CHAPTER 16 Headache
Headache
• Headache is one of the most common neurologic complaints
worldwide, causing significant disability.
• Classification (International Headache Society):
• Primary headache – headache itself is the disorder (e.g.,
migraine, tension-type, cluster).
• Secondary headache – due to another condition (e.g.,
meningitis, hemorrhage, glaucoma).
• Life-threatening headaches are uncommon but require vigilance.
Chronic Daily Headache (CDH) & Related Syndromes
1. General Approach
• First step: Rule out secondary headache causes.
• If primary headache → identify type (migraine, tension-type,
cluster, etc.) to guide treatment.
• Preventive therapy:
• Tricyclics (amitriptyline, nortriptyline up to 1 mg/kg) – useful
for migraine & tension-type CDH.
Anatomy & Physiology
• Other preventives: topiramate, valproate, propranolol,
candesartan, CGRP monoclonal antibodies, gepants.
• Pain-producing cranial structures: scalp, meningeal arteries, dural • Dosing often starts low and titrated upward.
sinuses, falx cerebri, proximal pial arteries.
• Non–pain-producing: brain parenchyma, pial veins, choroid 2. Medically Intractable Headache
plexus, ventricular ependyma.
• Newer treatments:
• Key structures:
• CGRP monoclonal antibodies – effective for chronic
• Trigeminovascular system (trigeminal nerve + intracranial migraine.
vessels + dura).
• Neuromodulation:
• Trigeminocervical complex (inputs from C1–C2 roots). § Transcranial magnetic stimulation (TMS) – modulates thalamic
• Pain-modulatory systems (brainstem, hypothalamus, pathways.
thalamus, cortex). § Noninvasive vagal nerve stimulation – useful in chronic cluster
• Cranial autonomic symptoms (lacrimation, congestion, rhinorrhea, headache, hemicrania continua, SUNA, SUNCT.
ptosis) occur in TACs and migraine.
• Migraine is a brain disorder, not a “vascular headache.” 3. Medication-Overuse Headache (MOH)
• Caused by frequent analgesic use → worsens headache,
Clinical Evaluation of Acute Headache makes preventives less effective.
• New, severe headache = high suspicion for serious cause • Key management principles:
(meningitis, subarachnoid hemorrhage, tumor, glaucoma, • Reduce/stop analgesics (gradual taper 10% every 1–2
sinusitis). weeks OR abrupt cessation if safe).
• Workup: detailed history, neurologic exam, CT or MRI, LP if • NSAIDs (e.g., naproxen bid) may help during withdrawal.
needed.
• Preventives started after or alongside analgesic withdrawal
• Assess cardiovascular, renal, ophthalmologic, and psychological (but less effective if overuse continues).
factors.
• Inpatient detox for severe or complicated cases:
• Underlying pain (e.g., sinus, ear, dental) may trigger migraine. o Complete withdrawal day 1.
• Most severe headaches are benign, but urgent evaluation is key. o Supportive care (IV fluids, antiemetics, clonidine
for opioid withdrawal).
o IV DHE regimen (every 8h × 5 days) + antiemetics
for refractory cases.
4. New Daily Persistent Headache (NDPH)
• Definition: Daily, persistent headache from a clearly
remembered onset, lasting without remission.
• Important to rule out secondary causes:
• Low CSF volume headache: Post-LP or spontaneous leak.
• Positional (worse upright, relieved lying down).
• Diagnosis: MRI with gadolinium → diffuse
meningeal enhancement.
• Treatment: bed rest, IV caffeine, blood patch.
• Raised CSF pressure:
Secondary Headache Causes • Idiopathic intracranial hypertension (pseudotumor cerebri).
1. Meningitis – acute headache + fever + stiff neck → LP • Headache worse in morning or recumbent.
mandatory. • Diagnosis: MRI/MRV + LP for CSF pressure.
2. Subarachnoid hemorrhage – sudden, maximal <5 min, stiff
neck, no fever → CT ± LP. • Treatment: acetazolamide, topiramate, weight loss, shunting
3. Brain tumor – dull, intermittent, worsens with exertion/position; if refractory.
sometimes mimics migraine. Posterior fossa tumor: vomiting • Posttraumatic headache: Can follow head injury, infection, or
precedes headache. meningitis. Often persistent but imaging normal.
4. Temporal (giant cell) arteritis – age >50, scalp tenderness, jaw • Other causes: Viral/postinfectious illness; must consider low CSF
claudication, risk of blindness. Prompt steroids (prednisone). ESR volume headache post-LP.
often high, biopsy diagnostic.
5. Glaucoma – severe eye pain, red eye, fixed mid-dilated pupil,
with nausea/vomiting.
Primary Headache Disorders
Headache
• Headache is one of the most common neurologic complaints
worldwide, causing significant disability.
• Classification (International Headache Society):
• Primary headache – headache itself is the disorder (e.g.,
migraine, tension-type, cluster).
• Secondary headache – due to another condition (e.g.,
meningitis, hemorrhage, glaucoma).
• Life-threatening headaches are uncommon but require vigilance.
Chronic Daily Headache (CDH) & Related Syndromes
1. General Approach
• First step: Rule out secondary headache causes.
• If primary headache → identify type (migraine, tension-type,
cluster, etc.) to guide treatment.
• Preventive therapy:
• Tricyclics (amitriptyline, nortriptyline up to 1 mg/kg) – useful
for migraine & tension-type CDH.
Anatomy & Physiology
• Other preventives: topiramate, valproate, propranolol,
candesartan, CGRP monoclonal antibodies, gepants.
• Pain-producing cranial structures: scalp, meningeal arteries, dural • Dosing often starts low and titrated upward.
sinuses, falx cerebri, proximal pial arteries.
• Non–pain-producing: brain parenchyma, pial veins, choroid 2. Medically Intractable Headache
plexus, ventricular ependyma.
• Newer treatments:
• Key structures:
• CGRP monoclonal antibodies – effective for chronic
• Trigeminovascular system (trigeminal nerve + intracranial migraine.
vessels + dura).
• Neuromodulation:
• Trigeminocervical complex (inputs from C1–C2 roots). § Transcranial magnetic stimulation (TMS) – modulates thalamic
• Pain-modulatory systems (brainstem, hypothalamus, pathways.
thalamus, cortex). § Noninvasive vagal nerve stimulation – useful in chronic cluster
• Cranial autonomic symptoms (lacrimation, congestion, rhinorrhea, headache, hemicrania continua, SUNA, SUNCT.
ptosis) occur in TACs and migraine.
• Migraine is a brain disorder, not a “vascular headache.” 3. Medication-Overuse Headache (MOH)
• Caused by frequent analgesic use → worsens headache,
Clinical Evaluation of Acute Headache makes preventives less effective.
• New, severe headache = high suspicion for serious cause • Key management principles:
(meningitis, subarachnoid hemorrhage, tumor, glaucoma, • Reduce/stop analgesics (gradual taper 10% every 1–2
sinusitis). weeks OR abrupt cessation if safe).
• Workup: detailed history, neurologic exam, CT or MRI, LP if • NSAIDs (e.g., naproxen bid) may help during withdrawal.
needed.
• Preventives started after or alongside analgesic withdrawal
• Assess cardiovascular, renal, ophthalmologic, and psychological (but less effective if overuse continues).
factors.
• Inpatient detox for severe or complicated cases:
• Underlying pain (e.g., sinus, ear, dental) may trigger migraine. o Complete withdrawal day 1.
• Most severe headaches are benign, but urgent evaluation is key. o Supportive care (IV fluids, antiemetics, clonidine
for opioid withdrawal).
o IV DHE regimen (every 8h × 5 days) + antiemetics
for refractory cases.
4. New Daily Persistent Headache (NDPH)
• Definition: Daily, persistent headache from a clearly
remembered onset, lasting without remission.
• Important to rule out secondary causes:
• Low CSF volume headache: Post-LP or spontaneous leak.
• Positional (worse upright, relieved lying down).
• Diagnosis: MRI with gadolinium → diffuse
meningeal enhancement.
• Treatment: bed rest, IV caffeine, blood patch.
• Raised CSF pressure:
Secondary Headache Causes • Idiopathic intracranial hypertension (pseudotumor cerebri).
1. Meningitis – acute headache + fever + stiff neck → LP • Headache worse in morning or recumbent.
mandatory. • Diagnosis: MRI/MRV + LP for CSF pressure.
2. Subarachnoid hemorrhage – sudden, maximal <5 min, stiff
neck, no fever → CT ± LP. • Treatment: acetazolamide, topiramate, weight loss, shunting
3. Brain tumor – dull, intermittent, worsens with exertion/position; if refractory.
sometimes mimics migraine. Posterior fossa tumor: vomiting • Posttraumatic headache: Can follow head injury, infection, or
precedes headache. meningitis. Often persistent but imaging normal.
4. Temporal (giant cell) arteritis – age >50, scalp tenderness, jaw • Other causes: Viral/postinfectious illness; must consider low CSF
claudication, risk of blindness. Prompt steroids (prednisone). ESR volume headache post-LP.
often high, biopsy diagnostic.
5. Glaucoma – severe eye pain, red eye, fixed mid-dilated pupil,
with nausea/vomiting.
Primary Headache Disorders
