_Headache is one of the most common neurological problems, in which the careful analysis of the details of history is particularly important.

_Duration of the headache may give clear idea of the seriousness of the und-

erlying disease.

_sudden headache for the first time may be due to meningitis, intracranial

hemorrhage, subarachnoid hemorrhage.

_Headache for years usually is psychogenic.

_Headache for weeks or months may suggest a progressive or an expanding

intracranial lesion& require careful investigation.

_Pain sensitive structures both inside and outside the head receive their

sensory innervation from the tigeminal, glossopharangeal and vagus

nerves or from the upper three cervical nerves

_If the headache is due to a lesion above tentorium pain is felt at

the distribution of ophthalmic division of trigeminal nerve.

_If the lesion is below tentorium the pain is referred to distribution

of upper three cervical nerves or ninth or tenth cranial nerves

_the duration and frequency are important when the headache is

periodic or recurrent, migraine may occur at regular intervals or

confined to certain times, at premenstrual period and may be absent during pregnancy.

_Aggravating factors are important, headache of increased intracra-

nial pressure is aggravated by change in posture or sudden movement also in vascular and post-concussional headache

_Certain food, cheese , chocolate and hypoglycemia may bring on

migraine, while rest will generally relieve vascular headache.

_ The quality of pain also helpful, in migraine is throbbing, but in

migrainous neuralgia may take the form of severe boring pain, while

in tension headache is dull, pressing and band-like.

Migraine.

Tension.

Cluster.

BENIGN PAROXYSMAL HEADACHES

Character of pain Duration Location

Comment

Ice pick Stabbing Very brief (split-second)

Variable, usually temporal or parietal

Benign, more common in migraine

Ice cream Sharp, severe 30-120 seconds Bitemporal/occipital

Obvious trigger by cold stimuli

Exertional/coital Bursting, thunderclap

Severe for minutes then less severe for hours

Generalised Subarachnoid haemorrhage needs exclusion

Cough Bursting Seconds to minutes

Occipital or generalised

Intracranial pathology needs exclusion (especially cranio-cervical junction)

Cluster headache

(migrainous neuralgia)

Severe unilateral, with ptosis, tearing, conjunctival injection, unilateral nasal congestion

30-90 minutes 1-3 times per day

Periorbital Usually men, occurring in clusters over weeks/months

Chronic paroxysmal hemicrania

Severe unilateral with cluster headache-like autonomic features (above)

5-20 minutes, frequently through day

Periorbital/temporal

Usually women, responds to indometacin

SUNCT* Severe, sharp, triggered by touch or neck movements

15-120 seconds, repetitive through day

Periorbital May respond to carbamazepine

SUNCT :Short-lasting, Unilateral, Neuralgiform headache with Conjunctival injection

Subarachoid hemorrhage.

Meningitis.

Intracranial tumors.

Temporal artritis.

Subdural hematoma.

“Red Flags” for headache evaluation

HIGH RISK HISTORICAL HIGH RISK HISTORICAL FEATURES FEATURES 

Sudden Onset Sudden Onset New onset > 50yrsNew onset > 50yrs Headache with exertion Headache with exertion Visual disturbancesVisual disturbances LocationLocation Medication Medication HIV , ImmunocompromisedHIV , Immunocompromised

Sudden onset Sudden onset 

Subarachnoid hemorrhage (SAH) often Subarachnoid hemorrhage (SAH) often presents with the abrupt onset of presents with the abrupt onset of excruciating pain.excruciating pain.

Other serious etiologies include carotid Other serious etiologies include carotid and vertebral artery dissections, venous and vertebral artery dissections, venous sinus thrombosis, pituitary apoplexy, sinus thrombosis, pituitary apoplexy, and hypertensive emergenciesand hypertensive emergencies

New Onset > 50 yrs of New Onset > 50 yrs of ageage

The "first" or "worst headache of The "first" or "worst headache of my life“my life“

Intracranial mass lesion and Intracranial mass lesion and temporal arteritistemporal arteritis

Headache with exertionHeadache with exertion

Cough, Valsalva, intercourse, Cough, Valsalva, intercourse, exercise.exercise.

Possibility of carotid artery Possibility of carotid artery dissection or intracranial dissection or intracranial hemorrhage.hemorrhage.

Headache associated Headache associated with visual with visual

disturbancesdisturbances May indicate conditions such as May indicate conditions such as

glaucoma or optic neuritisglaucoma or optic neuritis

Location of painLocation of pain

Unilateral temple headache in Unilateral temple headache in adult life (may indicate cranial adult life (may indicate cranial arteritis)arteritis)

Head pain that spreads into the Head pain that spreads into the lower neck and between the lower neck and between the shoulders may indicate meningeal shoulders may indicate meningeal infection.infection.

HIV and HIV and immunosuppression immunosuppression 

Significant risk for intracranial Significant risk for intracranial disease, including toxoplasmosis, disease, including toxoplasmosis, brain abscess, meningitis and brain abscess, meningitis and tumours.tumours.

MedicationsMedications

Use of anticoagulants or Use of anticoagulants or nonsteroidal antiinflammatory nonsteroidal antiinflammatory drugs eg, aspirin increases the risk drugs eg, aspirin increases the risk of intracranial bleeding.of intracranial bleeding.

Analgesics can mask severe Analgesics can mask severe symptoms or exacerbate migraine symptoms or exacerbate migraine headache headache

HIGH RISK EXAMINATION HIGH RISK EXAMINATION FINDINGSFINDINGS

Neurological abnormalitiesNeurological abnormalities MeningismMeningism Ophthalmologic findingsOphthalmologic findings Abnormal vital signsAbnormal vital signs

Neurological Neurological Abnormalities Abnormalities 

Best clinical predictor of intracranial Best clinical predictor of intracranial pathology.pathology.

Unilateral vision loss, ataxia, or seizure.Unilateral vision loss, ataxia, or seizure. Pupillary asymmetry, unilateral pronator Pupillary asymmetry, unilateral pronator

drift, or extensor plantar response drift, or extensor plantar response

Decreased level of Decreased level of consciousness consciousness 

Atypical of benign headachesAtypical of benign headaches

Increases the likelihood of meningitis, Increases the likelihood of meningitis, encephalitis, subarachnoid hemorrhage encephalitis, subarachnoid hemorrhage (SAH), or other space occupying lesion.(SAH), or other space occupying lesion.

MeningismMeningism

Nuchal rigidity Nuchal rigidity Photophobia Photophobia Kernig’s signKernig’s sign Brudzinski’s signBrudzinski’s sign

Ophthalmologic findingsOphthalmologic findings

PapilloedemaPapilloedema Raises the suspicion of raised intracranial Raises the suspicion of raised intracranial

pressurepressure Mass lesion or benign intracranial Mass lesion or benign intracranial

hypertension.hypertension.

Abnormal Vital SignsAbnormal Vital Signs

FebrileFebrile Increased BPIncreased BP BradycardiaBradycardia

_Its common, usually described as severe, continuous as sense of

pressure or tightness rather than pain, usually on the vault or less

frequently occipito-frontal and usually bilateral

_ migraine is very common and a wide variety of atypical and

partial forms are seen.

_usually start at adolescence as recurrent headache lasting 2 hs

to 2 days.

_the pain is usually unilateral associated with photophobia, nausea

and vomiting.

_Many patients experience an aura before the pain usually visual

disturbance as flashing lights, scotomata, or even hemianopia,

paraesthesiae may occur around the angle of the mouth or in the

hand.

Chronic migraine: headache (not attributable to another disorder) on ≥ 15 days/month for > 3 months fulfilling the following criteria for migraine:

At least 2 of the following: 1) unilateral location, 2) pulsating quality, 3) moderate/severe pain intensity, 4) aggravation by routine physical activityAt least 1 of the following: 1) nausea and/or vomiting, 2) photophobia and phonophobia.

A.At least 10 previous headache episodes meeting criteria B to DB.Lasting from 30 minutes to 7 daysC. At least 2 of the following pain characteristics

1. Pressing/tightening (nonpulsating) quality2. Mild or moderate intensity3. Bilateral location4. No aggravation by walking stairs

D. Absence of both of the following1. Nausea and vomiting2. Photophobia and phonophobia

Occasional TTH is seldom disabling (unlike chronic TTH) Both TTH and migraine are aggravated by stress (so can be hard to differentiate) Headache more often than once a week may be a mixture of TTH and migraine Successful management is dependent on recognition and management of each separate headache type

Formerly known as migrainous neuralgiaGenerally affects men (ratio 6:1), often smokers, in their 20s or olderTypically occurs in bouts for 6-12 weeks every one or two yearsAttacks typically occur at night, waking the patient 1 to 2 hours after falling asleep, lasting 30 to 60 minutesPain is intense, probably as severe as renal colic, and strictly unilateral

_Its much less common than migraine and more in males, onset

usually at third decade.

_Characterized by severe periodic unilateral periorbital pain with

conjunctival injection, unilateral lacrimation, nasal congestion

and partial horner`s syndrome

_The pain is brief last 30-90 minutes.

_usually occur at early morning for weeks disappear for months

followed by another cluster.

_Usually due to space occupying lesions, brain tumor, abscess, or

haematoma.

_Other causes of raised intracranial pressure, viral encephalitis,

lead encephalopathy and malignant hypertension.

_Severe headache occurs in meningeal irritation as in meningitis and

subarachnoid haemorrhage which are associated with vomiting and

neck rigidity.

_Usually middle-aged men develop sudden, severe headache at

the climax of sexual intercourse last for 10-15 minutes, a milder

headache may persist for few hours.

_A similar headache may occur after unaccustommed exertion in

unfit person.

_Most patients with persisting facial pain have, trigeminal neuralgia,

atypical facial pain or post-herpetic neuralgia.

_Trigeminal neuralgia causes very sharp lancinating pains in one

division of trigeminal nerve in middle-aged and elderly patients the

pain is severe, brief and repetitive make the patient to flinch.

_Atypical facial pain is continuous and unremitting, centered over

the maxilla most frequently on left side in middle-aged women.

_Post-herpetic neuralgia is continuous, felt as burning at affected

territory which is sensitive to light touch and there is history of

Herpes zoster.

Prevalence: less common in those aged over 60 years than in younger people. Common causes: trigeminal neuralgia, temporal arteritis and post-herpetic neuralgia, which occur rarely in younger patients. Migraine and tension headache: less common than in younger people. Raised intracranial pressure: not always associated with headache, vomiting or papilloedema because intracranial mass lesions can reach larger sizes before presentation, as the involutional process that occurs in ageing brains allows the accommodation of an expanding lesion more easily than in younger patients.