HEADACHE in

NEUROLOGY
Muhammad Akbar,
Neurologist

Indonesian Medical
Association

M. Akbar - IDI

Headache

Everyone has headaches (HA)

90% Migraine or Tension-Type
Headache
10% other : sinusitis, eye, trauma, ice
cream, cervicogenic, myofascial pain,
TMJ, hemorrhage, infection,
pseudotumor, vasculitis, tumor,

M. Akbar - IDI

History: Questions to
ask
Character of pain
Mode of onset
Mode of offset
Time of onset
Relieving factors
Aggravating factors

M. Akbar - IDI

History: Questions to
ask
Precipitating factors
Frequency of attacks
Duration of attacks
Associated symptoms
Family history of headache
Allergies

M. Akbar - IDI

Physical Exam

Gait assessment
Vital signs
Fundoscopic exam
Facial symmetry
Head & Neck
structures
Deep tendon reflexes
Plantar response
Limb strength
M. Akbar - IDI

Relevant Muscles
Trapezius
Sternocleidomastoid
Temporalis
Occipitofrontalis
Suboccipital muscles
Masseter

M. Akbar - IDI

Relevant Muscles
Medial & Lateral Pterygoid
Anterior & Posterior Digastric
Fascial muscles
Splenius Capitis
Posterior Cervical musculature
Deep Anterior Cervical
musculature

M. Akbar - IDI

Cervical Dysfunction

Upper cervical nerves posses fibers

for pain from the lower part of the
occipital sinus, vertebral and
posterior meningeal arteries, and
the dural floor of the posterior
fossa (C1, C2, C3)

M. Akbar - IDI

Causes of headaches.
1. Traction or dilatation of intracranial or

extracranial arteries.
2. Traction of large extracranial veins
3. Compression, traction or inflammation of
cranial and spinal nerves
4. Spasm and trauma to cranial and cervical
muscles.
5. Meningeal irritation and raised intracranial
pressure
6. Disturbance of intracerebral serotonergic
projections

M. Akbar - IDI

Age-related causes of
headache*
Children:

Intercurrent infections
Psychogenic
Migraine
Meningitis
Post-traumatic

Adults including middle age

Migraine
Cluster headache
Tension
Cervical dysfunction
SAH
Combination

Elderly
Cervical dysfunction
Cerebral tumour
Temporal arteritis
Neuralgias
Pagets disease
Glaucoma
Cervical spondylosis
Subdural
haemorrhage
M. Akbar - IDI

Seven danger signals

of an ominous
headache
A first headache
Headache due to exertion
Headache with fever
Headache in a drowsy or confused
patient

M. Akbar - IDI

Seven danger signals

of an ominous
headache
Headache in a patient with nuchal
rigidity or meningeal signs
Headache in a patient with
abnormal physical signs
Headache in a patient who looks
ill

M. Akbar - IDI

 RED FLAG
Headaches
Headache with altered mental status
Headache with focal neurological
findings
Headache with papillidema
Headache with meningeal signs
The worst headache of life
Headache in the patient with AIDS

M. Akbar - IDI

WORRISOME HEADACHE RED FLAGS

SNOOP
Systemic symptoms (fever, weight loss) or
Secondary risk factors (HIV, systemic cancer)
Neurologic symptoms or abnormal signs

(confusion, impaired alertness, or consciousness)

Onset: sudden, abrupt, or split-second

Older: new onset and progressive headache,

especially in middle-age >50 (giant cell arteritis)

Previous headache history: first headache or

different (change in attack frequency, severity, or

clinical features)
M. Akbar - IDI

Dangerous / Serious
headache

Intracranial tumours *
Meningitis *
Subarachnoid haemorrhage (SAH) *
Temporal arteritis (TA) *
Raised intracranial pressure *
Idiopathic intracranial hypertension *
Primary angle-closure glaucoma
Carbon monoxide (CO) poisoning

Features: (*)
# Late in life
# sudden onset
# Progressive
# associatedM. Akbar - IDI

M. Akbar - IDI

Old Ad-hoc Headache

Classification
1.

Migraine
Migraine variants, vascular headaches, atypical facial neuralgia

2.
3.

Tension headache (muscular contraction headache)

Headache associated with intracranial disturbances
Arteriosclerotic brain diseases, vascular anomalies, aneurysms, tumor,
infections

4.

Headache associated with extracranial disturbances

Eye, ear, nose, bones of the skull and neck

5.
Headache associated with cranial trauma
6.
Hypertension, allergy, arteritis (temporal), fevers,
infection
7.
Psychogenic headaches
Conversion, tension headaches

M. Akbar - IDI

The International
Headache Society
Classification
The International Headache
Society (IHS) classifies headache
disorders under :
# primary and
# secondary conditions
M. Akbar - IDI

Classification of
headaches

Primary headaches
OR Idiopathic
headaches

THE HEADACHE IS
ITSELF THE DISEASE
NO ORGANIC LESION
IN THE BEACKGROUND
TREAT THE HEADACHE!

Secondary headaches
OR Symptomatic
headaches
THE HEADACHE IS ON LY A
SYMPTOM OF AN OTHER
UNDERLYING DISEASE
TREAT THE UNDERLYING
DISEASE!

M. Akbar - IDI

IHS Classification
Primary Headaches
Migraine
Without aura
With Aura

Tension-type Headache

Episodic
Chronic

Cluster Headache and other trigeminal

autonomic cephalalgias
M. Akbar - IDI

IHS Classification
Secondary Headaches

Headache attributed to

Head and/or neck trauma

Vascular disorders
Non-vascular intracranial disorders
A substance or its withdrawal
Infection
Disorder of homeostasis
Disorder of cranium neck, eyes, ears, nose, sinuses,
teeth, mouth or other facial or cranial structures
Psychiatric disorder

Cranial neuralgias and central causes of pain

Headache unspecified/not classified

M. Akbar - IDI

Cluster headache
(migrainous neuralgia)

Paroxysmal clusters of unilateral

headache
Males : females = 6:1
Onset usually third or fourth decade
Usually nocte / early hours of the
morning
Site = around one eye (always the
same side)
Radiates to frontal and temporal
regions
1-3x/day for 4-6 weeks or months

M. Akbar - IDI

Cluster headache
(migrainous neuralgia)

Attacks

Usually nocte / early hours of the morning

(awaken the patient )
Come in clusters and recur at regular, often
annual, intervals
Common triggers: alcohol, vasodilator, histamine
and nitroglycerin
Characteristic: unilateral and periorbital;
excruciating, burning, and knife-like pain; often
associated with lacrimation, conjunctival
injection, rhinorrhea, and miosis
Last 15 min to 3 h

M. Akbar - IDI

Cluster headache (migrainous

neuralgia)
Associations:
family history
ipsilateral rhinorrhoea / lacrimation
ipsilateral red eye
flushing of forehead and cheek
Horners syndrome
Treatment:
sumatriptan / ergotamine
avoid alcohol during attacks
consider nocte ergotamine during the clusters

M. Akbar - IDI

Tension Headaches
Define

Emotional or
physical stress
constriction of
the muscles in
the neck & scalp

M. Akbar - IDI

Tension headache diagnostic

criteria
Ref: NPS Table 1

Headache lasting 30 min to 7 days

At least two of the following:

bilateral location
non-pulsatile character
no aggravation with routine activity
mild to moderate intensity

and neither of the following:

nausea and/or vomiting
photophobia andphonophobia (but may have
one or the other)

M. Akbar - IDI

Tension headaches:
Tension-type headaches are either episodic
or chronic.
Episodic Less than 15 days of pain a
month
Chronic More than 15 days of pain a
month

M. Akbar - IDI

Episodic Tension headaches

diagnostic criteria: (IHS)
At least 10 previous headaches fulfilling criteria below:

Headaches lasting from 30 minutes to 7 days

At least 2 of the following pain characteristics:
Pressing (non-pulsating) quality
Mild or moderate intensity
Bilateral location
No aggravation by physical activity
Both of the following:
No nausea or vomiting
Photophobia and phonophobia are absent, or only one is
present
Secondary headache types not suggested orM.
confirmed
Akbar - IDI

Chronic tension-type
Diagnostic criteria (IHS)
headache:
Average headache frequency of more than 15 days per month for
over 6
months.
At least 2 of the following pain characteristics:
Pressing (non-pulsating) quality
Mild or moderate intensity (may inhibit, but not prohibit
activities
Bilateral location
No aggravation by walking stairs or similar routine physical
activity
Both of the following:
No vomiting
No more than one of the following: nausea, photophobia,

M. Akbar - IDI

Tension headache treatment

Often nil required

Lifestyle factors: reduce stress,
massage, neck muscle stretches, reduce
caffeine, regular exercise etc
If analgesia required, use simple
analgesics eg. aspirin or paracetamol
or NSAID
If recurrent, consider amitriptyline or
sodium valproate

M. Akbar - IDI

Chronic Daily Headache

Up to 30% of headache-center patients

complain of daily headache.
Controversy: Is this a separate category or
the result of a transformation of a
previously known episodic disorder into a
daily one?
Persons with either migraine or tensiontype headache may develop this syndrome.
Postulated contributing factors

Medication overuse
Stress
Hypertension
Psychologic disturbances

M. Akbar - IDI

Medication Overuse Headache

(MOH)
Affects an estimated 1 in 50 people
First noted with phenacetin and
ergotamine
Typically results from overuse of OTC
analgesics
A related syndrome occurs with
triptans
A detailed medication history is
essential

M. Akbar - IDI

Medication overuse
headache

Suspect when
(i) any acute migraine drugs are used 10 or
more days per month (eg triptans,
ergotamine, compound analgesics, opioids),
or
(ii) if simple analgesics are used 15 or more
days per month.

Rx = withdrawal of the overused agent. This

may take weeks or even months.

M. Akbar - IDI

Subarachnoid
Hemorrhage
Physical Examination
Nuchal rigidity most common
finding
- present 1 - 3 hours after
bleed
Altered mental status or coma
Absence focal neurological findings
systolic BP > 200 mmHg

M. Akbar - IDI

Subarachnoid
Hemorrhage
Predisposing Factors
Pregnancy and childbirth
Poorly controlled hypertension
Valsalva maneuver
Intercourse
Cocaine / stimulant abuse
Chronic cigarette smoking

M. Akbar - IDI

Subarachnoid
Hemorrhage
Emergency
Management

Resuscitate unstable patients ABCs

Hyperventilation
Nimodipine for spasm
Urgent neurosurgical consult

M. Akbar - IDI

Subarachnoid
Hemorrhage
Complications
Acute hydrocephalus
Chronic Hydrocephalus
Intracranial arterial spasm
SIADH

M. Akbar - IDI

Hypertensive
Encephalopathy

Usually occurs in patients over age 40

Results from cerebral hyperperfusion

from loss autoregulatory mechanisms

Symptoms improve with lowering the

blood pressure

M. Akbar - IDI

Meningitis
Mortality > 90% untreated bacterial
meningitis
20-25% cases bacterial meningitis involve
adolescents or young adults
Classic triad - fever, headache, nuchal
rigidity
20% present in an atypical fashion

M. Akbar - IDI

Meningitis
Physical Examination
Fever
Altered mental status
Cranial nerve abnormalities
Papilledema
Petechia, purpura
Meningeal signs

M. Akbar - IDI

Meningitis
Diagnostic Studies

Lumbar puncture required

CT scan if suspect infectious mass

lesion or signs increased intracranial
pressure

Do not delay antibiotics while waiting

for CT scan
M. Akbar - IDI

Temporal arteritis typical

features

Age > 50
Forehead and temporal region; may radiate to side of
head
Unilateral
Severe burning pain, constant ache
Onset usually non-specific; worse in morning
Aggravated by stress and anxiety
+/- tender, thickened palpable temporal arteries
Associated features:
malaise; intermittent blurred vision (50%); vague
aches and pains in muscles; weight loss; scalp
sensitivity; jaw claudication on eating; polymyalgia
rheumatica

M. Akbar - IDI

Temporal Arteritis
Historical Features
Headache - dull onset, intensifies to
burning, jabbing pain. Localized over
temporal arteries.
Jaw claudication
Visual symptoms - blindness without
warning
Females affected 4 times more than males
Systemic symptoms

M. Akbar - IDI

Temporal arteritis
Investigations:
ESR usually markedly elevated
Diagnosis is by biopsy
Treatment:
Oral corticosteroids immediately
Starting dose = 60-100mg daily prednisolone
Delayed treatment may blindness
May take 1-2 years to resolve

M. Akbar - IDI

Raised Intracranial
Pressure
Causes

Mass
Obstructive hydrocephalus
Benign intracranial
hypertension

M. Akbar - IDI

Raised intracranial
pressure typical features
Examination may demonstrate
focal CNS signs, papilloedema
Headache generalised, often
occipital
Associated vomiting, vertigo /
dizziness, drowsiness, confusion,
May radiate retro-orbitally
Dull ache

M. Akbar - IDI

Raised intracranial
pressure typical features
Worse in mornings, usually
intermittent, can waken from sleep
Aggravated by coughing,
straining, sneezing and movement
Consider tumour / subdural
haematoma
Some relief from analgesics

M. Akbar - IDI

Benign intracranial
hypertension - typical
features

Also known as Pseudotumor Cerebri.

Usually young obese women
Key clinical features = headache, visual
blurring, nausea, papilloedema
Main concern = visual deficits
Sometimes linked to drugs including
tetracyclines **, nitrofurantoin, vitamin A
preparations

Caused by increased brain water content and

decreased CSF outflow.

M. Akbar - IDI

Benign intracranial
hypertension - Associated
History

Mastoid or ear
infection
Menstrual
irregularity
Steroid exposure
Retro-orbital or
vertex headache

Vision fluctuation
Unilateral or
bilateral tinnitus
Constriction of
visual fields
Weight gain

M. Akbar - IDI

Benign intracranial
hypertension

Investigations:
CT and MRI = normal
LP increased CSF pressure and normal CSF
analysis
Treatment:
weight reduction
corticosteroids
diuretics.
sometimes repeated LP relieves pressure
Rarely - surgery to decompress optic nerves

M. Akbar - IDI

Brain Tumor

In elderly, brain tumor is usually metastatic

from lung or breast carcinoma.
Primary brain tumor are more common in
adults younger than 50 years
HA is caused either by direct pressure on
the brain or elevated ICP
Typical presentation is headache that
worsens over over weeks to months
HA is usually present on awakening
initially, then it becomes continuous.
M. Akbar - IDI

Mass Lesion - Brain

Tumor
Children - 75% infratentorial
Adults - 75% supratentorial
Metastatic tumor most common
mid-life
Symptoms due to increased
intracerebral pressure, tissue
destruction, irritation

M. Akbar - IDI

Mass Lesion
Physical Examination
Initially

may be nonfocal
Mental status changes
Behavioral changes
Focal neurological deficits
Seizures
M. Akbar - IDI

Post Traumatic
Headache

Estimated

that 30-50% of 2 million

closed head injuries per year develop
headache.
Associated with dizziness, fatigue,
insomnia, irritability, memory loss,
and difficulty with concentration.
Acute PTHA develops hours to days
after injury and may last up to 8
weeks.
M. Akbar - IDI

Post Traumatic
Headache
Chronic

PTHA may last from

several months to years.
Patients have normal neurological
examination and imaging
Treatment for acute PTHA is
symptomatic while for chronic
PTHA, adjunct therapies include
beta-blockers and antidepressants.
M. Akbar - IDI

Migraine Definition

IHS criteria: Migraine/aura (3

out of 4)
One or more fully reversible
aura symptoms indicates
focal cerebral cortical or
brainstem dysfunction.
At least one aura symptom
develops gradually over
more than 4 minutes.
No aura symptom lasts
more than one hour.
HA follows aura w/free
interval of less than one
hour and may begin before
or w/aura.

IHS Diagnostic criteria: migraine

w/o aura
HA lasting for 4-72 hrs
HA w/2+ of following:
Unilateral
Pulsating
Mod/severe intensity.
Aggravated by routine
physical activity.
During HA at least 1 of
following
N/V
Photophobia
Phonophobia

History, PE, Neuro exam show no

other organic disease.
At least five attacks occur

M. Akbar - IDI

Migraine:
pathophysiology

H/A is proceeded by
in serotonin level
Vaso constriction
in serotonin level
Vaso dilitation
PAIN
Migraine H/A are
caused by constriction
blood vessels in the
brain followed by
dilation

M. Akbar - IDI

Migraine mechanism

Neurovascular theory.
Abnormal brainstem
responses.
Trigemino-vascular system.
Calcitonin gene related
peptide
Neurokinin A
Substance P

Extracranial arterial vasodilation.

Temporal
Pulsing pain.
Extracranial neurogenic
inflammation.
Decreased inhibition of central
pain transmission.
Endogenous opioids.

M. Akbar - IDI

Aura Mechanism

Cortical spreading depression

Self propagating wave of neuronal and glial depolarization across
the cortex
Activates trigeminal afferents
Causes inflammation of pain sensitive meninges that
generates HA through central/peripheral reflexes.
Alters blood-brain barrier.
Associated with a low flow state in the dural sinuses.

M. Akbar - IDI

Migraine
Classification:

Migraine without aura

Migraine with typical aura
Migraine with prolonged aura
Familial hemiplegic migraine
Basilar migraine
Migraine aura without headache
Migraine with acute onset aura
Ophthalmoplegic migraine
Retinal migraine
M. Akbar - IDI

IHS diagnostic criteria

Migraine without aura
An idiopathic recurring headache with:
A. At least 5 attacks fulfilling B-D
B. Attacks last 4-72 hours
C. At least 2 of the following
- Unilateral location
- Pulsating quality
- Moderate or severe pain intensity
- Aggravated by routine physical activity
D. At least one of the following during an attack
- Nausea and/or vomiting
- Photophobia and phonophobia
E. Not attributed to another disorder

M. Akbar - IDI

IHS diagnostic criteria

Migraine with aura

Aura precedes headache

Symptoms of migraine aura:

Transient hemianopic disturbances prior to

headache, lasting 10-30 minutes (occasionally
up to 1 hour)
A spreading scintillating scotoma (patients may
draw a jagged crescent)
Other reversible focal neurological
disturbances e.g. unilateral paraesthesiae of
hand, arm or face

Visual blurring and spots are not diagnostic

Patients may have attacks of migraine with aura
and migraine without aura at different times
M. Akbar - IDI

Migraine: etiology / triggers

Dietary-foods, alcohol,hunger, MSG,

Chocolate, caffeine withdrawal

Sleep Related-deprivation, excess, irregular

Hormonal-menstrual,O.C.,menopause, HRT
Physiological-fatigue, travel,exercise,smoking
Emotional -anxiety, stress, relaxation post stress,

excitement

Physical- neck/back injury, head trauma,

hypertension

M. Akbar - IDI

Environmental Factors

Flickering lights
Sunlight/ Bright lights
Heat
High altitude
Loud noise
TV/ VDU screens
Strong smells
Meterological changes
Barometric Changes

M. Akbar - IDI

Migraine Headache:
Complications

Cerebrovascular accidents
Risk is slightly increased with migraine,
especially for women
Presence of known stroke risk factors
increases risk
Oral contraceptive use and/or smoking
increases risk slightly

Epilepsy
Psychiatric disorders
M. Akbar - IDI

M. Akbar - IDI

Treatment

Abortive

Stepped
Stratifie
d
Staged

Preventiv
e

M. Akbar - IDI

Treatment-Abortive
Mild to Moderate Moderate to Severe
Attacks
Attacks
Acetaminophen
Aspirin
Ibuprofen
Naprosyn

Refractory Attack,
Status Migrainosus

Dihydroergotamine(1mg
Dihydroergotamine
IV or IM), may repeat 1 hr Steroids
Sumatriptan,(6 mg SC/
25-100mg PO)
Rizatriptan, Naratriptan,
Zolmitriptan,
Prochlorpethazine
Metaclopromide
Ketorolac, Meperidine
M. Akbar - IDI

Abortive care strategies

Stepped

Start with lower level drugs, then

switch to more specific drugs if
symptoms persist or worsen.
Analgesics

Tylenol, NSAIDs
Vasoconstrictors
sympathomimetics
Opioids (try to avoid) - Butorphanol
Triptans sumatriptan (oral, SQ,
nasal), naratriptan, rizatripatan,
zomatriptan.

Limited by patient compliance.

M. Akbar - IDI

Abortive care strategies

Stratified

Adjusts treatment according to

symptom intensity.
Mild

analgesics, NSAIDs
Moderate analgesic plus
caffeine/sympathomimetic
Severe opioids, triptans,
ergots

Severe sx treatment limited

due to concomitant GI sxs.
M. Akbar - IDI

Abortive care strategies

Staged

Bases treatment on
intensity and time of
attacks.
HA diary reviewed with
patient.
Medication plan and backup
plans.

M. Akbar - IDI

Preventive therapy

Consider if pt has more than 3-4 episodes/month.

Reduces frequency by 40 60%.
Breakthrough headaches easier to abort.
Tricyclic antidepressants like Amitriptyline
Beta blockers like propanolol
Calcium channel blockers
Depakote
Lifestyle modification.
Biofeedback.

M. Akbar - IDI

Botox
51% migraineurs treated
had complete
prophylaxis for 4.1
months.
38% had prophylaxis for
2.7 months.
Randomized trial showed
significant
improvement in
headache frequency
with multiple
treatments.

M. Akbar - IDI

M. Akbar - IDI

Then Why do we Fail?

Misdiagnosis
Poor Choices for
Therapy
Failure to treat
psychiatric factors
Failure to treat comorbidities
Ignoring headache
prevention
M. Akbar - IDI

Why we fail (and what to

do about it)
Misdiagnosis exclusion, inclusion
Unrealistic expectations
Chronic Daily headache and
rebound
Logic and Persistence
Ignoring psychological factors
Missing Red Flags

M. Akbar - IDI

Misdiagnosis

Migraine underdiagnosed

Cause of headache until proved otherwise

TTH
Sinus Headache

Failure of typography: Cluster, SUNCT, CIH

Failure to assess psychosocial milieu
Eating disturbance
Ennui: dissatisfaction with life

Failure to diagnose more serious condition (RARE!!)

SAH
Pseudotumor and tumor
Schaltenbrandts low pressure headache

M. Akbar - IDI

Preventi
ve
Abortiv
e

Symptom-Relief
Preventi
ve

M. Akbar - IDI

Headache
Pathophysiology 1

Direct stimulation (via the thalamus) of

the cortical pain areas situated in higher
centres of the CNS which produce the
pain of headache

Direct effects and the secondary

vasoactive responses account for the
headache in patients who have migraine
attacks without the aura.
M. Akbar - IDI

Headache
Pathophysiology2

Trigeminovascular activation

Release of inflammatory neuropeptidesin the trigeminal vascular system:-

Substance P
Neurokinin A
Calcitonin gene-related peptide
-vasodilation.

M. Akbar - IDI