Table of Contents
- Cluster headache
- Tension-type headaches
- Common Precipitating Factors
- Cluster Headache
- Tension-type Headache
- Diagnostic Criteria
- ICHD-3 Criteria for Migraine Without Aura
- ICHD-3 Criteria for Migraine with Aura
- ICHD-3 Criteria for Cluster Headache
- ICHD Criteria for Episodic Tension-type Headache
- Detailed History
- Neurologic examination
- ‘Red Flags’ indicating further need for imaging
- Differential Diagnosis
- Further Reading
- Defined as pain or discomfort in the head.
- One of the most common symptoms reported to clinicians.
- A great majority of headaches arise due to benign conditions.
- It necessitates thorough investigation because, sometimes, it can represent an early manifestation of a possibly grave disorder.
Classification per International Classification of Headache Disorder (ICHD), 3rd Ed
- Tension-type headache
- Trigeminal autonomic cephalgia
- Other primary headache disorders
- Trauma or injury to the head and/or neck
- Cranial or cervical vascular disease
- Nonvascular intracranial disorder
- A substance or its withdrawal
- Disorder of homeostasis
- Disorder of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cervical structure
- Psychiatric disorder
- Painful cranial neuropathies and other facial pain
- Other headache disorders
- Lifelong prevalence of headaches is 96%, with a female predominance.
- Global prevalence of Tension-type headache and Migraine is 40% and 10%, respectively.
- Migraine occurs between ages 25 to 55 years, 3 times more common in women.
- Cluster headache has a population prevalence of 0.1% and a male/female ratio of 3.5-7:1.
- Worldwide prevalence of chronic daily headaches has been consistent at 3%-5%, which mostly represents Chronic Migraine.
- Caused presumably by genetically induced hypersensitivity of the brain.
- Arises from the activation and sensibilization of the trigeminovascular system.
- Results in the release of neuropeptides and other substances.
- Both cause local inflammation and distant amplification of neural circuitry in the brainstem, trigeminal nucleus caudalis, thalamus, and cortex, leads to central sensitization and symptom worsening.
- Reduced activity in central descending inhibitory systems and reduced ability to control or extinguish the headache attack.
- Hypothalamus, a higher brain center, is involved in initiation of migraine attack.
- Calcitonin-gene related peptide (CGRP) is involved in migraine.
- Imbalance between the sympathetic and parasympathetic neural system causes cranial-autonomic symptoms.
- Calcitonin-gene related-peptide (CGRP) is also involved in cluster headaches.
- Greater role played by environmental factors.
- Contributing factors; tenderness of pericranial muscles, co-existing mood disorders, and mechanical disorders of the spine and neck.
- Peripheral and central sensitization are relevant in chronification of migraine and tension-type headache.
Common Precipitating Factors
- Skipping meals
- Too much or too little sleep
- Stressful events
- Depression or anxiety
- Drinking too much alcohol, particularly red wine
- Loud or sudden noises
- Processed meats that contain nitrates, aspartame, MSG, aged cheese, and chocolate
- Birth control pills or hormone replacement therapy
- Headache medicine used on a daily or near daily basis
- More common in those who smoke
- Head trauma, such as an injury or surgery
- Arthritis in the neck
- Changing hormone levels for females, due to the menstrual cycle, pregnancy and menopause, among other situations and conditions
- Fatigue from sleep deprivation or other causes
- Injury to the head or neck area
- Eye, neck or back strain caused by poor posture
- Teeth grinding and jaw clenching
ICHD-3 Criteria for Migraine Without Aura
- A. At least 5 headache attacks fulfilling the criteria B-D
- B. Attacks last 4-72 h
- C. With at least 2 of the following 4 characteristics:
- Unilateral location
- Pulsating quality
- Moderate or severe pain intensity
- Aggravation by or causing avoidance of routine physical activity
- D. At least 1 of the following during headache:
- Nausea and/or vomiting
- Photophobia and phonophobia
- E. Not better accounted for by another ICHD-3 diagnosis
ICHD-3 Criteria for Migraine with Aura
- A. At Least two attacks fulfilling criteria B and C
- B. One or more of the following fully reversible aura symptoms:
- Speech and/or language
- C. At least two of the following characteristics:
- At least one aura symptom spreads gradually over ≥5 minutes, and/or two or more symptoms occur in succession
- Each individual aura symptom lasts 5-60 minutes
- At least one aura symptom is unilateral
- The aura is accompanied, or followed within 60 minutes, by headache
- D. Not better accounted for by another ICHD-3 diagnosis, and transient ischemic attack has been excluded
ICHD-3 Criteria for Cluster Headache
- A. At least five attacks fulfilling criteria B–D
- B. Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15–180 minutes (when untreated)
- C. Either or both of the following:
- At least one of the following symptoms or signs, ipsilateral to the headache:
- a) Conjunctival injection and/or lacrimation
- b) Nasal congestion and/or rhinorrhoea
- c) Eyelid edema
- d) Forehead and facial sweating
- e) Forehead and facial flushing
- f) Sensation of fullness in the ear
- g) Miosis and/or ptosis
- A sense of restlessness or agitation
- D. Attacks have a frequency between one every other day and eight per day for more than half of the time when the disorder is active
ICHD Criteria for Episodic Tension-type Headache
- Family history of migraine
- Childhood migraine proxy symptoms: car sickness, gastrointestinal complaints.
- Age of onset
- Frequency, severity, and tempo over time
- Triggering, aggravating, or alleviating features
- Autonomic features
- Aura features
- Current and prior treatments
- Drugs and toxins exposure
- Lifestyle features; IV drug user (risk of infection)
- Comorbid conditions
- Immunosuppressive disorders
- Hypertension (risk of hemorrhage)
- Malignancy (risk of metastasis)
- General physical examination to rule out secondary causes. Should include,
- Cardiovascular assessment
- Palpation of head and face
- Tonometry to rule out Acute Angle Closure Glaucoma.
- Mental status
- Level of consciousness
- Cranial nerve testing particularly II, III, IV and VI
- Pupillary responses
- Motor strength testing
- Deep tendon reflexes
- Pathologic reflexes (e.g. Babinski's sign)
- Cerebellar function and gait testing
- Signs of meningeal irritation (Kernig's and Brudzinski's signs)
‘Red Flags’ indicating further need for imaging
- New headache in older patients
- Abnormal neurologic examination including papilledema and change in mental status
- New change in headache pattern or progressive headache
- New headache in the setting of HIV risk factors, cancer, or immunocompromised status
- Signs of a systemic illness (eg, fever, stiff neck, rash)
- Triggered by cough, exertion, Valsalva maneuver
- Headache in pregnancy/postpartum period
- First or worst headache
- MRI scan (more sensitive in identifying intracranial pathologies)
- Lumbar Puncture, if CT-scan is negative to rule out Subarachnoid Hemorrhage
- Tumors, particularly pituitary masses
- Bacterial or viral meningitis (an infection or inflammation of the membrane that covers the brain and spinal cord)
- Pseudotumor cerebri (increased intracranial pressure)
- Hydrocephalus (abnormal build-up of fluid in the brain)
- Infection of the brain
- Encephalitis (inflammation of the brain)
- Blood clots
- Head trauma
- Sinus blockage or disease
- Malformation (such as Arnold-Chiari)
- Infections, such as Lyme disease
- Temporal Arteritis
- West Nile Virus
- Carbon monoxide poisoning
- The International Classification of Headache Disorders - ICHD-3. (2021). Retrieved 13 September 2021, from https://ichd-3.org/
- Headache Rizzoli, Paul et al. The American Journal of Medicine, Volume 131, Issue 1, 17 - 24
- PMC E. Europe PMC [Internet]. Europepmc.org. 2021 [cited 13 September 2021]. Available from: https://europepmc.org/abstract/MED/3248935
- Spierings, E., Ranke, A., & Honkoop, P. (2021). Precipitating and Aggravating Factors of Migraine Versus Tension-type Headache.
- Headaches: Types, Symptoms, Causes, Diagnosis & Treatment. Cleveland Clinic. (2021). From https://my.clevelandclinic.org/health/diseases/9639-headaches.
- Headache Causes. Mayo Clinic. (2021). From https://www.mayoclinic.org/symptoms/headache/basics/causes/sym-20050800.
- Risk Factors for Headache | Winchester Hospital. Winchesterhospital.org. (2021). From https://www.winchesterhospital.org/health-library/article?id=19555.
- PRIME PubMed | Precipitating and relieving factors of migraine versus tension type headache. Neuro.unboundmedicine.com. (2021). From https://neuro.unboundmedicine.com/medline/citation/22920541/Precipitating_and_relieving_factors_of_migraine_versus_tension_type_headache_.
- Clinch, C. (2021). Evaluation of Acute Headaches in Adults. Aafp.org. From https://www.aafp.org/afp/2001/0215/p685.html#afp20010215p685-t4.
- Approach to the Patient With Headache - Neurologic Disorders - MSD Manual Professional Edition. MSD Manual Professional Edition. (2021). From https://www.msdmanuals.com/professional/neurologic-disorders/headache/approach-to-the-patient-with-headache.
- Just In Time Medicine. Differential Diagnosis of Headache. Justintimemedicine.com. (2021). From https://www.justintimemedicine.com/CurriculumContent/p/6830.
- Gilmore, B., & Michael, M. (2021). Treatment of Acute Migraine Headache. Aafp.org. From https://www.aafp.org/afp/2011/0201/p271.html.
- Headache Management. Research.birmingham.ac.uk. (2021). From https://research.birmingham.ac.uk/portal/files/20437602/Sinclair_et_al_Headache_management_practneurol_2015_001167.full.pdf.
- What Are the Symptoms of a Headache?. Verywell Health. (2021). From https://www.verywellhealth.com/headache-symptoms-1719563.
- Tension headache: Background, pathophysiology, etiology. (2021, July 12). Diseases & Conditions - Medscape Reference. https://emedicine.medscape.com/article/792384-overview#a7
ECFMG Certified. Research Fellow at NeuroCare.AI Academy and Postdoc Intern at Global Innervation LLC.
ECFMG Certified. Research Associate at NeuroCare.AI Academy
Founder NeuroCare.AI, Practicing Neurologist, sub-specialized in the field of Neurocritical Care, Stroke & Epilepsy