Headache: Causes and Types

Introduction:

Headache is one of the most common complaints for which patients seek medical attention. The underlying cause could be neurological, ENT-related (ear, nose, and throat), systemic diseases, or idiopathic (cause not known). Everyone most commonly experiences headaches, but it may sometimes be manifested due to a serious illness such as brain tumors, intracranial hemorrhage, meningitis, and temporal arteritis.

What Is the Pathological Basis of Headache?

• The distension, stretching, and irritation of the pain-sensitive intracranial structures such as the dura mater and proximal parts of the blood vessels cause headaches.

• Brain parenchyma, cerebral ventricles, choroid plexus, and arteries over the cerebral convexities are insensitive to pain.

• Inflammation and trauma to cranial and cervical muscles and irritation of cranial and spinal nerves may also lead to a headache.

How Is Headache Classified?

The headache is classified as primary and secondary. Secondary headache has an underlying cause, and the clinical features vary according to the cause.

Primary Headache:

• Migraine.

• Tension headache.

• Cluster headache.

• Rebound headache.

• Headache due to raised intracranial pressure.

Secondary Headache:

Intracranial causes -

• Subdural and intracerebral hematoma.

• Brain abscess.

• Meningitis.

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• Encephalitis.

• Head injury.

Extracranial causes -

• Giant cell arteritis (temporal arteritis).

• Sinusitis.

• Glaucoma.

• Dental diseases.

• Temporomandibular joint disease.

Systemic causes-

• Fever.

• Hypertension.

• Anemia.

• Allergy.

• Drugs (nitrates).

• Depression.

How to Differentiate Primary and Secondary Headaches?

The first step is to differentiate between serious and benign headaches. Some of the symptoms that suggest a serious underlying disease are as follows:

• Sudden onset headache.

• Worst ever headache.

• Vomitingbefore the headache.

• Pain interferes with sleep.

• Headache with fever.

• The patient is above the age of 55.

Location of Pain - Sometimes, the site of the pain can give us a clue to the diagnosis, like temporal region in temporal arteritis, facial pain in sinusitis, etc.

Duration of Pain - The duration of the headache becomes important, like in instant onset (ruptured aneurysm), cluster headache (three to five-minute peak), and migraine (peak pain over minutes to hours).

How Is a Headache Diagnosed?

Complete neurological and ENT examinations help suspect some of the common causes of headaches. In the examination, if abnormal findings are encountered, then imaging investigations are undertaken (CT - computed tomography or MRI - magnetic resonance imaging). Lumbar puncture becomes important if meningitis or encephalitis is suspected. A psychological state assessment of the patient might be needed if there is a suspicion of depression.

What Are the Common Types of Headaches?

Migraine:

Migraine is a common cause of headaches, and it is more common in females. It is typically a one-sided headache, increased by movement, lasts for hours to days, is associated with nausea or vomiting, photophobia, and phonophobia, and is relieved by sleep. It is defined as episodes of unilateral throbbing headache, nausea, and vomiting, or symptoms of neurological dysfunctions. Family history is usually present. Following are different types of migraine:

a. Classical Migraine: Headache is characteristically associated with premonitory sensory, motor, or visual symptoms (aura).

b. Common Migraine: There is a headache without aura. It is the most frequent type of migraine.

c. Migraine Equivalent: Rarely can cause migraine present with focal neurological deficit without headache.

d. Complicated Migraine: Migraine with transient focal neurological features or that leaves a persistent neurological deficit is called complicated migraine.

The headache typically starts with nonspecific prodromal symptoms like malaise and irritation, followed by an aura of a focal neurological event. There is a severe throbbing hemicranial headache with nausea, vomiting, photophobia, and phonophobia. The patient prefers to be in a quiet and darkened room to go to sleep. The aggravating factors for the headache are:

• Menses.

• Red wine.

• Hunger.

• Lack or excess of sleep.

• Alcohol.

• Emotional or physical stress.

• Perfumes.

• Oral contraceptive pills.

It is important to identify these, as avoidance constitutes an important step in the management of migraines. The deactivators or relieving factors are sleep, pregnancy, and triptans.

The most common aura is visual, which is in the form of hallucinations and fortification spectra. The latter is pathognomonic for migraines and is characterized by silvery zig-zag lines marching across the visual fields for 20 to 25 minutes. When headaches occur more than three times per month, then preventive treatment should be followed. Sumatriptan is a commonly prescribed drug to control migraine headaches. Other medications used to treat or prevent cluster headaches or chronic migraines are:

• Beta-blockers (Propranolol, Atenolol).

• Methysergide maleate (reduces blood vessel constriction).

• Verapamil (calcium channel blocker).

• Valproic acid (anti-seizure medication).

• Amitriptyline (antidepressant).

• Dihydroergotamine.

• Topiramate.

• Lithium.

Tension Headache:

This is a very common type of headache which is experienced by the majority of the population at some time.

• The headache is constant, generalized, and may continue for weeks or months.

• It is commonly described as a dull, tight, pressure, or band-like sensation.

• Pain is less noticeable when the patient is busy and becomes worse at the end of the day.

• Emotional stress, noise, and fatigue may precipitate the headache.

• Unlike migraine, there is no photophobia, nausea, vomiting, or focal neurological symptoms.

• Management of underlying anxiety or depression often helps. Relaxation techniques like massage, hot baths, and biofeedback are also helpful.

Cluster Headache:

Attacks occur in clusters. It is unilateral and associated with pain behind the eyes, running nose, and watering from the eyes. It is a rare form of a headache, and recurrence is characteristic.

• It is common in middle-aged males, and there is no family history.

• The pain occurs periodically at a specific time of the day, generally in the early morning. The pain is severe and lasts for 30 to 90 minutes. There is unilateral periorbital pain associated with nasal congestion, lacrimation, rhinorrhea, or redness of the eye.

• Horner’s syndrome may occur during the attack.

• Patients may remain asymptomatic for weeks or months before another headache (cluster) occurs.

• Alcohol and smoking trigger the attack. Inhalation of 100 % oxygen (7 L/min for 15 minutes) is the most effective modality of treatment for an acute attack.