Symptoms & Disease
Headache is usually benign symptom, and only occassionaly is due to a serious underlying cause. Even in emergency settings, only 5 percent of patients with headache have a serious underlying disorder. However, 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 underlying disorder.
1. Red wine
2. Sustained exertion
3. Organic odor
5. Lack of sleep
6. Weather changes
1. Induced by bending, lifting, coughing
2. First severe headeche ever
3. Disturbs sleep or occurs immediately upon awakening
4. Abnormal neurological examination
5. Fever or other unexplained
6. Vomiting preceeds headache.
7. Age over 55 years
Patients who present with first severe headache
ever can be due to some serious cause like
meningitis, subarachnoid hemorrhage, glaucoma or
purulent sinusitis. In these patients, the
following laboratory tests will reveal the
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 intracoular pressure
7. 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.