Summary Of Headache And Type Of Headache ( Symptoms, Diagnosis, Management)

I. Introduction

Headache is the most frequent medical problem among the other causes that everyone in the world has experienced. Some people are very concerned about the headache. There are so many causes that might be anticipated in this problem. In general speaking, headache affects both children and adolescents. ( More definition click here)

II. Type of headache

There are 2 main types of headache

1.Primary Headache

– Migraine
– Tension-type
– Cluster headache

2. Secondary Headache

1.A.Migraine

Migraine often makes you have recurrent headaches and is characterized by throbbing(pulsatile) pain in quality and located in a part of the head. Many studies suggest that migraine was caused by the dilatation of the vessels meanwhile aura (early signs of migraine) is resulted from vasoconstriction. Migraine can be triggered by stress, insomnia, menstruation, fasting, weather changes, etc. There are 4 phases of migraines.
– Premonitory migraine: In this episode, the patients have some changes in mood such as thirst, increased appetite, or drowsiness before having the migraine 24 hours. It is caused by changing the serotonin antagonist that makes us drowse and hungry for sweet things
– Prodromal migraine: there are 2 types of this: classic migraine and protracted prodromal migraine.
+ Classic migraine: the patients have a problem with their vision because of the vasoconstriction of vessels in one of the ophthalmic arteries. These symptoms have happened before the migraine around 10 to 60 minutes.
+ Migraine equivalent: might be affecting our neurological system familiar to the migrainous prodrome without headache.
– Nonprodromal migraine: there are also 2 types of this migraine
+ Common migraine: most frequently, it affects unilateral( headache at one side of your head) and the patients have nausea, vomiting, and photophobia.
+ Interposed migraine: The patients have neurological symptoms with a headache. Vision problems ( photophobia ) also present in this stage.
– Complicated migraine: might be associated with another disease more than common migraines and usually, the patients suffer retinal and neurological deficits after the headache.
The prodrome of migraine (signs before real migraine: yawning, euphoria, depression, irritability, constipation, or neck stiffness)is generated by the reduction of the blood flow into the brain result of cortical ischemia or depressed cortical function. The headache of migraine according to many experts has shown that it occurs because of increasing cerebral and extracranial blood flow. Additionally, some theories suggested that the release of sensitizing bradykinin-like substance and serotonin making the affected vessels vasodilation. The depression of cortical function can make changes in hormones and diminish blood flow in occipital areas producing the migraine. The diagnosis of migraine is based on physical examination and history.
 For the treatment of migraines, the patients should keep away from stimuli such as light, loud noises, etc, and treat their symptomatic. The patients can also be able to take medicines in case they have moderate to severe headaches. Those include triptans ( eg sumatriptan) or ergotamine. Note: before taking medicines, you should consult with real doctors because the side effect of the medication can result in death. For example, Sumatriptan cannot use with patients that have coronary artery disease or are pregnant and breastfeeding.

1.B. Tension headache( or muscle-contraction)

When we talk about tension headaches, we will see the word tension. The tension here represents the causes of this kind of primary headache. Being stressed, fatigue, loud noises are counted as the main cause of tension headaches. The characteristic of the pain is bandlike-sensation,non-pulsating, often bilateral of the head, situated at the frontal of the head, temporal, or occipital areas. The tension headache tends to affect both men and female but the female(age 30 to 40 ) have a higher percentage for this form of headache. The duration of the headache is the last 30 minutes to 2 or 4 days. The patients can have nausea, photophobia(intolerance of light). We can treat the patients with tension headaches by NSAID (a non-steroid anti-inflammatory drug )( eg aspirin or ibuprofen) and acetaminophen. If you don’t want to take medicines, you can change your daily routine or your quality of life. Getting rid of stress, anxiety or depression is the best way to non-pharmacological therapy.

1.C.Cluster headache

Cluster headache is a type of headache that mostly affects adult men. We have named it cluster because it occurs as episodes or patterns. The patients suffering from this always present the pain unilateral of the head and last around 15 minutes to 3 hours, sometimes the pain occurs behind the eyes(redness of one eye) or at the forehead region or temporal area. The mechanism of cluster headache has not yet explained. The components in cluster headache are Horton’s histaminic cephalgia and migrainous neuralgia. It is called chronic cluster headache when the recurrent symptoms are presented in more than a month. The majority of patients are around 20 to 40 years old. A cigarette is the best risk factor for this. The differences between migraine headaches and cluster headache are the restlessness and agitation of the patients that are classified in cluster headache while the patients maybe seek the silent place or dark in migraine headache. For the management of cluster headache, we just give oxygen or treat with triptans. (Read more about primary headache click here ). 

2. Secondary headache

The secondary headache is classified as a serious disorder that requires close attention from physicians.
The causes are categorized :

1. Bleeding

– Epidural hemorrhage: headache located at the traumatized area and the patients can lose consciousness, vomit, or seizures. Diagnosis can be made by CT scan ( biconvex, hyperdense lesion)- Subdural hemorrhage: Diffuse headache at the affected side of the head. The patient can have problems with mental status such as hemiparesis, gait, speech, and dilated pupil. The presence of increased intracranial pressure occurs in this type. The diagnosis can be confirmed by CT scan (concave, hyperdense hemorrhage)- Subarachnoid hemorrhage: the patients have a sudden onset and severe headache, loss of consciousness, and seizures. The severity of this headache can result in the rupture of vessels in the brain(aneurysm. The diagnosis is confirmed by blood in subarachnoid space ( hyperdense ) and Red blood cell count is increased when we do lumbar puncture.

2. Vascular

– Cerebral venous thrombosis: The patients can have signs of increased intracranial pressure ( nausea, vomiting) or nonspecific headache. There are specific risk factors in venous thrombosis diseases: pregnancy, oral contraceptives, prothrombotic states… ). We can confirm the disease by increased D-dimer, papilledema, or signs of thrombosis in CT or MRI.

3. Autoimmune

Temporal arteritis( giant cell arteritis): The patients have pain in the temporal area, jaw claudication, scalp tenderness, fever, malaise, and partial or complete vision ( unilateral or bilateral) diplopia. For complete blood count, we see increased ESR(erythrocyte sedimentation rate), CRP increased and more specificity we do temporal artery biopsy ( gold standard) or MRI ( enhancement of the temporal artery).

4. Infectious

– intracranial infections
+ Meningitis: we have a classic triad that is easy to remember: fever, headache, neck stiffness, mental status alteration, seizure, and vomiting. We can see an increase in WBC( white blood cells) and procalcitonin. For a lumbar puncture, we are expecting bacterial infection if WBC>1000 cells/µl, elevated protein, low glucose, positive gram stain, and virus if WBC 10-500 cells/µl ( lymphocyte predominated, normal protein, normal glucose). ( Read more about secondary headache click here )

5. Others

– Glaucoma: a group of diseases that affect the pressure of the eye which increases the volume of water that normally presented in the eye. There are 2 types: Open-angle glaucoma and Angle-closure glaucoma. The patients have severe headaches in Angle-closure glaucoma. The patients can have a frontal headache, pain behind the eye and your eye becomes hard on palpation, your pupil is mild-dilated and irregular. For diagnosis of Angle-closure glaucoma, we can do slit-lamp examination which shows a shallow anterior chamber. Moreover, We can use direct fundoscopy to make sure whether or not it is undilated pupils. The treatment of angle-closure glaucoma is direct parasympathomimetic which is pilocarpine and alpha-2 agonist which is apraclonidine or beta-blocker timolol. Acetazolamide also plays an important role because it is a carbonic anhydrase inhibitor.
– Brain tumors: the presence of the mass in the brain by presenting abnormal cells. The most frequent type of brain tumors is glioblastoma multiforme, meningioma, hemangioblastoma, schwannoma, oligodendroglioma, and pituitary adenoma.
– Trigeminal neuralgia: The pain located at the unilateral of the head but the type of pain is stabbing. The diagnosis is based on clinical signs and compression of the trigeminal root on the MRI brain.
– Increased intracranial pressure: the increased pressure in the skull of the brain. The normal pressure intracranial is <15 mmHg in adults. It has a Cushing triad: irregular breathing, widening pulse pressure, and bradycardia. Headache always presents and get involve with papilledema and vomiting. For the management of increased intracranial pressure, we use Mannitol and hypertonic saline. Mannitol can be given 1g/kg and a repeat dose of 0.25 to 0.5g/kg generally six to eight hours. We can use other agents like furosemide 0.5 to 1.0 mg/kg intravenously and it can use with mannitol. Giving oxygen has an advantage in reducing intracranial pressure depending on the volume of PaCo2.When PaCo2 decreases, the pressure of intracranial pressure decreases too. Besides using the medication, we can use surgery instead such as Removal of cerebral fluid in the brain, decompressive craniectomy.