70-90% of adults will suffer from a headache sometime in their lifetime. Visits to the doctor because of headaches are more common than Asthma and Diabetes combined; nearly 4% of all doctor visits and 30% of total Neurologist visits are for a headache. Many patients come with the query, “Doctor, I have a severe headache…Is it a brain tumour?” and medical students often ask “should imaging be done for all headache patients?”

International Classification of Headache disorders lists over 200 headache types and broadly, headaches are classified into primary and secondary headaches. Primary Headache disorders are not associated with underlying pathology and include Migraines, Tension Type Headache, Cluster Headache and Trigeminal Autonomic Cephalgias.

Secondary Headaches are attributed to an underlying pathological condition like brain infections, brain tumours, Brain Haemorrhage, Intracranial hypotension or hypertension. The WHO ranks Migraine in its top 20 disabling conditions for women age 15 to 45 years of age.

When a patient with a headache comes to doctors, the goal is to exclude a secondary headache and appropriate pain management. Most primary headaches can be managed in primary care and investigations are rarely needed. So the most important step in management is to make the correct diagnosis; the gold standard for diagnosis and management of a headache is a careful interview and clinical examination.

Signs and Symptoms

A detailed history about the type of headache, onset, frequency, whether episodic or continuous, time to peak, time and duration, triggering or relieving factors like food, fasting or sleep disturbance and whether these symptoms get worse with time, aura in the form of nausea, vomiting or photophobia, any comorbidity like hypertension, diabetes, seizure or depression should be taken.

The history of drug intake should also be noted as overuse of analgesics is to be avoided and if it is happening, should be recognised. The exact location of pain gives some indication of diagnosis; patients who present with recurrent severe disabling headache associated with nausea and sensitivity to light with normal neurological examination should be considered to have a migraine. They usually don’t need imaging if the symptoms are clear.

Patients with the first presentation of a thunderclap headache should be referred immediately to the hospital for specialist assessment and CT scan. In case of frequent, brief unilateral headache with watering and redness, trigeminal autonomic cephalgias like a cluster headache should be considered. Sufferers of cluster headaches tend to remain agitated. pain is so severe that females who have suffered from this pain consider it comparable to labour pains.

Examination mainly involves assessment of fundus, neck discomfort, temporal area palpation, and Blood pressure monitoring. Patients who present with a headache and ‘Red Flags’ require further proper assessment in the form of imaging (CT scan or MRI brain) or a lumbar puncture.

Red Flag Features

New onset or change in headaches in patients who are aged over 50 years

Thunderclap: rapid time to peak headache intensity (seconds to 5 mins.)
Focal neurological symptoms (e.g. limb weakness)
Non-focal neurological symptoms (e.g. cognitive disturbance)
Change in headache frequency, characteristics or associated symptoms
Abnormal neurological examination
Headache that changes with posture
Headache precipitated by physical exertion or coughing, laughing, straining etc.
Patients with risk factors for cerebral venous sinus thrombosis
Jaw claudication or visual disturbance
Neck stiffness
Fever
New onset of a headache in a patient with HIV infection

New onset of aheadache in a patient with a history of cancer

Management

Treatment of a secondary headache is mainly the treatment of basic cause along with symptomatic treatment. Once the secondary causes are ruled out, the treatment of a primary headache is of two types – Abortive treatment (Termination of attack) and Prophylactic treatment (preventing the occurrence of attack).

For abortive therapy, usually analgesics and antagonists are used. Care should be taken because abuse of abortive therapy can actually increase a headache.

If the attack frequency is more than 3 to 5 per month or in migraine variants like a hemiplegic migraine doctors start prophylactic treatment. The goal of preventive therapy is to decrease attack frequency by 50%, prevent medication overuse, improve function/reduce disability, decrease days missed of work and guard against progression to a chronic migraine.

The rule is to ‘start low and go slow’ and ensure good compliance. Patients always have a query whether they have to take medication for life; but with good control for 6-12 months, tapering can be started. When a migraine becomes chronic and remains more than 15 days per month, botulism toxin can be used. Non-pharmacological treatments should not be forgotten as relaxation and dietary changes include avoiding certain foods like caffeine, nitrates, alcohols, chocolates, cheese, processed meats, nuts etc. can help.

At the same time, it’s very important to look at the psychological status of a chronic headache such as depression.