A headache is one of the most common and painful conditions for which a patient seeks medical attention. Globally, the percentage of the adult population with active headache disorders are 46% for headaches in general, 11% for migraines, 42% for tension-type headaches and 3% for chronic daily headaches. The disability attributable to tension-type headaches is larger, worldwide than that due to a migraine. On the World Health Organization’s ranking of causes of disability, headache disorders fall into the 10 most disabling conditions for the two genders, and into the five most disabling conditions for women.
Headaches are divided into two broad categories which are, primary headaches (without any underlying cause) and secondary headaches (with an underlying cause).
Primary headaches usually include Migraines, Tension-type headaches and Trigeminal Autonomic Cephalalgias. With migraines and tension-type headaches being the most common causes of headaches.
About 90% of headaches are caused by primary headaches, with the remaining 10% being caused due to secondary headaches. The responsibility of the clinician is to identify a secondary headache (which is more dangerous) as early as possible in order to prevent complications. There are some warning signs or red flags for the diagnosis of a primary headache. The presence of these red flags indicates the diagnosis of a secondary headache. The red flags are as follows.
- A headache that is worse in supine, disturbs sleep or presents immediately upon awakening
- A headache triggered by a cough, Valsalva, bending & exertion
- A headache associated with Visual obscuration’s, double vision, transient changes in vision with change in posture
- Vomiting preceding the headache
- Headache onset after the age 50
- First severe headache of life
- Worsening of headache day by day
- A headache associated with known systemic illness or systemic symptoms (Fever, neck stiffness)
- A headache with abnormal neurological examination
- New onset severe Headache during pregnancy or post-partum
- A headache worsened in standing & relieved in supine
- A thunderclap headache (time to peak headache intensity is sec to 5 min)
- A new headache in a patient with AIDS and cancer patients
If the patient has a headache and presents any of the above features, it is important to rule out the secondary causes of a headache by doing the appropriate investigation (which in most cases is a brain MRI).
If the patient does not have any of the red flags, and their history is suggestive of one or more of the primary headache syndromes then the diagnosis does not require further tests and investigation.
The historical points in favour of the diagnosis of migraines are as follows:
- One-sided headaches with alternating sides getting affected
- The presence of visual or sensory aura symptoms before a headache begins.
- Associated with nausea, vomiting, irritation of light, sounds and or smell during a headache
- Pulsating nature of a headache
- Triggered by a lack of sleep, stress, fasting, excess sunlight exposure, strong smell, travel, food items etc.
- A headache worsened by and causing the restriction of the movements
The historical points in favour of tension-type headaches are as follows:
- Both sided headache
- Pressure like or band-like sensation
- No or mild nausea, irritation of light or sounds (Any one of them)
- Mild to moderate in severity
- Usually not aggravated by movement
Patients with recurrent headaches should seek medical attention to decide whether they are suffering from the primary or secondary cause of a headache.
If it is a primary headache condition, it is important to prevent the medication over-use i.e. overuse of over the counter painkillers. They are detrimental because of two reasons 1) Painkiller overuse itself can trigger a headache 2) Long-term effects on the kidneys
If it a secondary headache condition, it is important to determine the appropriate cause by relevant investigations to prevent any further complications.
Specialist in Neurology
Aster Speciality Clinic, International City