1. HEADACHE SYNDROMES
Dr. M. A. Sofi MD; FRCP; FRCPEdin; FRCSEdin Al Maarefa College of Science & Technology

2. HEADACHE SYNDROMES Introduction to headache IH Classification
Primary Headaches
Secondary Headaches
Differential diagnosis
History key questions
Examination
Investigations
Red flags

3. HEADACHE SYNDROMES
Headache are the most common disorders of the nervous system.
47% of the adult population have headache at least once within last year in general.
Headache disorders are associated with burdens of pain, disability, damaged quality of life and financial cost.
A minority of people with headache disorders worldwide are diagnosed appropriately by a health-care provider.
Headache has been underestimated, under-recognized and under-treated throughout the world.

6. INTERNATIONAL HEADACHE CLASSIFICATION
PRIMARY HEADACHES
Migraine
Migraine Variants
Tension Headache
Cluster Headache
Paroxysmal Hemicrania
Headache Associated with Sexual Activity
Primary Stabbing Headache
Primary Thunderclap Headache
Primary Couch Headache
Primary Exertion Headache
SECONDARY HEADACHES
Headaches associated with Head & Neck Trauma
Cranial & Cervical Vascular anomalies
Subarachnoid hemorrhage
Intracranial vascular malformations
Intracranial nonvascular disorders
CNS Infections
Intracranial noninfectious inflammatory disorders
Substance abuse disorders
Psychiatric disorders

7. HEADACHE SYNDROMES

8. HEADACHE SYNDROMES

9. MIGRAINE PREVALANCE
There are currently 28 million migraine sufferers age 12+ in the United States
21 million female
7 million male
Nearly 1 in 4 households has at least 1 migraine sufferer
Migraine prevalence peaks between the ages of 25–55

15. TENSION HEADACHE Episodic or attack-like episodes
Variable, often low frequency
Short lasting, no more than several hours
Can be unilateral more often generalized
Pressure or tightness, “like a vice” or tight band.
Commonly spreads to or from neck
Stress related, functional or structural cervical or cranial musculoskeletal abnormality
Chronic no longer respond to analgesia, occurs ≥15 days month. Disabling!
Management : reassurance & symptomatic Rx,
Caution: Medication overuse

21. HEADACHE SYNDROMES
Subarachnoid hemorrhage: (SAH) in British English, is bleeding into the subarachnoid space—the area between the arachnoid membrane and the pia mater surrounding the brain.
Think SAH with all headache
•50% have warning bleed
•50% have no physical signs
•50% consult a doctor
•50% die with missed initial bleeds
Subarachnoid hemorrhage

23. Leptomeningeal Angiomatosis
Giant Aneurysm
A/V Malformation
Leptomeningeal Angiomatosis

24. CNS Angiitis
Temporal Arteritis

26. HEADACHE SYNDROMES
MRI Brain tumor with surrounding edema and midline shift.

27. BENIGN INTRACRANIAL HYPERTENSION
Primarily in young, obese women of child bearing age
Headache, transient visual obscurations (Seconds), pulsatile
intracranial noises, double vision
Visual acuity and color vision are preserved, but optic nerve
related visual field defects are present in more than 90% of
patients

28. HEADACHE FROM ACUTE & CHRONIC HYDROCEPHALUS
Obstructive Hydrocephalus
Normal Pressure Hydrocephalus

30. HEADACHE SYNDROMES
Brain abscess (or cerebral abscess) is an abscess caused by inflammation and collection of infected material, coming from local spread or hematological dissemination.
Brain Abscess

38. Headache Assessment: History Taking
Onset
Quality,
Severity,
Location,
Laterality
Time course – episodic and similar or progressive
changing
Associated systemic symptoms – fever, personality changes, seizures
Preceding symptoms – aura, gradual/rapid onset
Exacerbating features:
Migraines worse with activity.
Worse with laying or nocturnal or with cough/straining – signs of elevated ICP;
Worse with standing – signs of low ICP.
Medical history –
NF1
Sturge-weber
connective tissue disorder
Sickle cell disease
Immuno-compromised.

39. Examination
Vitals – fever, ICP signs
Good neurologic exam
? Altered mental status
Abnormal eye movements
Visual field testing
Fundoscopic exam
Focal weakness
UMN signs
Abnormal gait

40. Headache Assessment: Physical Examination
Vitals – fever, ICP signs
Good neurologic exam
Good systemic examination
Altered mental status
Abnormal eye movements
Visual field testing
Fundoscopic exam
Focal weakness
UMN signs
Abnormal gait

41. Imaging CSF analysis First or worst headache of a patient's life
Work up
Imaging
First or worst severe headache
Change in the pattern of previous migraine
Abnormal neurologic examination
Onset of migraine after age 50 years
New onset of headache in an immunocompromised patient
Headache with fever
Signs of elevated ICP
CSF analysis
First or worst headache of a patient's life
Severe, rapid-onset, recurrent headache
Progressive headache
Unresponsive, chronic, intractable headache
Pseudotumor
Meningitis
Meningismus
Fever
New seizures
Immunocompromised
SAH -Thunderclap headache

42. HEADACHE RED FLAFGS Red Flags: (Mnemonic - SNOOP)
Systemic symptoms or illness
Fever
Altered Level of Consciousness
Anticoagulation
Pregnancy
Cancer
HIV Infection
Neurologic symptoms or signs
Papilledema
Asymmetric Cranial Nerve function
Asymmetric motor function
Abnormal Cerebellar Function
Onset sudden, abrupt, first ever worst.
Onset after age 40 years, progressive
Prior Headache History that is different or progressive
Different location is less useful as predictor of serious cause
Pain response to standard Headache therapy is not predictive of serious cause