Headache is usually benign symptom, and only occasionally is due to a serious underlying cause.
Even in emergency settings, only 5 percent of patients with headache have a serious underlying disorders.
it is necessary to identify and treat these serious
conditions. Therefore it is better to classify any
patient of headache as benign or due to serious
Serious Underlying Disorders :-
Serious Underlying Disorders :-
Lack of sleep
Induced by bending, lifting, coughing
First severe headache ever
Disturbs sleep of occurs immediately
Abnormal neurological examination
Fever or other unexplained systemic signs
Vomiting preceeds headache.
Age over 55 years.
Patients who present with the first severe headache ever can be due to some serious cause like meningitis, subarachnoid hemorrhage, subdural hematoma, glaucoma or purulent sinusitis. In these patients, the following laboratory tests will reveal the underlying cause.
1. Neurological examination
2. Abnormal examination to be followed by MRI or CT scan.
3. Measurement of blood pressure
4. Urine examination
6. Measurement of intraocular pressure.
Psychological state of the patient.
Headache with nausea vomiting and photophobia. Reccurent attack with pain free interval. Hereditary predisposition. More common in women.
Red wine, menses, hunger, glare, lack of sleep, perfumes, worry.
Sleep, NSAIDS, Sumatriptan, pregnancy.
1. Aspirin or paracetamol
2. Ibuprofen[600-800 mg.]
3. Naproxen[375-750 mg]
4. Ergotamine 3 mg
If oral therapy is not effective subcutaneous sumatriptan or IV Chlopromazine or prochlorperazine.
Propranolol [60-320 mg] daily
Amitriptyline [10-175 mg] daily
Valproate [500-1500 mg] daily
One to three short lived attacks daily of periorbital pain over a 4 to 8 weeks followed by pain free interval of nearly one year. Associated with nausea, nasal stuffiness, red eye, ptosis. More common in males. Hereditary factor is absent.
Pain is unilateral and affects the same side in subsequent months. Attacks last for 30 minutes to 2 hours.
Food or emotional factors do not play a role. Alcohol provokes attacks in 70% of patients.
1. Inhalation of 100% oxygen [9L/min} for 15 minutes.
2. Sumatriptan 6 mg subcutaneously.
1. Propranolol and amitriptyline not effective
2. Lithium [600-900 mg daily] is useful
3. Prednisone, 60 mg daily for 7 days followed by a rapid tapering dose.
4. Ergotamine [1 mg] is most effective when given 1-2 hours before an expected attack.
Chronic headache with tight band like discomfort and tight posterior neck muscles.
Pain increases slowly, fluctuates in severity and persists for many days.
Associated with anxiety or depression.
More common in female.
Factors similar to migraine.
Lumbar puncuture headache
Follows lumbar puncture within 48-72 hours. Begins when the patient sits or stands upright and relief by reclining or compression of abdomen. Associated with nausea, stiff neck, photophobia, vertigo. Resolves over a few days.
1. I.V. caffeine sodium benzonate [500mg]
2. Injection of 15 ml. of autologous whole blood in those who do not respond to caffeine.
Post concussion headache
Follows an apparently trivial injury to head.
Headache, dizziness, vertigo, impaired memory, anxiety, irritability and difficulty in concentration.
Headache resolves after several weeks.
1. Symptomatic support
Temporal [gaint cell] arteritis
Common in people above 50 years of age. It is due to inflammation of external carotid arteries.
Headache with malaise and muscle ache. Occurs over temporal arteries with red streaking of the overlying skin. Pain is superficial, external to skull and not deep inside. Scalp tenderness is marked. Burshing of hair or resting the head over pillow is very painful. If untreated it results into blindnness.
1. ESR- elevated
2. Temporal artery biopsy to confirm the diagnosis.
Prednisone 80 mg daily for 6 weeks.
Transient, severe head pain upon coughing, bending, lifting, sneezing, stooping. Pain lasts for seconds or a few minutes H/o lower respiratory infection with severe coughing. More common in males.
MRI is neccessary in all patients since structural anomalies are seen in 25 percent of patient.
1. For benign disorder, indomethacin [50-200 mg] daily.
2. Threpeutic lumber puncture with removal of 40ml. of CSF.
More common in males. Abrupt in onset and subsides in a few minutes. If coitus is interrupted. Headache is always benign. If it persists for hours or accompainied by vomiting subarachnoid hemorrhage should be excluded.
Headache due to systemic illness
E.G SLE, infections mononucleosis chronic pulmonary failure, inflammatory bowel disease, HIV and malignant hypertension. Also drugs like oral contraceptives, ovulation promoting drugs or withdrawal of corticosteroids.
Thrift AG, for the Melbourne Risk Factor Study Group (Austin and Repatriation Med Ctr, Heidelberg, Australia)
Three Important Subgroups of Hypertensive Persons at Greater Risk of Intracerebral Hemorrhage
Hypertension 31: 1223-1229, 1998
The authors bring out that a higher risk of intracerebral hemorrhage is expected in hypertensives in the below 55 years, in smokers and those discontinuing medication for hypertension.
The SPAF III Writing Committee for the Stroke Prevention in Atrial Fibrillation Investigators (SPAF Statistical Coordinating Ctr, Seattle)
Patients With Nonvalvular Atrial Fibrillation at Low Risk of Stroke During Treatment With Aspirin: Stroke Prevention in Atrial Fibrillation III Study
JAMA 279: 1273-1277, 1998
Events responsible for thromboembolic episodes in non valvular atrial fibrillation are 1 previous such episodes, 2 preceding congestive cardiac failure or impaired left ventricular function and females above 75 years of age and 4 systolic pressure above 160 mm Hg. Subjects without these were given 325 mg of aspirin per day and followed up for 2 years.
Less than 3% of ischemic or embolic episodes including strokes were observed annually. Bleeding from aspirin occurred in 0.5% of subjects. Authors recommend aspirin instead of warfarin anticoagulation.
Lehto S, Niskanen L, Ronnemaa T, et al (Univ of Kuopio, Finland; Univ of Turku, Finland)
Serum Uric Acid Is a Strong Predictor of Stroke in Patients With Non-Insulin-Dependent Diabetes Mellitus
Stroke 29: 635-639, 1998
High serum levels of uric acid contribute to insulin resistance and are found in non-insulin-dependent diabetes mellitus. It is an independent pointer for coronary artery disease, strokes and greater mortality in normal population. Low levels are found in patients with multiple sclerosis.
The authors suggest greater research in this field.
Bucher HC, Griffith LE, Guyatt GH (Kantonsspital Basel, Switzerland; McMaster Univ, Hamilton, Ont, Canada)
Effect of HMGcoA Reductase Inhibitors on Stroke: A Meta-Analysis of Randomized, Controlled Trials
Ann Intern Med 128: 89-95, 1998
This work represents MEDLINE and EMBASE search of 1996 and represents a very large data. It compares the effects of resins, fibrates and diet with 3-hydroxy-3-methylglutaryl co A reductase inhibitors in evaluation of strokes.
The authors conclude that lowering of cholesterol was more with HMGcoA reductase inhibitors than others hence led to lower stroke and coronary heart disease.
RÆnning OM, Guldvog B (Central Hosp of Akershus, Nordbyhagen, Norway)
Stroke Units Versus General Medical Wards: Twelve- and Eighteen- Month Survival: A Randomized, Controlled Trial
Stroke 29: 58-62, 1998
Patients of a stroke were admitted either to a general medical ward or a stroke unit.
Evaluation, at 12 and 18 months favoured the stroke unit. Reason for this is not known.