• Dr. Pramod Dhonde

Approach to a patient of Headache

Headache is one of the commonest symptoms and almost each one of us has experienced it in our lifetime. Conditions causing headache are divided into primary (where headache is the sole manifestation in the absence of any structural lesion) and secondary (which is secondary to neurologic, systemic, or local pathology). Table 1 gives few examples of primary and secondary headaches, although the actual list will be very large.

Table 1: Examples of primary and secondary headaches











Schreiber CP et al found that nearly 80% of patients who presented with self-reported or physician diagnosed ‘sinus headaches’ were in fact having migraine. [10 Schreiber CP,04] This underscores the importance of accurate diagnosis in patients with headache. The purpose of this review is to brief clinical approach to a patient of headache.


Age:

Common causes of headache in different age groups vary. Headache for which children are usually brought to emergency department are more likely due to viral infections and sinusitis than migraine or tension headache. [5Burton LJ, 97] In children, the incidence of headache is increases at the start of school [3Anttila P, 99], and school phobia usually leads to chronic tension headache. [33 Fujita M, 09] Acute confusional migraine [72. Sheth RD, 95], Basilar migraine and Opthalmoplegic migraine [Bradley] are usually seen in children.

Migraine is present in 4% of boys and girls without much gender difference. It usually develops in the second decade of life, with the peak incidence in adolescence [62.Silberstein SD, 00], and peak prevalence in the third and fourth decades of life. [24 Contag SA, 09] In Indian adolescents, Migraine (17%) is more prevalent than Tension type headache (11%).[172. Gupta R,09]


In adults, tension type headache is probably the commonest headache affecting up to 78% of the general population.[ 193. Bendtsen L,09] Cluster headaches occur in adults of nearly 30 years age[75. Rozen TD, 01]. Chronic Migraine [18 Beckmann YY. 09], Nummular headache [203. Grosberg BM,07] and Primary angiitis of the central nervous system (PACNS) [117. Birnbaum J, 09] are more common in 5th decade.


In elderly population, tension headache is commonest, whereas migraine is rare. [221. Poser CM. 76] Other important causes include Giant cell arteritis [137. Brodmann M,09] and Hypnic headache.


Table 2 gives prevalence of headache in general population. However, the numbers may not necessarily hold true for Indian population as most of studies were done in western population.

Table 2: Prevalence of headache:

Primary stabbing headache, primary exertional headache, primary headache associated with sexual activity, primary cough headache are uncommon causes of headache and its prevalence was found to be 12.6%, 5.3%, 1.6% and 0.4% of all headache patients in one study.[ 235. Tuğba T,08]


Gender:

Episodic migraine [62.Silberstein SD, 00], Chronic Migraine [18 Beckmann YY. 09], Nummular Headache [ 203. Grosberg BM,07] and idiopathic intracranial hypertension are more common in females; whereas Cluster Headache, Headache on sexual activity, Primary Angitis of CNS are more common in males.(Table 3)


Table 3: Sex wise distribution of different headaches

Occupation:

Headaches are more frequent in men holding managerial posts. [17 Tobiasz-Adamczyk B, 82] Patients of cluster headache were found to be working for longer time than those without it. [13 Sjöstrand C, 09] Barotrauma due to diving or flying can cause short-lived pain in sinuses. [36 Jones NS, 09] Space travel can also lead to headache (space headache) in about 70% of astronauts who don’t have any headache while on earth. [197. Vein AA,09]


Aura:

Aura prior to headache occurs in 15-20% of migraneurs, and even more infrequent in cluster headache. Aura may involve vision (commonest), sensation, language and motor power. [Bradley] About 40% patients of migraine with aura may get migraine attacks without aura too. [20 Hauge A, 09] Migraine aura may occur without headache. Migrainous infarct may occur if the aura lasts more than 1 week. [170. Solomon S.01]


Site:

Migraine, Trigeminal Autonomic Cephalalgias, Hemicranias Continua, Nummular Headache, Neck-tongue syndrome are usually unilateral; whereas Tension type Headache is bilateral.[Bradley]


Tension type headache is characterized by bilateral fronto-occipital pain.[ 220. Pfaffenrath V,88] Pain is in form of tight band around head, pressure or bursting sensation. [Bradley]

Nummular headache is a primary headache in the form of local pain in a circular/elliptical area of < 7 cm in diameter. It usually occurs over tuber parietale. It is usually a chronic headache associated with exacerbations and short periods of remission. [195. Alvaro LC,09] Pain is mild to moderate, but occasionally may be severe. It is unilateral, side-locked and fixed in location. Paresthesias, allodynia, and dysesthesias are frequently complained in the affected region.[ 203. Grosberg BM,07]


Neck-tongue syndrome is an uncommon condition characterized by brief attacks of intense unilateral stabbing pain in the upper neck or occipital region upon sudden rotation of the head accompanied by ipsilateral numbness of the tongue. Interconnections between Lingual nerve, Hypoglossal nerve and C2-C3 nerve roots is hypothesized to lead to this headache. [119. Lewis DW, 03]


Cervicogenic headache is characterised by pain spreading to the neck, occipital region of skull, jaw, eyeballs and arms. It is caused by pathology in bones, soft tissues and nervous structures of cervical spine. It is probably caused due to communication between C1-C3 cervical roots and trigeminal neurons. [130. Gasik R. 08] Upper cervical pain is frequently present in different primary headaches including Migraine and as such do not qualify for diagnosis of Cervicogenic headache. Symptoms and signs of neck involvement such as a mechanical precipitation of attacks, a restriction in range of motion of the cervical spine and the existence of ipsilateral neck/ shoulder/ arm pain are considered valid reasons for the diagnosis of Cervicogenic headache. [140. Frese A, 08] Photophobia is uncommon in Cervicogenic headache compared to migraine. [139. Sjaastad O.08]


Presence of autonomic features along distribution of Trigeminal nerve:

Autonomic features along distribution of Trigeminal nerve include increased lacrimation, sweating, rhinorrhea, conjunctival injection and facial flushing. It is typically seen in Trigeminal- autonomic cephalalgias (TAC) and Hemicrania continua; though it can occur in migraine too [18 Beckmann YY. 09]. Trigeminal- autonomic cephalalgias include cluster headache (commonest), paroxysmal hemicrania and SUNCT. [89. Rubí CJ, 08]


Cluster headache attack usually last 15-180 minutes. Attacks may happen at precise time, especially at night. [100. Leroux E,08] Patients on an average get nearly 3 attacks per day for nearly 10-11 weeks followed by 21-23 months of remission. [75. Rozen TD, 01] This type of clustering of attacks has led to the name of this disease.


Paroxysmal hemicranias presents as attacks lasting 10-30 minutes (range 2-120 minutes) with frequency of 1-40 attacks per day (average 6/day) for 2 weeks to 5 months with remission for 1-36 months. [Bradley]


SUNCT has male preponderance (4.25 : 1). The mean age at onset is nearly 50 years. Attacks are mostly in the orbital/periorbital area and always recurred on the same side with remissions of varying durations. Most attacks are moderate to severe in intensity and burning, electrical, or stabbing in character. Autonomic features are prominently present ipsilaterally. The usual duration of attacks is10 to 60 seconds, but it can last maximum for 300 seconds. The frequency of attacks during the symptomatic period varies from less than 1 attack daily to more than 30 per hour.


Tip to remember different TAC is that bigger the name of particular cephalalgia, shorter is the duration of individual attack and more are the number of attacks of that particular headache in a day.


Hemicrania continua is characterized by a mild to moderate continuous (hence the name) background headache with acute exacerbation leading to severe, unilateral headache which is responsive to indomethacin. In acute exacerbations there is photophobia, phonophobia, nausea and autonomic symptoms. Occipital tenderness is found in nearly 70% patients.[76. Peres MF, 01]


Attack duration:

Usual untreated migraine attacks last 4-72 hours. [Bradley] If the migraine attack lasts more than 3 days, it is called "status migrainosus". [170. Solomon S.01]


Chronic daily headache is diagnosed when headaches last for more than 4hours/day, with 15 headache days per month or more, over a period of 3 consecutive months, without an underlying pathology. Chronic daily headache (CDH) affects 2-4% of adolescent females and 0.8-2% of adolescent males. [86. Cuvellier JC, 08] Primary Chronic daily Headache includes transformed migraine, chronic tension-type headache, new daily persistent headache, and hemicrania continua. [30 Katarzyńska A, 09] In one study, 78% of these patients had transformed migraine, 15.3% had chronic tension-type headache, and 6.7% had other headache disorders. [80. Silberstein SD, 96]


Type of pain:


Pain can be described as thunderclap, sharp, pulsating, stabbing, grinding, dull aching in various disorders. Kelman L et al observed that headaches in patients of migraine, probable migraine and chronic migraine all together were throbbing in 73.5%, aching in 73.8%, pressure in 75.4%, and stabbing in 42.6% patients. In episodic migraine it is more of throbbing pain, whereas in chronic migraine it is more of aching pain. [242. Kelman L.06]


Thunderclap type of pain is particularly important. It is sudden onset severe headache. Its recognition is necessary to rule out underlying serious brain disorder. Causes of thunderclap headache include subarachnoid haemorrhage, intracranial hematoma, or cerebral venous thrombosis. Some primary headache disorder such as migraine, tension headache with an unusual sudden onset, exertional headache, coital headache, cough headache, or cluster headache can also lead to thunder clap headache. [251. Linn FH,02]


Primary stabbing headache is a short-lasting troublesome headache disorder. It may be seen in patients with migraine, but can occur without it especially in patients > 50 years age. Headache is unilateral in 3/5th and always in same fixed area in 1/3rd patients. [241. Fuh JL,07]


Photophobia, phonophobia, osmophobia, nausea and vomiting:


Photophobia, phonophobia and osmophobia stands for sensitivity to light, sounds and smell respectively. This occurs in migraine, but can be present in other types of headache too. Beckmann YY et al observed photophobia in 83.5% and phonophobia in 72.7% patients of chronic migraine. [18 Beckmann YY. 09] Porta-Etessam J et al noted that osmophobia was present in 54% patients of migraine without aura, 40% patients of chronic migraine and none of patients with migraine with aura and tension type headache. [2. Porta-Etessam J,09] In case of cluster headache, photophobia is present in 75-80% patients and phonophobia in nearly 50%. [75. Rozen TD, 01] Photophobia, phonophobia, nausea and vomiting is uncommon in tension type headache. [Bradley]


Photophobia or phonophobia can be unilateral. Irimia P et al noted that 4% patients of episodic migraine, 13% of chronic migraine and none of medication overuse headache had unilateral photophobia or phonophobia. In contrast, 48% chronic cluster headache, 80% episodic cluster headache, 55% hemicrania continua, 56% SUNCT and 67% of chronic paroxysmal hemicrania complained of the same. Thus, unilateral photophobia/ phonophobia is observed more commonly in trigeminal autonomic cephalgias than migraine and may be of diagnostic help.[90. Irimia P,08]


Diminution of vision:

Retinal migraine (also known as ocular or ophthalmic migraine) is characterized by fully reversible unilateral visual loss associated or followed by migraine headache. [179. Coroi M,07] Mostly occurs in women in the second to third decade of life. During the attack ipsilateral partial or complete visual loss lasting less than1 hour occur. Recurrent episodes may subsequently develop permanent monocular blindness in nearly half of them. [216. Grosberg BM,06] Approximately 25% of sufferers have a positive family history. [219. Lewinshtein D,04]


Suspect idiopathic intracranial hypertension (i.e increased intracranial pressure in the absence of intracranial mass or obstructive hydrocephalus) in patients of headache with pulsatile tinnitus, visual disturbance and papilloedema [82. Wang SJ, 98]. They may occasionally develop CSF rhinorrhea / otorrhoea [271. Jindal M, 09].


In case of Giant cell arteritis, visual impairment occurs in nearly 50% of patients, amaurosis fugax in 30%, and diplopia in 10%. An arteritic anterior ischemic optic neuropathy is found in about 80%-90% of patients with visual loss and an arteritic central retinal artery occlusion in rest 10%-20%. Without therapy, involvement of the other eye may occur within hours or days in a patient with monocular blindness. [141. Schmidt D,09] About 45% of patients with Giant cell arteritis present with symptoms of Polymyalgia rheumatic. [132. Schmidt WA.09] Jaw pain may occur while chewing (jaw claudication). [142. Vaith P,09]


Headache and transient visual loss can also be seen in ipsilateral internal carotid occlusion. [185. Tomsak RL. 91]

Vertiginous sensation:

Vertiginous sensation may occur during migraine attack. Vestibular migraine is an entity where episodic spontaneous or positional vertigo lasting seconds to days occur along with other migrainous features such as photophobia or auras, but often with absence of headaches. [1 Lempert T, 2009]


Postnasal drip:


It may occur in patients of acute sinusitis. Patients with chronic bacterial sinusitis rarely have any pain unless the sinus ostia are blocked and their symptoms are then the same as in acute sinusitis. [36 Jones NS,09]


Triggers:


It is important to know triggers for headache to avoid things that aggravate it, but more importantly it may help in diagnosis of headache itself. Stress, bright light, intense emotional influences and sleeping too much or too little are the trigger factors for headache in migraneurs. Women usually have more number of trigger factors than men. [20 Hauge A, 09]


Food:

Food items and food additives that trigger migraine include cheese, chocolate, citrus fruits, hot dogs, monosodium glutamate, aspartame, fatty foods, ice cream, caffeine withdrawal and alcohol (especially red wine and beer).[ 262. Millichap JG,03]


Menstruation:

In Premenstrual Syndrome, migraine without aura was the most common type of headache (60%), followed by tension type headache (30%). [39. Fragoso YD, 09] Onset of migraine with aura and tension headache is usually within first 2 days of menses, whereas that of common migraine is 2 days prior to onset of menses. Intensity of Migraine headache is more for during the first 2 days of menses. [79. Stewart WF, 00]


When menstruation is one of the trigger factor for migraine, it is called Menstrually-related migraine. Menstrually-related migraine begins at menarche in 33% of affected women. [62.Silberstein SD, 00] Migraine occurring exclusively at the onset of menstruation is called Pure Menstrual migraine. [61. Silberstein SD, 08] Both are considered to be due to fall in estrogen level and improve during pregnancy due to sustained estrogen levels. [62.Silberstein SD, 00}


Posture:

Low CSF pressure headache (Intracranial hypotension) typically become worse on assuming upright position and is relieved by lying supine. It usually occurs following lumbar puncture, but can also occur due to fistula draining CSF outside subarachnoid space. Patients of cluster headache avoid recumbent posture during attack as it aggravates headache. [Bradley]


Exertion:

Prevalence of headache increasing on exertion is nearly 12%. [252. Sjaastad O,03] About 90% of migraneurs may complain that their headache increases with exertion. [242. Kelman L.06] It can also occur in patients of subarachnoid hemorrhage, space occupying lesion in the brain, anomaly of the posterior fossa, cardiac cephalgia and headache associated with sexual activity.


Cardiac cephalalgia is headache associated with ischemic cardiovascular event, of which it may be the sole manifestation in 27%. It usually occurs after exertion and has no specific pattern of clinical features. Pain location is variable. This condition is suspected if chest pain, palpitations, breathless on exertion and sweating is present along with it. Occasionally, routine examination, cardiac enzymes, ECG and stress test may be negative, but coronary angiography may help in diagnosis. [ 205. Bini A,09] Therapeutic trial of nitroglycerin may be helpful. [258. Green MW.01] Coronary angioplasty may abolish the attacks completely. [238. Cutrer FM, 06]


Sexual activity:

Headache occurring on sexual activity is an uncommon form of headache. In one Indian study, only 24 patients were seen by the author in 20 years. Commonest type of headache was pre-orgasmic tension type headache seen in 58% of them. Masturbatory headache simulating tension headache was seen in 12.5% patients. Few had associated migraine and none had ever experienced exertional headache. [237. Chakravarty A.06]


Eating cold food:

Headache aggravated by eating ice cream or other cold food items is called ice cream headache. As much as 40% adolescents in age group 13-15 may have it. Prevalence is more in boys than in girls. It is present in higher frequency in those with migraine.[ 261. Fuh JL,03]


Fasting:

Headaches which occur on fasting and consequent hypoglycaemia are called fasting headaches. The probability of its onset increases directly with the duration of fasting. They have clinical features similar to tension-type headache. [31 Torelli P, 09]


Cough:

Headache occurring on cough usually occurs in Arnold Chiari malformation type 1. [14 Prat R, 09]


Relieving factors:


Physical exertion may relieve cluster headache. [Bradley] Indomethacin does wonders to relieve headaches of paroxysmal hemicrania, hemicrania continua, primary stabbing headache and hypnic headache. [256. Dodick DW.04]


Affect:


Patients of tension headache have greater amount of suppressed anger. [224. Hatch JP,91] Patients of medication overuse headache are more likely to anxiety, depression and obsessive-compulsive behaviour compared to those of episodic and chronic migraine.[ 206. Kaji Y,09][ 213. Cupini LM,09]


Timing of attacks:


Headache which is more in morning, aggravated by coughing/straining and associated with projectile vomiting is suggestive of raised intracranial tension.


Most episodes of migraine and chronic migraine start any time of day. [242. Kelman L.06] Attacks of Cluster headache and Hypnic headache usually occur at night especially in rapid eye movement sleep.[ 244. Cohen AS,04]


Hypnic headache is a rare sleep-associated primary headache disorder, usually affecting aged people. About 40% have unilateral headache. Patients usually get single or multiple headache attacks exclusively in sleep that too at a consistent time each night. In two-third of patients pain is mild-moderate and in the rest it is severe. Location is fronto-temporal in 40% of cases. Its character may be throbbing (38%), dull (57%) or stabbing (< 5%). Nausea occurs in 1/5th cases. Photophobia or phonophobia or both are present only 1/15th cases. Mild autonomic signs may rarely occur. [243. De Simone R,06]


About 18-74% patients of obstructive sleep apnoea syndrome complain of morning headache. Higher the apnoea-hypoapnoea index, more is the chance that patient will have morning headache.[270. Goksan B, 09]


Headache following trauma:


Post-traumatic Headache usually starts within 7 days following trauma. [38 Martins HA,09] It may have migraine (nearly 40%) [128. Martins HA,09] , tension-type (nearly 35%)[128. Martins HA, 09], cluster, cervicogenic headache etc like character. [124. Lenaerts ME, 04] Traumatic fracture of cribriform plate with leakage of CSF will result in low CSF pressure headache.


Headaches in patients of brain tumours:


Headache is present in nearly half of patients with brain tumour. In 4/5th of them, it resembles tension type headache and 1/10th of them simulate migraine. It is usually bifrontal and worse ipsilaterally. Headache is the worst symptom in half of the patients having it. [11 Forsyth PA, 93]


Seizures:


Headache in patients of epilepsy can be pre-ictal, ictal or (mostly) post-ictal symptom. [52. Cai S, 08] Younger age of onset of seizures is a risk factor for post-ictal headache.[ 68. Ito M, 00] Pre-ictal and post-ictal headaches are more frequently encountered in case of secondary generalized tonic-clonic seizures (GTCS) compared to other seizure types. Post-ictal headache is usually 'throbbing' in complex partial seizures and 'steady' in GTCS. [53. Karaali-Savrun F,02] Amongst the localisation related epilepsy, post-ictal headaches are more common with occipital lobe epilepsy than frontal or temporal lobe epilepsy. Peri-ictal headaches are usually ipsilateral to seizure onset in temporal lobe epilepsy than extra-temporal epilepsy. [67. Bernasconi A, 01]


Drugs History:


Drug which can cause headache include nitroglycerine, calcium channel blockers , immunoglobulins [46. Diener HC,06], sildenafil [47. Young WB, 04], carbachol [22 Schytz HW, 09], interferon beta [32 Doi H, 09], estrogens [62.Silberstein SD, 00], hyoscine [171. Ikeda K,09] etc. Drugs like non-steroidal anti-inflammatory drugs, intravenous immunoglobulins, lamotrigine, intrathecal agents and vaccines can lead to headache by causing aseptic meningitis. [41. Green MA,09] Some drugs like tetracyclines, steroids, nitrofurantoin, sulphonamides etc cause idiopathic intracranial hypertension. Oxcarbazepine can precipitate status migranosus in patients of migraine. [44. Piovesan EJ, 07]


Medication overuse headache is a condition that occurs in patients of headache who frequently consume drugs which are used in treatment of acute attack of headache. Incidence is more in females than males. [9Zeeberg P, 06] The delay between the frequent intake of anti-headache drug and daily headache is shortest for triptans (mean 1.7 years), longer for ergot alkaloids (mean 2.7 years) and longest for analgesics (mean 4.9 years). [49. Katsarava Z, 01] Those following migraine show better improvement than those following tension headaches. Triptan and ergot overuse headache shows better improvement after withdrawal as compared to analgesics. [9Zeeberg P, 06]


Concurrent medical illness:


Migraine can occur in patients of patent foramen ovale [19 Papa M, 09], Mitochondrial encephalopathy Lactic Acidosis and Stroke- like episodes (MELAS), Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) , photosensitive epilepsy [51. Piccioli M, 09], and Sussac syndrome. MELAS can present as migraine, stroke like episodes, diabetes mellitus, dementia, hemianopia and seizures. CADASIL presents as recurrent subcortical ischemic strokes, subcortical dementia, and migraine with aura. [174. Ueda M,09]


Migraine (41.2%) and tension-type headaches (20.6%) are the most common headaches in remission of Multiple Sclerosis, and primary stabbing headache (PSH) (27.8%) is common in the relapsing phase. Headache frequency in multiple sclerosis correlates with number of periventricular lesions. [26 Ergün U,09]


Personal history:


Cluster headache is common in patients who drink alcohol (2-3 times/week or more), smoke and whose parents used to smoke during childhood / adolescence of the patient. [13 Sjöstrand C, 09] Patients who abuse psychoactive drugs are more likely to develop tension type headache. [225. el-Mallakh RS,91]


Pregnancy:


Eclampsia, cortical venous sinus thrombosis, migraine and tension type headache are common causes of headache in pregnancy. [71. Silberstein SD, 04]


Family history:


Familial hemiplegic migraine is rare autosomal dominant inherited disease in which hemiplegia occur during migraine with aura attack.[Bradley] About 10% of patients of cluster headache also have a positive family history. [100. Leroux E, 08] Autosomal dominant transmission is occurs in CADASIL, while maternal transmission is occurs in MELAS.


Examination:


Blood pressure:

Hypertension can cause headache and if missed can lead to increased morbidity and mortality.


Obesity:

Obese migraneurs have frequent attacks compared to non-obese migraneurs. [158. Kinik S,09] Idiopathic intracranial hypertension is usually occur in obese females. [271. Jindal M, 09]


Sinus tenderness:

Look for sinus tenderness if acute sinusitis is suspected.


Subcutaneous nodules:

In a patient with partial seizures, headache and multiple subcutaneous nodules, suspect cysticercosis.


Scalp:

Patients of Giant Cell Arteritis who develop scalp necrosis have higher incidence of visual disturbance (nearly 67%) compared to those without necrosis (nearly 20%). Also, they have higher mortality. [133. Tsianakas A,09] Occasionally, tongue necrosis may also develop. [137. Brodmann M,09]


Nummular headache leads to trophic changes in the affected part of scalp in the form of round or oval patch of skin depression, hair loss, reddish discolouration, and increased local temperature. [202. Pareja JA,08]


Active trigger points are present in anterior and middle part of temporalis muscles in chronic tension headache. [186. Fernández-de-las-Peñas C,09]


Confusion:

Migraine associated with transient episodes of confusion and amnesia lasting 1-12 hours usually occurs in children and is called as acute confusional migraine. [72. Sheth RD, 95] However, in most patients of headache with confusion or altered sensorium, secondary causes of headache like meningitis, encephalitis, intracranial haemorrhage etc will have to be ruled out.


Papilloedema:

Papilloedema in a patient of headache is suggestive of raised intracranial tension and conditions like meningitis, intraparenchymal haemorrhage, cortical venous sinus thrombosis, idiopathic intracranial hypertension, malignant hypertension, brain tumours etc should be kept in mind. Thus, opthalmoscopic examination is one of the most important parts of clinical examination in a patient of headache.


Extraocular movements:

During acute attacks of vestibular migraine, there may be central spontaneous or positional nystagmus. [1 Lempert T, 2009]


Ophthalmoplegic migraine involves transient migraine-like headache accompanied often by long-lasting oculomotor, abducens or, rarely, trochlear nerve palsy in the absence of any demonstrable intracranial lesion. [152. Levin M, 04] [149. Bek S, 09] Pupillary abnormality and ptosis occur with oculomotor nerve involvement. Ophthalmoplegic migraine generally occurs in children and occasionally in adults. Prognosis is good because symptoms almost always resolve. However, some deficits may persist after several episodes. [152. Levin M, 04] Other causes of painful opthalmoplegia include cavernous sinus thrombosis, Tolosa-Hunt syndrome etc. Headache with acute oculomotor nerve palsy can occur with rupture of posterior communicating artery aneurysm. [185. Tomsak RL. 91]


Hemiparesis:

Hemiparesis in a patient of headache should prompt a search for secondary causes of headache. However, hemiplegic migraine and cluster headaches are known. [74. Siow HC, 2002] Hemiparesis is considered as motor aura in such cases. It usually lasts 20-30 minutes, but it may last for days together.[Bradley]


Ataxia:

Attacks of Basilar migraine presents as ataxia, dysarthria, vertigo and blindness with severe occipital headache. [Bradley]

In practise, headaches usually seen include secondary headaches, migraine and tension type headache. Other types of primary headache are rare. Sometimes, urgent neuroimaging is required to aid in diagnosis. Such conditions include:

1. Headaches in immuno-compromised patients.

2. Presence of neck stiffness, focal neurodeficit, altered sensorium.

3. Features suggestive of raised intracranial tension.

4. Abrupt change in already existing headache.

5. Any sudden onset severe headache especially in elderly.


Conclusion:

Headache is a symptom of varied aetiology. Detailed history and examination is helpful in the diagnosis of headache at the bedside.

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