
Table56.6Typesofvascularheadache
Commonmigraine(auraisvagueorabsent)
Classicmigraine
Complicatedmigraine
Unusualformsofmigraine
hemiplegic
basilar
retinal
migrainousstupor
ophthalmoplegic
migraineequivalents
statusmigrainosus
Clusterheadache
Chronicparoxysmalhemicrania
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Menstrualmigraine
Lowerhalfheadache
Benignexertionalsexheadache(bewareofSAH)
Miscellaneous(e.g.icepickpains,icecreamheadache)
Source:AfterDay11

Typicalclinicalfeaturesofclassicmigraine
Site:
Radiation:
Quality:
Frequency:
Duration:
Onset:
Offset:
Precipitatingfactors:
Aggravatingfactors:
Relievingfactors:
Associatedfactors:

Otherpointers:

temporofrontalregion(unilateral)(Figure56.4)canbebilateral
retroorbitalandoccipital
intenseandthrobbing
1to2permonth
4to72hours(average68hours)
paroxysmal,oftenwakeswithit
spontaneous(oftenaftersleep)
tensionandstress(commonest)othersinTable56.7
tension,activity
sleep,vomiting
nausea,vomiting(90%)irritability
auravisual25%(scintillation,scotoma,hemianopia,fortification)
sensory(unilateralparaesthesia)
abdominalpaininchildhoodfamilyhistoryofmigraine,asthmaandeczema

Figure56.4Typicaldistributionofpaininmigraine(rightside)
Table56.7Migrainoustriggerfactors
Exogenous
Foodstuffschocolate,oranges,tomatoes,citrusfruits,cheeses,glutensensitivity(possible)
Alcoholespeciallyredwine
Drugsvasodilators,oestrogens,monosodiumglutamate,nitrites(hotdogheadache),indomethacin,
OCP
Glareorbrightlight
Emotionalstress
Headtrauma(oftenminor),e.g.jarringfootballer'smigraine
Allergen
Climaticchange
Excessivenoise
Strongperfume
Endogenous
Tiredness,physicalexhaustion,oversleeping
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Stress,relaxationafterstressweekendmigraine
Exercise
Hormonalchangespuberty
menstruation
climacteric
pregnancy
Hunger
Familialtendency
?Personalityfactors

DxT:headache+vomiting+visualaura=
migranewithaura(classic)

IHScriteriaforcommonmigraine
TheIHScriteriaformigrainewithoutaurainvolvesthechecklistbelow.
1. Thepatientshouldhavehadatleastfiveoftheseheadaches.
2. Theheadacheslast472hours.
3. Theheadachemusthaveatleasttwoofthefollowing:
a. unilaterallocation
b. pulsingquality
c. moderateorsevereintensity,inhibitingorprohibitingdailyactivities
d. headacheworsenedbyroutinephysicalactivity
4. Theheadachemusthaveatleasttwoofthefollowing:
a. nauseaand/orvomiting
b. photophobiaandphonophobia
5. Secondarycausesofheadacheareexcluded(e.g.normalexamand/orimagingstudy).

IHScriteriaformigrainewithtypicalaura(classic)
Thereshouldbeatleasttwoattacks,includingatleastthreeofthefollowing:
1.
2.
3.
4.

reversiblebrainsymptoms(corticalorbrainstem)
gradualdevelopmentover4minutes
auradurationlessthan60minutes
headachefollowsaurainlessthan1hour

Note:Iftheauralastslongerthan1hour,itismigrainewithprolongedaura.Ifitlastslongerthan24
hours,itisamigrainousinfarction(stroke).

Management
Patienteducationprovideexplanationandreassurance,especiallyifbizarrevisualandneurological
symptomsarepresent.Patientsshouldbereassuredaboutthebenignnatureoftheirmigraine.Foreach
migrainesufferer,anindividualtreatmentplanincludingamigraineactionplanshouldbedevised.
Counsellingandadvice
Tailortheadvicetotheindividualpatient.
Avoidknowntriggerfactors,especiallytension,fatigue,hungerandconstantphysicalandmental
stress.
Advisekeepingadiaryoffoodstuffsordrinksthatcanbeidentifiedastriggerfactors.Considera
lowaminediet:eliminatechocolate,cheese,redwine,walnuts,tuna,vegemite,spinachandliver.
Practiseahealthylifestyle,relaxationprograms,meditationtechniquesandbiofeedbacktraining.
Beopentonondrugtherapies(e.g.trialofacupuncture,hypnotherapy).

Treatmentoftheacuteattack
Commencetreatmentatearliestimpendingsign.
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Mildheadachesmayrequirenomorethanconventionaltreatmentwith2aspirin(orparacetamol),
andagoodliedowninaquietdarkroom.11
Restinaquiet,darkened,coolroom.
Placecoldpacksontheforeheadorneck.
Avoiddrinkingcoffee,teaororangejuice.
Avoidmovingaroundtoomuch.
Donotreadorwatchtelevision.
Forpatientswhofindrelieffromsimplysleepingoffanattack,considerprescribingtemazepam10
mgordiazepam10mginadditiontothefollowingmeasures.3
Formoderateattacksuseoralergotamineorsumatriptanandforsevereattacksuseinjection
therapy.
Avoidpethidineandsimilardrugsofdependence.
Medication(ifnecessary)10
Firstlinemedication

Aspirinorparacetamol+antiemetic:e.g.solubleaspirin(Dispirindirect)600900mg(o)
and
metoclopramide10mg(o)
Paracetamol(forchildren)
ConsiderNSAIDs(e.g.ibuprofen,diclofenacrapid)
Ifnauseaandvomitingisafeature:
metoclopramide510mgIMorIV
or
prochlorperazine12.5mgIMor12.525mgrectally
considernasalsumatriptan
Alternatives

Chooseanergotaminepreparationoratriptanpreparation.
Ergotamine(helpsabout80%ofpatients)
oral:e.g.ergotamine1mg+caffeine100mg(Cafergot)
2tabsat1stwarningthen60minutesifnecessary(max.6perday)
Mayneedmetoclopramide(o),IMorIV
or
suppository:e.g.ergotamine2mg+caffeine100mg(CafergotS)
1suppositoryat1stwarningthenevery60minutes(max.3perday)
or
medihaler:e.g.1inhalationstatimthenevery5minutes(max.6perday)
or
IMinjection:e.g.dihydroergotamine0.51mg,precededbymetoclopramide10mgIM,20
minutesbeforehand
Sumatriptan(aserotoninreceptoragonist)10
50100mg(o)atthetimeofprodrome,repeatin2hoursifnecessarytomaximumdose300
mg/24hours
or
nasalspray1020mgpernostril(upto40mg/24hours)
or
6mg,SCinjection,repeatin1ormorehourstomaximumdose12mg/24hours
Zolmitriptan2.55mg(o),repeatin2hoursifnecessary(max.10mg/24hours)
Naratriptan2.5mg(o),repeatin4hours(max.5mg/24hours)
Avoidtriptansinpatientswithcoronaryarterydisease,Prinzmetalangina,uncontrolledhypertensionor
duringpregnancy.Donotuseitwithergotaminesimultaneouslyandceaseifchestpaindevelops,albeit
transientinayoungpatient.UsewithcautioninpatientstakingSSRIs,MAOIsandlithium.
Thesevereattack

(ifotherpreparationsineffective)
Caution:Considerthepossibilityofunderlyingcerebralvascularmalformation,SAHorpethidine
addiction.
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Ifathome:12
dihydroergotamine0.51mg(IM)+metoclopramide10mg(IM)
or
sumatriptan6mg(SC)
Ifinsurgeryoremergencyroom:
metoclopramide10mg(IV)slowlyover2minutes+oralanalgesics
or
metoclopramide10mg(IV)+dihydroergotamine0.5mgIVslowly
or
sumatriptan6mg(SC)
Caution:Donotuseergotaminepreparationsifsumatriptanusedinprevious6hours,anddonotuse
sumatriptanifergotaminepreparationsusedinprevious24hours.

Practicetipforsevereclassic
migraine:
IVmetoclopramide+1litreNsalineIVin
30minutes+oralaspirinorparacetamol
Continuehighfluidintake

Statusmigrainosis:IVdihydroergotamine(mayhavetobegiven8hourlyover37daysinhospital)or
chlorpromazine0.1mg/kgIV,repeatedevery15minutesforupto3doses(ifnecessary).Consider
corticosteroids(e.g.dexamethasone1020mgIVstatimandthentaper).

Prophylaxis
Considerprohylactictherapyforfrequentattacksthatcausedisruptiontothepatient'slifestyleandwell
being,aruleofthumbbeingtwoormoremigraineattackspermonthcertainlyconsideritforweekly
attacksandapoorresponsetotherapyfortheacuteattack.Donotgiveergotamine.10
Themostcommonlyuseddrugsinclude:
betablockerspropranolol40mg(o)bdortds(max.320mg/day),metoprolol,atenolol
pizotifen0.52.0mgatnight
cyproheptadine(idealforchildren)
tricyclicantidepressantsamitriptyline
clonidine
methysergide(reserveforunresponsiveseveremigraine)1mgtdsafterfoodupto4monthsonly
calciumchannelblockersnifedipine,verapamil
NSAIDsnaproxen,indomethacin,ibuprofen
MAOIsphenelzine,moclobemide
sumatriptan
gabapentin
sodiumvalproate
topiramate
Menstrualmigraine
Naproxen550mg(o)bd,48hoursbeforeattackfor410days
Guidelines10,12
Selecttheinitialdrugaccordingtothepatient'smedicalprofile:
iflowornormalweightpizotifen
ifhypertensiveabetablocker
ifdepressedoranxiousamitriptyline
iftensionabetablocker
ifcervicalspondylosisnaproxen
foodsensitivemigrainepizotifen
menstrualmigrainenaproxenoribuprofen
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Commonlyprescribedfirstlinedrugsarepropranololorpizotifen:10
propranolol40mg(o)bdortds(atfirst)increasingto320mgdaily(ifnecessary)
pizotifen0.51mg(o)nocte(atfirst)increasingto3mgaday(ifnecessary)
Eachdrugshouldbetriedfor2monthsbeforeitisjudgedtobeineffective.Amitriptyline50mgnoctecan
beaddedtopropranolol,pizotifen(bewareofweightgain)ormethysergideandmayconvertarelatively
poorresponsetoverygoodcontrol.3

Clusterheadache
Clusterheadacheisalsoknownasmigrainousneuralgia.Itoccursinparoxysmalclustersofunilateral
headachethattypicallyoccurnightly,usuallyintheearlyhoursofthemorning,althoughpatientsmay
haveheadachesthatoccuratothertimes.Ahallmarkisthepronouncedcyclicalnatureoftheattacks.It
occurstypicallyinmales(6:1ratio)andisrareinchildhood.Therearenovisualdisturbancesorvomiting.

DxT:retroorbitalheadache+rhinorrhoea
+lacrimation=clusterheadache

Typicalclinicalfeatures
Site:
Radiation:
Quality:

Frequency:
Duration:
Onset:

overoraboutoneeye(Figure56.5)alwayssameside
frontalandtemporalregions
severe
13timesaday,atregulartimeslikeclockwork
15minutesto23hours(average30minutes)theclusterslast46weeks(canlast
months)
suddenlyduringnight(usually),sametimeabout23hoursafterfallingasleepthealarm
clockheadache(e.g.24am)
spontaneous
alcohol(duringcluster)

Offset:

Aggravating
factors:
Relieving drugs
factors:

familyhistoryrhinorrhoea,ipsilateralnoselacrimationflushingofforeheadandcheek
Associated rednessofipsilateraleyeHorner'ssyndrome(uncommon)(Figure56.6)
features:

Figure56.5Typicaldistributionofpaininclusterheadache

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Figure56.6Featuresofanattackofclusterheadache:ptosis,lacrimationandadischargefromthe
nostrilonthesideofpain

Management
Acuteattack(brieftreatmentseldomeffective):
consider100%oxygen10L/minfor15min(usuallygoodresponse)
sumatriptan6mgSCinjection(or20mgintranasal)or
ergotamine(e.gmedihalerorrectally)
metoclopramide10mgIV+dihydroergotamine0.5mgIVslowlyor1mgIM
considerlocalanaestheticgreateroccipitalnerveblock
Avoidalcoholduringcluster.
Prophylaxis(onceaclusterstarts)
Considerthefollowing:
ergotamine(takeatnightduringacluster):oralordihydroergotamineIM(preferablygiven1hour
priortopredictedtimes)
methysergide2mg(o)tds
prednisolone50mg/dayfor10daysthenreduce
lithium250mg(o)bd
verapamilSR160mg(o)dailyupto320mg
pizotifen
indomethacin(helpsconfirmdiagnosis)
sodiumvalproate
Note:Someoftheabovecanbeusedlongtermforfrequentclusters.

Cervicaldysfunction/spondylosis
Headachefromneckdisorders,oftenreferredtoasoccipitalneuralgiaorcervicogenic,isfarmore
commonthanrealisedandisveryrewardingtotreatbyphysicaltherapy,includingmobilisationand
manipulationandexercisesinparticular.
Headachecanbecausedbyabnormalitiesinanystructureinnervatedbytheuppertwocervicalnerves
C2,C3(usuallytheC12,C23facetjoints).Painfromcervicalstructurescanbereferredretroorbitally
andoveronehalfofthehead.Theheadacheisoftenincorrectlydiagnosedasmigrainebutclinical
examinationoftheneckhelpsdifferentiation.13Theneckmayberesponsibleforsocalledtension
headachebutclinicaldifferentiationcanbemoredifficult.

Typicalclinicalfeatures
Thepainisusuallysitedintheoccipitalregionwithpossibleradiationtotheparietalregion,vertexofskull
andbehindtheeye.(Figure56.7)Itisusuallypresentonwalkingandsettlesduringtheday.Thereis
usuallyahistoryoftraumaincludingaMVAorblowtothehead.Associatedfeaturesincludestiffnessand
gratingoftheneck.OnexaminationthereisusuallytendernesstopalpationovertheC1,C2and/orC3
levelsofthecervicalspine,especiallyonthesideoftheheadache.
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Figure56.7Typicaldistributionofpainincervicaldysfunction(rightside)
Treatment
Physiotherapymodalities:hydrotherapy,muscleenergytherapy,mobilisation,manipulation(from
experts)andneckexercises(veryimportant)
Supportiveneckpillow
NSAIDsforcervicalspondylosis
Forintractablecasesconsidermobilisationundergeneralanaesthesia,injectionsofcorticosteroids
around,orsurgicalsectionof,thegreateroccipitalnerve.13

Combinationheadache
Combined(alsoknownasmixed)headachesarecommonandoftendiagnosedaspsychogenic
headacheoratypicalmigraine.Theyhaveacombinationofvariousdegreesof:
tensionand/ordepression
cervicaldysfunction
vasospasm(migraine)
drugs:
analgesics(rebound)
alcohol
nicotine
caffeine
NSAIDs
Theheadache,whichhasmanyofthefeaturesoftensionheadache,isusuallydescribedasaheavy
deepacheasthoughmyheadisreadytoburst.Ittendstobeconstant,beingpresentthroughoutevery
wakingmoment.Ittendstolastfordays(average37)butcanlastforweeksormonths.Itisoften
relatedtostressandadverseworkingconditions,andsometimesfollowsanaccident.

Management
Animportantstrategyistoevaluateeachpossiblecomponentoftheheadacheasastepwisetrialbyan
eliminationprocess:
drugevaluationandmodification
cervicaldysfunctionphysicaltherapyifpresent
depression
tensionandstress
otherpsychogenicfactors(e.g.conversionreaction)
vasospasm
Treatmentincludescognitivetherapy,reassurancethatthepatientdoesnothaveacerebraltumour,and
lifestylemodification.Themosteffectivemedicationisamitriptylineorotherantidepressant.

Temporalarteritis
TAisalsoknownasgiantcellarteritisorcranialarteritis.Thereisusuallyapersistentunilateralthrobbing
headacheinthetemporalregionandscalpsensitivewithlocalisedthickening,withorwithoutlossof
pulsationofthetemporalartery.Itisrelatedtopolymyalgiarheumatica20%ofsuffererswilldevelopTA.

Typicalclinicalfeatures
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Description
TAisatypeofcollagendiseasecausinginflammationofextracranialvessels,especiallythesuperficial
temporalartery.Itusuallypresentsasaunilateralintermittentheadacheinapersonover50years.
Age
Site:
Radiation:
Quality:
Frequency:
Duration:
Onset:
Offset:
Aggravatingfactors:
Relievingfactors:
Associatedfeatures:
Otherpointers:

over50years(meanage70years)
foreheadandtemporalregion(unilateral)(Figure56.8)
downsideofheadtowardsocciput
severeburningpain
daily,aconstantache
usuallyconstant(gettingworse)
nonspecific,tendstobeworseinmorning
nil
stressandanxiety
nil
malaise,vagueachesandpainsinmuscles(especiallyofneck),weightloss
intermittentblurredvision
tendernessonbrushinghair
jawclaudicationoneating
polymyalgiarheumatica
hypertension
abnormalemotionalbehaviour

Figure56.8Typicaldistributionofpainintemporalarteritis(rightside)
TAmayalsoinvolvetheintracranialvessels,especiallytheophthalmicarteryorposteriorciliaryarteries,
causingopticatrophyandblindness.Visionisimpairedinaboutonehalfofpatientsatsomestage.Once
thepatientgoesblinditisusuallyirreversible.
Diagnosis
Diagnosisisbybiopsyandhistologicalexaminationofthesuperficialtemporalartery.TheESRisusually
markedlyelevatedbutmaybenormal.ThebiopsymaybenormalasTAhasafocalnature.MRIhasa
highsensitivityandspecificity.
Note:Consideritwithanynewheadache.
Treatment
TAisveryresponsivetocorticosteroidsstarttreatmentimmediatelytopreventpermanentblindness.
Initialmedicationisprednisolone60mgorallydailyintwodivideddosesinitiallyfor24weeks.Dose
reductionandprogressismonitoredbytheclinicalstateandESRandCRPlevels.10Concomitantuseof
H2receptorantagonistsmaybeappropriateinitially.Temporalarteritismaytake12yearstoresolve.

Frontalsinusitis
Theheadacheoffrontalsinusitiscanbeadiagnosticproblemespeciallyintheabsenceof,oralapsein
timesince,anobviousupperrespiratoryinfectionorvasomotorrhinitis.Somepatientsdonothavea
historyofaprecedingrespiratoryinfectionnorhavesignsofnasalobstructionorfever.Contraryto
popularbelief,sinusitisisarelativelyuncommonsourceofheadache.
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Typicalclinicalfeatures
Itpresentstypicallyasafrontalorretroorbitalheadache(Figure56.9).Acharacteristicisitsdiurnal
variation,developinginthemorningaround9am,beingmostintenseinthemiddleoftheday,then
subsidingtooffsetaround6pm.

Figure56.9Typicaldistributionofpainoffrontalsinusitis(rightside)
Examination
Thereistendernessoverthefrontalsinusandpainonpercussionoverthesinus.Ewing'ssignmaybe
elicited.Feverandoedemaoftheuppereyelidmaybepresent.

Management
Principlesoftreatment
Drainthesinusconservativelyusingsteaminhalations
Antibiotics:amoxycillin/clavulanateorcefaclorordoxycycline
Analgesics
Referral
IfresolutioncannotbeaccomplishedbyconservativemeansthenreferraltoanENTspecialistis
advisable.Acutepurulentsinusitiscanbetreacherousifitpersistandspreads,causingcollectionsofpus
intheextraduralorsubduralspace,cerebralabscessorbloodbornespreadofinfection.
Complications
Orbitalcellulitis
Subduralabscess
Osteomyelitis
Cavernoussinusthrombosis
Symptomsindicatingspreadofinfection:
increaseinfeverandchills
vomiting
oedemaoftheeyelidsandforehead
visualdisturbances
dullingofthesensorium
convulsions

Raisedintracranialpressure
Importantcausesofaspaceoccupyinglesionincludeacerebraltumourandsubduralhaematoma.
Sometimesitisnotpossibletodifferentiatebetweenasubduralandanextraduralhaematoma,although
thelatterclassicallyfollowsanacuteinjury.Typicalfeaturesaregeneralisedheadache,usuallyworsein
themorning,aggravatedbyabruptchangesinintracranialpressureandlaterassociatedwithvomiting
anddrowsiness.Headacheisanuncommonpresentingsymptomofacerebraltumour.

Typicalclinicalfeaturesoftheheadache
Site:
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Radiation:
Quality:
Frequency:
Duration:
Onset:
Offset:
Aggravating
factors:
Relieving
factors:
Associated
features:

retroorbital
dull,deepsteadyache
daily
maybehoursinmorning
worseinmornings,usuallyintermittent,canawakenfromsleep
laterinday(ifatall)
coughing,sneezing,strainingattoilet
analgesics(e.g.aspirin),sitting,standing
vomiting(withoutprecedingnausea)vertigo/dizzinessdrowsinessconfusion(later)
neurologicalsigns(dependingonside)

DxT:drowsiness+vomiting+seizure=
raisedintracranialpressure
Examination
FocalCNSsigns
Papilloedema(Figure56.10)(butmaybeabsent)

Figure56.10Papilloedemawithswollenopticdiscoftheocularfundusduetoraisedintracranial
pressure

Intracerebraltumours
Incidenceis510per100000population
Twopeaksofincidence:children<10years33560years
Maintypesoftumour:
children
medulloblastoma
astrocytoma(posteriorfossa)
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ependymoma
glioma(brainstem)
adults
cerebralglioma
meningioma
pituitaryadenoma
cerebralmetastases(e.g.lung)

Investigations
CTscanandMRI

Subarachnoidhaemorrhage
SAHisalifethreateningeventthatshouldnotbeoverlookedattheprimarycarelevel.Theincidenceis
12per100000populationperannum.About40%ofpatientsdiebeforetreatment,whileaboutonethird
haveagoodresponsetotreatment.
Clinicalfeatures:
suddenonsetheadache(moderatetointenseseverity)
occipitallocation
localisedatfirst,thengeneralised
painandstiffnessoftheneckfollows
vomitingandlossofconsciousnessoftenfollow
Kernig'ssignpositive
neurologicaldeficitmayinclude
hemiplegia(ifintracerebralbleed)
thirdnervepalsy(partialorcomplete)(Figure56.11)

Figure56.11Thirdnervepalsy(rightside)
Aboutonethirdofpatientsexperienceasentinelheadache.

DxT:occipitalheadache+vomiting+
neckstiffness=SAH

Diagnosis
CTscanningistheinvestigationofchoiceandshouldbeperformedinthefirstfewhours.Lumbar
punctureisnotnecessaryifthediagnosiscanbemadebyCT,butisusediftheCTscanisnegative
(usually1020%ofcases).Itmaybefalselynegativeafter7days.EvenbloodstainingofCSFand
xanthochromiaisapositivefeatureonlumbarpuncture.

Specialnotes
Lesssevereheadachescancausediagnosticdifficulties.
ConsideranangiomaratherthanananeurysmasthecauseofSAHifpreviousepisodes.

Management
Immediatereferralisrequired.Ifthereislingeringdoubt,reviewthepatientwithin1224hours.
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Meningitis
Theheadacheofmeningitisisusuallygeneralisedandradiatestotheneck.Itisconstantandsevereand
occasionallymaybeginabruptly.Itisaggravatedbyflexionoftheneck.Kernig'ssignispositive.Fever
andneckstiffnessisusuallypresent.Urgentreferraltohospitalisnecessary.Ifmeningitisissuspectedor
ifachildoradulthasheadachewithfeverandneckstiffness,antibioticsmustnotbegivenuntilalumbar
puncturehasbeenperformed.

Drugreboundheadache
Reboundheadachesareusuallyassociatedwithanalgesicandergotaminedependence.Alonglistof
overthecounterandprescriptionmedicationscancauserebound,forexample,aspirin,paracetamol,
ibuprofen,opioidsandcaffeine.Theheadacheispresentonwakingandtypicallypersiststhroughoutthe
daybutfluctuatesinintensity.Itisamildtomoderate,dull,bilateralachewithadistributionsimilarto
tensionheadache.Drugreboundheadachesshouldbesuspectedinanypatientwhocomplainsof
headachealldayeveryday.Acarefuldrughistoryshouldbetaken.Treatmentincludesgradual
withdrawalofthedrugsandthesubstitutionofantiemeticsandsedativesorbetablockeroverabout14
days.

Chronicparoxysmalhemicrania
Thisisarareheadachesyndromewhichoverlapswithclusterheadacheandfacialpain.Theunilateral
pain,whichcanbeexcruciating,islocatedintheareaofthetemple,forehead,eyeandupperface.Itcan
radiatetotheear,neckandshoulder.Itdiffersfromclusterheadachesinthatthepatientsareinvariably
female,theparoxysmsareshort(average2030minutes)andmorefrequent,withattacksoccurringup
to14timesaday.Thedisorderresemblesclusterheadachesinnatureanddistributionandassociated
autonomicfeatures,suchasipsilateralnasalstuffinessorrhinorrhoea,lacrimation,conjunctivalinjection
andptosis.Theaetiologyisunknownbuttheheadacheoftenrespondsdramaticallytoindomethacin(25
mg(o)tds).10

Postlumbarpunctureheadache10
Thisiscommonandisusuallypresentwhenstandingorsittingandrapidlyimproveswithlyingflat.Itisa
formoflowpressureheadache,possiblyduetoCSFleakage.Itcanbeseverewithnauseaandvomiting.
Inmostresolutionoccurswithin27days.Treatmentincludesbedrestuntilresolution.Ifpersistent
referralforanepiduralbloodpatchisrecommended.

Trigeminalneuralgia
Thepainoftrigeminalneuralgiacomesinexcruciatingparoxysms,whichlastforsecondstominutesonly
andusuallyaffectthefaceratherthanthehead(seep.572).Thelightninglikejabsofsearingorburning
painusuallylast1to2minutesbutcanlastaslongas15minutes.

Icepickheadache
Icepickheadachesaresimilarsuddenstabbingpainslastingafewsecondsusuallyatthetemple(often
bilateral)andaremorecommoninmigrainesufferers.Theycanoccurunpredictably30ormoretimesa
day.Treatmentiswithindomethacin25mgtds.10

Hypertensionheadache
Ittendstooccuronlyinseverehypertensionsuchasmalignanthypertensionorhypertensive
encephalopathy.Theheadacheistypicallyoccipital,throbbingandworseonwakinginthemorning.
Theheadachemaybepsychogenicinorigin,developingafterthediagnosisofhypertensionisdisclosed
tothepatient.However,theoccasionalpatienthasgenuineheadacherelatedtomilderhypertensionand
thisservesasanaccurateindicatoroftheirbloodpressurelevel.

Benignintracranialhypertension(pseudotumour
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cerebri)
Thisisararebutimportantsinisterheadacheconditionthattypicallyoccursinyoungobesewomen.Key
featuresareheadache,visualblurringandobscurations,nauseaandpapilloedema.TheCTandMRI
scansarenormalbutlumbarpuncturerevealsincreasedCSFpressureandnormalCSFanalysis.
Itissometimeslinkedtodrugs,includingtetracyclines(mostcommon),nitrofurantoin,oralcontraceptive
pillandvitaminApreparations.Themainconcernisvisualdeficitsfromthehighintracranialpressure.
Medicaltreatmentincludesweightreduction,corticosteroidsanddiuretics.Thetreatmentofchoiceto
alleviatesymptomsisrepeatedlumbarpuncture.Surgery,whichinvolvesdecompressionoftheoptic
nervesorlumboperitonealshunting,issometimesrequiredforfailedmedicaltherapy.
DxT:headache+visualobscurations+
nausea=benignintracranialhypertension

Headachesrelatedtospecificactivities
Sexheadache
Thiscanmanifestasadullorexplosiveheadache,provokedbysexualarousalandactivity,especially
withorgasm.Someareclearlyaformofexertionalheadache.Sometimessexheadacheismistakenfor
SAHbutifthesevereheadachecoincidedwithorgasm,wasnotassociatedwithvomitingorneck
stiffness,orsettledwithinhours,SAHisunlikely.Treatmentiswithprophylacticbetablockersor
ergotamine1mg(0)12hoursbeforeactivity.

Coughandexertionalheadache
Somepeopleexperienceaseveretransientpainwithfactorssuchascoughing,sneezing,stooping,
straining,liftingandvarioussportingactivities.Itisusuallybenignandexaminationisnormal.ACTscan
isindicatediftherearefocalsignsorifthesymptomsdonotsettle.
Treatmentisindomethacin25mg(0)23timesdailyforcoughheadacheand12hoursbefore
exertionalactivity.

Gravitationalheadache
Occipitalheadache,comingonwhenstandinguprightandrelievedbylyingdown,ischaracteristicofa
postlumbarpuncture,anepiduralblockorlowpressureheadache.Itcanlastforseveralweeksafterthe
procedure.

Icecreamheadache
Frontalorglobalheadachecanbeprovokedbytherapidingestionofverycoldfoodanddrink.Itisaform
ofvascularheadache.

Whentorefer
EvidenceorsuspicionofSAHorintracerebralhaematoma
Complicatedmigraine
Uncertaindiagnosis
Positiveneurologicalsignsdespitetypicalheadaches

Practicetips
Apatient>55yearsoldpresenting
withunaccustomedheadachehas
anorganicdisordersuchasTA,
intracerebraltumourorsubdural
haematomauntilprovedotherwise.
TheESRisanexcellentscreening
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testtodiagnoseTAbut
occasionallycanbenormalinthe
presenceofactiveTA.
Ifapatientpresentstwicewithin24
hourstothesamepracticeor
hospitalwithheadacheand
vomiting,considerothercauses
apartfrommigrainebefore
dischargingthepatient.8
Treatanunusualorunaccustomed
headachewithalotofrespect.
Ifmigraineattacksaresevereand
unusual(e.g.alwaysonthesame
side)considerthepossibilityof
cerebralvascularmalformation.
CTscansandMRIhave
supersededotherinvestigationsin
thediagnosisofcerebraltumours
andintracranialhaemorrhagebut
shouldbeorderedsparinglyand
judiciously.
Ifaheadacheisoccipitalinorigin
oraccompaniedbyneckpain,
considerthelikelypossibilityof
cervicaldysfunctionandreferto
theappropriatetherapistoncethe
diagnosisisestablished.
Forrecurrentmigrainesufferers
emphasisetheimportanceof
triggerfactoravoidanceandof
takingaspirinandmetoclopramide
medicationattheearliestwarning
ofanattack.
Asevereheadacheofsudden
onsetisSAHuntilproved
otherwise.
SAHisoverlookedsometimes,
mainlybecauseitisnotconsidered
inthedifferentialdiagnosis.
Suspectwithverysevereand
protractedheadache,drowsiness
andneckstiffness.
Medicalevidenceindicatesthat
mostheadachesarerelatedto
fatigue,stressormigrainetriggers
andrespondtoapplicationofheat
orcold,exerciseandcommon
analgesics,includingaspirinand
ibuprofen.14
Ifwomenwithmigrainedemand
theoralcontraceptive,usealow
doseoestrogenpreparationand
monitorprogress.
Theuseofnarcoticsformigraine
treatment(suchaspethidineand
codeine)istobeavoided
wheneverpossiblethefrequent
useofergotamine,analgesicsor
narcoticscantransformepisodic
migraineintochronicdaily
headache.4

Headachesincreasinginfrequency,despiteprophylaxis
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Murtagh's General Practice Series - Fourth Edition

Dangersignalswithheadache:
suddenonsetwithoutprevioushistory
recentonsetforfirsttimeinanolderperson
recurrentinchildren
progressive
wakesthepatientatnight
localisedpainindefiniteareaorstructure(e.g.ear,eye)
precipitatedbyraisedintracranialpressure(e.g.coughing)
associatedneurologicalsymptomsorsigns:
convulsions
fever
confusion
impairedconsciousness
neckstiffness
dizziness/vertigo
personalitychange

REFERENCES
1. CormackJ,MarinkerM,MorrellD.Thepatientcomplainingofheadache.In:Practice.London:
KluwerMedical,1982:3.12.
2. WrightM.Recurrentheadachesinchildren.AustPaediatrRevi,19911(6):12.
3. AnthonyM.Migraineandtensionheadache.In:MIMSDiseaseIndex(2ndedn).Sydney:IMS
Publishing,1996:31316.
4. StarkR.Managementofheadache.Proceedingsof25thupdatecourseforGPs.Monash
University,2003.
5. LanceJW.Headacheandfacialpain.MedJAust,2000172:4505.
6. DavisA,BolinT,HamJ.SymptomAnalysisandPhysicalDiagnosis.Sydney:Pergamon,1990.
7. LanceJW.MechanismandManagementofHeadache(3rdedn).London:Butterworths,1978:
10912.
8. SmithL.Childhoodheadache.In:AustralianDoctorEducation,GPPaediatrics,2005.
9. BurnsR.Pitfallsinheadachemanagement.AustFamPhysician,199019:18216.
10. TillerJ(Chair).Therapeuticguidelines:Neurology(Version2).Melbourne:TherapeuticGuidelines
Ltd,2002:2553.
11. DayTJ.Migraineandothervascularheadaches.AustFamPhysician,199019:17971804.
12. HeywoodJ,ZagamiA.Treatingacutemigraineattack.CurrTher,199737(12):337.
13. AnthonyM.Thetreatmentofmigraineoldmethods,newideas.AustFamPhysician,199322:
140105.
14. RosserW,ShafirMS.Evidencebasedfamilymedicine.Hamilton:BCDeckerInc.,1998:1646.

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