Headache

Headache, also known as cephalalgia, is a common symptom of pain in the head, neck, or face. It can present in various forms such as migraine, tension-type headache, or cluster headache. About half of adults experience headaches annually, with tension headaches being the most common, followed by migraines.

Causes

Headaches are broadly classified into primary and secondary types. Primary headaches, which include tension-type headaches and migraines, are benign and recurrent, not caused by underlying diseases. Secondary headaches result from underlying conditions such as infections, head injuries, or vascular disorders, and can be life-threatening.

Primary Headaches

Primary headaches account for 90% of all headaches and typically begin between the ages of 20 and 40. The most common types include:

• Tension-type headaches: Characterised by non-pulsing "bandlike" pressure on both sides of the head.
• Migraines: Present with pulsing head pain, nausea, photophobia, and phonophobia.
• Cluster headaches: Severe pain around one eye with autonomic symptoms, occurring at the same time daily.

Other rare primary headaches include trigeminal neuralgia, primary stabbing headache, and primary exertional headache.

Secondary Headaches

Secondary headaches can result from various conditions such as meningitis, brain tumours, temporal arteritis, and acute closed-angle glaucoma. They often present with additional symptoms like fever, stiff neck, or focal neurological deficits.

Pathophysiology

The brain itself lacks pain receptors, but several areas of the head and neck, including extracranial arteries, cranial nerves, and meninges, have pain receptors. Headaches often result from the irritation or traction of these structures. Primary headaches, such as migraines, are thought to involve dysfunction of brain nerves, while tension headaches are related to peripheral nerve activation in head and neck muscles.

Diagnosis

Diagnosis of headaches primarily relies on clinical history. Most headaches can be diagnosed without imaging unless "red flags" indicating dangerous secondary headaches are present. The mnemonic "SSNOOP" helps remember these red flags:

• Systemic symptoms (fever or weight loss)
• Systemic disease (HIV infection, malignancy)
• Neurologic symptoms or signs
• Onset sudden (thunderclap headache)
• Onset after age 40 years
• Previous headache history (first, worst, or different headache)

Neuroimaging

For new headaches with red flags, neuroimaging is recommended. Non-contrast CT scans are usually the first step, useful for detecting acute head bleeds. MRI is more sensitive for detecting brain tumours and posterior fossa issues.

Treatment

Primary Headaches

Migraines

Lifestyle changes can help manage migraines, but medications are often required. Preventive medications include beta blockers, antidepressants, and anticonvulsants. Abortive therapies include NSAIDs, triptans, and antiemetics.

Tension-type Headaches

These are usually managed with NSAIDs or acetaminophen. For chronic tension-type headaches, amitriptyline is effective.

Cluster Headaches

Abortive therapy includes subcutaneous sumatriptan and high-flow oxygen therapy. Preventive treatments may involve verapamil, lithium, or a short course of prednisone.

Secondary Headaches

Treatment involves addressing the underlying cause, such as antibiotics for meningitis or surgery for brain tumours.

Epidemiology

Approximately 64–77% of adults experience headaches at some point in their lives. Most headaches are primary and not dangerous. Migraines affect about 12–18% of the global population, with a higher prevalence in women. Cluster headaches are less common, affecting 1–3 per thousand people.

Children

Children experience similar types of headaches as adults, but their symptoms may differ. Most headaches in children are benign. Serious causes include brain bleeds and infections. Preventive measures and treatments are similar to those for adults, but certain medications are avoided in children.

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Self-assessment MCQs (single best answer)

What is the medical term for a headache?

Which type of headache is characterised by severe pain around one eye with autonomic symptoms, occurring at the same time daily?

Which mnemonic is used to remember the red flags for dangerous secondary headaches?

What percentage of all headaches are primary headaches?

Which of the following is NOT a characteristic symptom of migraines?

Which imaging modality is more sensitive for detecting brain tumours and posterior fossa issues?

What is the first-line abortive therapy for cluster headaches?

What percentage of adults experience headaches at some point in their lives?

Which of the following medications is effective for chronic tension-type headaches?

Which symptom is NOT typically associated with secondary headaches?