19 July 2010
Headaches are a pain or discomfort that can be generalized or local affecting any part of the cephalum (head). There are many causes of HA, some originating from the head region itself, others are referred from the neck and upper back, as well as ophthalmologic origins.
Most causes of HA’s are benign and have no underlying significant pathology, however, it is imperative to evaluate more severe causes before beginning treatment for the benign causes. Headaches themselves are one of the most common complaints from people visiting a physician. Headaches can be classified as “Primary” or “Secondary.” Primary HA’s are not caused by an underlying pathology or disease. Meaning, they are benign HA’s which can further be subdivided as Cluster, Tension, and Migraine headaches. Secondary HA’s are associated with a pre-existing pathology causing the pain, which may be benign or malignant of origin.
A patient who experiences an acute onset of pain, without prior history of headaches should be further evaluated before assuming it is of primary origin.
Some of the more severe causes of acute headaches that require immediate treatment include:
- Intracranial/ subarachnoid hemorrhages – typically from a bleeding aneurysm or trauma
- Meningitis (viral, bacterial, fungal)
- Strokes
- Malignant hypertension – caused by rapid elevation of blood pressure.
Other pathologies that are more subacute, or have an insidious onset may be malignant tumors (primary or malignant) or ophthalmologic (glaucoma, cataract). There are other diseases associated with HA and these all should be evaluated by your physician before treating your HA.
Diagnosis
- Computed Tomography (CT) scan – Initial work up of an acute HA includes a CT scan to exclude an intracranial bleed.
- Magnetic Resonance Imaging (MRI) – MRI may secondarily be obtained to evaluate for an ischemic stroke, brain tumor, or signs of infection.
- Magnetic Resonance Angiography (MRA) – Sometimes include with the MRI to evaluate for aneurysm.
- Lumbar puncture (LP) – Evaluates the spinal fluid for infection and blood.
If secondary causes of headaches have been excluded then treatment can be based on the type of primary headache. In the acute setting, a cluster headache is the most common primary headache.
Men are more commonly affected by cluster headaches than women with a peak age of onset around 25 years. Patients will present with a severe, unilateral, pulsatile, periorbital pain that typically lasts anywhere from 20 minutes to 3 hours. Patients describe the pain associated with Cluster HA to be far more severe than is experienced in Tension or Migraine HA’s. Risk factors for Cluster HA are vasodilating medications as well as recent alcohol or illicit drug use. A specific trait to Cluster HA’s are that they occur in “clusters”, hence the name, meaning they affect the same location of the head, around the same time of day, during the same time of year. Patients may also experience tearing from the eye on the same side of the head as the pain as well as nasal discharge or stuffiness, or neurological complications (Horner’s syndrome, ptosis). In contrast with the other two types of primary HA, emotion and food are NOT triggers in Cluster HA.’s
Treatment
Pharmacologic treatment for acute primary headaches can be classified as “abortive” or “preventive.” However, preventive therapy is not typically initiated if there is no history of headache. Also, it is imperative that secondary causes be excluded prior to treating the headache.
Abortive therapy
Abortive therapies are directed at terminating the pain immediately. Although this may provide relief from the HA, it does not decrease the frequency/ intensity nor does it prevent the attack from recurring. They also are not equally effective each time and efficacy varies from person to person. Typical over the counter medications have no use for Cluster headaches. Some commonly used abortive therapies for HA’s are:
- Oxygen – most commonly used acutely in Cluster HA.
- Ergots
- Triptans
- NSAID’s
- Anti-emetics
- Opiates
- Butalbital with aspirin or acetaminophen
Preventive therapy
Medications and techniques that are considered Preventive therapies are directed at reducing the frequency and severity of the attacks. Unfortunately, most of these medications are not able to terminate an acute episode so they are typically used in conjunction with the abortive therapies during an attack. Some of the common preventive medications are:
- Cardiovascular drugs (Beta blockers, Calcium channel blockers)
- Antiseizure medications
- Antidepressants
- Antihistamines
The content on this website is for educational purposes only, and is in no way intended to replace your physician's advice. Please always consult your doctor before taking any advice learned here or on any other website.
