Headache

International headache society (HIS) classification of headache

HEADACHE

Part I: The Primary HeadachesPart II: The Secondary HeadachesPart III: Cranial Neuralgias, Central and Primary Facial Pain And Other Headaches

PRIMARY HEADACHE

1. Migraine2. Tension-type headache (TTH)3. Cluster headache and other trigeminal

autonomic cephalalgias (TAC)4. Other primary headaches

SECONDARY HEADACHE

1. Post traumatic Headache 2. Vascular Headache of cranial or cervical origin3. Non vascular headache intracranial origin4. Post infective headache5. Headache due to substance abuse/withdrawal6. Headache due to disorder of homoeostasis7. Headache due to non cranial causes8. Headache attributed to psychiatric disorders

PART I-PRIMARY HEADACHE

MIGRAINE

1. Migraine without aura2. Migraine with aura3. Childhood periodic syndromes4. Retinal migraine5. Complications of migraine6. Probable migraine

MIGRAINE WITH AURA

CHILDHOOD PERIODIC SYNDROME

COMPLICATIONS OF MIGRAINE

PROBABLE MIGRAINE

TENSION TYPE HEADACHE

Cluster headache and other trigeminalautonomic cephalalgias (TAC)

1. Cluster headache2. Paroxysmal hemicrania3. Short-lasting unilateral neuralgiform

headache attacks with conjunctival injection and tearing (SUNCT)

4. Probable TAC

Other primary headaches

• Primary stabbing headache• Primary cough headache• Primary headache associated with sexual activity• Primary exertional headache• Primary thunderclap headache• Hypnic headache• Hemicrania continua• New daily-persistent headache

PART II- SECONDARY HEADACHE

1. POST TRAUMATIC HEADACHE

• Acute post-traumatic headache• Chronic post-traumatic headache• Acute whiplash headache• Chronic whiplash headache• Traumatic intracranial hematoma• Other head and/or neck trauma• Post-craniotomy headache

2. Vascular headache of cranial or cervical origin

• Nontraumatic intracranial hemorrhage• Ischemic stroke or TIA• Unruptured vascular malformation• Arteritis• Carotid or vertebral artery pain• Cerebral venous thrombosis• Other intracranial vascular disorder

3. Nonvascular headache of intracranial origin

• High CSF pressure (intracranial hypertension)• Low CSF pressure (intracranial hypotension)• Non-infectious inflammatory disease• Intracranial neoplasm• Intrathecal injection• Epileptic seizure• Chiari malformation type I• Transient headache and neurological deficits with CSF

lymphocytosis (HaNDL)• Other nonvascular intracranial disorder

4. Headache due to a substance abuse/ withdrawal

• Acute substance use or exposure• Medication-overuse headache (MOH)• Adverse effect of chronic medication• Substance withdrawal

5. Headache attributed to infection

• Intracranial infection• Systemic infection• HIV/AIDS• Chronic post-infection headache

6. Headache due to to disorder ofhomoeostasis

• Hypoxia and/or hypercapnia• Fasting• Arterial hypertension• Dialysis headache• Cardiac cephalalgia• Hypothyroidism• Other disorder of homoeostasis

7. Headache or facial pain due to extracranial causes

• Disorder of cranial bone• Disorder of neck• Disorder of eyes• Disorder of ears• Rhinosinusitis• Disorder of teeth, jaws, or related structures• Disorder of temporomandibular joint(TMJ)• Other disorder of cranial, facial, or cervical

structures

PART IIICranial neuralgias and central causes

of facial pain and other headaches

• Trigeminal neuralgia Glossopharyngeal neuralgia• Nasociliary neuralgia Superior laryngeal neuralgia• Supraorbital neuralgia Occipital neuralgia• Other terminal branch neuralgias Neck−tongue syndrome • Nervus intermedius neuralgia External compression headache • Cold-stimulus headache Optic neuritis• upper cervical roots lesions Herpes zoster• Ocular diabetic neuropathy Tolosa-Hunt syndrome• Ophthalmoplegic “migraine” Central causes of facial pain• Constant pain caused by compression irritation, or distortion of

cranial N

History in headache• Duration of headache• Nature of headache• Site • Severity of headache• Continuous / episodic• Duration of episodes• Frequency of episodes• Associated features• Relieving features• Diurnal variations

Intensity

• Throbbing pulsatile- migraine • Thunderclap – subarachnoid hmge

LOCATION

• Migraine headache – is unilateral in two thirds of attacks – commonly associated with nausea, vomiting, and

sensitivity to light, sound, and smells.• Less sharply localized pain:– Paranasal sinuses, teeth, eyes, and upper cervical

vertebrae induce a less sharply localized pain

• Occipitonuchal pain :– Posterior fossa lesion localised to the homolateral side of

lesion• Frontotemporal pain:– Supratentorial lesions induce, or approximate the site of

the lesion.• Frontal regions :– Glaucoma – Sinusitis – Increased intracranial pressure– Thrombosis of the vertebral or basilar artery, – Pressure on the tentorium,

• Periorbital and supraorbital pain, – indicative of local disease– dissection of the cervical portion of the internal carotid

artery. • Vertex or Biparietal regions:– are infrequent– sphenoid or ethmoid sinus disease – thrombosis of the superior sagittal venous sinus

MIGRAINE

CLUSTER HEADACHE

TRIGEMINAL NEURALGIA

Mode of onset, the variation of the pain over time, and duration

• subarachnoid hemorrhage – (caused by a ruptured aneurysm) occurs as an abrupt attack

that attains its maximal severity in a matter of seconds or minutes;

– Thunder clap headache• Meningitis– it may come on more gradually, over several hours or days.

• Migraine – Ophthalmodynia :

• Brief sharp pain, lasting a few seconds,in the eyeball or

– cranium (“ice-pick”pain) and “ice-cream headache” caused by pharyngeal cooling is more common in migraineurs.

• Migraine of the classic type– onset in the early morning hours or in the daytime, – reaches its peak of severity typically over several to 30

min, – and lasts, unless treated, for 4 to 24 h, occasionally for as

long as 72 h or more. – Often it is terminated by sleep

• Cluster headache:– unbearably severe unilateral orbitotemporal pain – Coming on within an hour or two after falling asleep or at

predictable times during the day – recurring nightly or daily for a period of several weeks to

months is typical of cluster headache; – usually an individual attack of “cluster” dissipates in 30 to

45 min

• Intracranial tumor:– may appear at any time of the day or night; – it will interrupt sleep, vary in intensity, – last a few minutes to hours; as the tumor raises

intracranial pressure. – With posterior fossa masses, the headache tends to be

worse in the morning, on awakening. • premenstrual tension:– occur regularly in the premenstrual period– are usually generalized and mild in degree

• catamenial migraine:– attacks of migraine may also occur at this time

• Headaches of cervical spine disease – origin after a period of inactivity, such as a night’s sleep, – movements of the neck are stiff and painful.

• Sinusitis :– often face ache, with clock-like regularity, upon awakening or in

midmorning – is characteristically worsened by stooping– and changes in atmospheric pressure; – there is associated midfrontal or maxillary tenderness.

• Eyestrain headaches, – follow prolonged use of the eyes, – as after long-sustained periods of reading, peering into glaring

headlights, or exposure to the glare of video displays. • alcohol, intense exercise (such as weight lifting), stooping,

straining, coughing, and sexual intercourse are known to initiate a special type of bursting headache,

Pain-Sensitive Cranial Structures• (1) skin, subcutaneous tissue, muscles, extracranial arteries,

and periosteum of the skull; • (2) delicate structures of the eye, ear, nasal cavities, and

paranasal sinuses; • (3) intracranial venous sinuses and their large tributaries,

especially pericavernous structures; • (4) parts of the dura at the base of the brain and the arteries

within the dura, particularly the proximal parts of the anterior and middle cerebral arteries and the intracranial segment of the internal carotid artery;

• (5) the middle meningeal and superficial temporal arteries; and • (6) the optic, oculomotor, trigeminal, glossopharyngeal, vagus,

and first three cervical nerves.

Pain insensitive structure• Much of the pia-arachnoid and dura over the

convexity of the brain, • parenchyma of the brain,• ependyma • Choroid plexuses lack sensitivity.

Pain pathway in headache• V1 and V2 division – Fore head – Orbit – Anterior & middle cranial fossa upto superior surface of

tentorium :• sphenopalatine branches of the facial nerve – impulses from the nasoorbital region

• Ninth and tenth cranial nerves and the first three cervical nerves – impulses from the inferior surface of the tentorium and – All of the posterior fossa.

• Sympathetic fibers from the three cervical ganglia and parasympathetic fibers from the sphenopalatine and otic ganglia are mixed with the trigeminal and other sensory fibers.

• The tentorium roughly demarcates the trigeminal from the cervical–vagal–glossopharyngeal innervation zones.

• To summarize, – pain from supratentorial structures is referred to the

anterior two-thirds of the head, i.e., to the territory of sensory supply of the first and second divisions of the trigeminal nerve;

– pain from infratentorial structures is referred to the vertex and back of the head and neck by 9th 10th and the upper cervical roots.

Referred pain• Trigeminal and cervical sensory inputs converge on

the second order neurons at the C2 level. Permitting pain from the neck and occipital regions to be referred to the forehead, and vice versa

• The 7,9,10th cranial nerves refer pain to the nasoorbital region, ear, and throat. There may be local tenderness of the scalp at the site of the referred pain

• With the exception of the – cervical portion of the internal carotid artery, from which

pain is referred to the eyebrow and supraorbital region– the upper cervical spine, from which pain may be referred

to the occiput, pain because of disease in extracranial parts of the body is not referred to the head.

Mechanisms of Cranial Pain• Intracranial mass lesions– cause headache only if they deform, displace, or exert

traction on vessels and dural structures at the base of the brain,

– and this may happen long before intracranial pressure rises.

• High intracranial pressure– bioccipital and bifrontal headaches – that fluctuate in severity, – probably because of traction on vessels or dura.

• Dilatation of intracranial or extracranial arteries– follow seizures, infusion of histamine, – ingestion of alcohol – Nitroglycerin.– headache that accompanies febrile illnesses – rises in blood pressure • as occurs with pheochromocytoma, malignant hypertension,

sexual activity,

– cough and exertional headaches

Cerebrovascular diseases causing head pain• extracranial temporal and occipital arteries,– when involved in giant cell arteritis (cranial or

“temporal” arteritis), give rise to severe, persistent headache,

– at first localized on the scalp and then more diffuse• Vertebral artery, – occlusion or dissection produce pain in the upper neck

or postauricular area; • Basilar artery thrombosis – causes pain to be projected to the occiput and

sometimes to the forehead

• carotid artery – Occlusion/dissection may produce ipsilateral eye and

brow and the forehead also produced by– occlusion of the stem of the middle cerebral arteries.

• PCA/ DISTAL ICA:– Aneurysm /dilatation produce pain projected to the eye

• Sinusitis :– frontal and ethmoidal sinusitis, • the pain tends to be worse on awakening • gradually subsides when the patient is upright;

– Maxillary and sphenoidal sinusitis• the opposite happens

– pain is ascribed to filling of the sinuses and its relief to their emptying, induced by the dependent position of the ostia.

– Bending over intensifies the pain by causing changes in pressure, as does blowing the nose and air travel, especially on descent,

Headache of ocular origin,• Site :– orbit, forehead, or temple, is of the steady, – aching type – follow prolonged use of the eyes in close work.

• Hypermetropia and astigmatism (rarely myopia), – which result in sustained contraction of extraocular as

well as frontal, temporal, and even occipital muscles. – Correction of the refractive error abolishes the headache.

• Iridocyclitis and in acute angle closure glaucoma,– in which raised intraocular pressure causes steady, aching

pain in the region of the eye, radiating to the forehead

Headache of upper cervical spine• Headaches that accompany disease of ligaments,

muscles,and apophysial joints in the upper part of the cervical spine

• are referred to the occiput and nape of the neck on the same side and sometimes to the temple and forehead.

• Degenerative changes in the cervical spine• Arthritic – Pain on first movements after prolonged rest for some hours

are – stiff and painful.

• Pain of fibromyalgia:– a controversial entity, is putatively characterized by tender

areas near the cranial insertion of cervical and other muscles.

Headache of meningeal irritation• (infection or hemorrhage) is acute in onset, usually

severe, generalized, deep seated, constant, • associated with stiffness of the neck, particularly on

forward bending.• dilatation and inflammation of meningeal vessels • chemical irritation of pain receptors in the large

vessels and meninges by endogenous chemical agents, particularly serotonin and plasma kinins,

• are probably more important factors in the production of pain and spasm of the neck extensors.

Spontaneous/post LP low CSF pressure headache,

• steady occipitonuchal and frontal pain coming on within a few minutes after arising from a recumbent position

• is relieved within a minute or two by lying down• this type of headache is increased by compression of

the jugular veins but is unaffected by digital obliteration of the carotid artery.

• Headache caused by caudal displacement of the brain, with traction on dural attachments and dural sinuses

Exertional headaches

• are usually benign but sometimes related to • pheochromocytoma, • arteriovenous malformation, or other

intracranial lesions, • in addition to the aforementioned

subarachnoid hemorrhage from ruptured aneurysm