Headache

What is Headache?

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A migraine headache simply means a pain or discomfort felt in the head region -whether it is the face, back of the head (occiput), forehead, scalp, behind the eyes etc.A headache can also be caused by referral from the upper neck or even teeth and sinuses. A cluster headache can also be present even though there is no actual organic cause for it (e.g. depression).

Statistics on Headache?

Headache is a very common complaint and virtually all people will suffer headache at least occassionally throughout their lives. Almost 85% of the population would experience headache in a year and around 40% of adults will have had a headache within the previous 2 weeks. Headache is not always severe enough for patients to seek medical advice, but nevertheless a large number of doctor consultations are due to headaches. Approximately 3-5% of the worldwide population suffer daily headaches, which are associated with substantial disability, reduced quality of life and impaired physical, social, and occupational functioning.

Risk Factors for Headache

There are numerous causes of a headache, and they can be grouped in various ways. The commonest causes of headache, both acute or chronic, include:

Upper respiratory infection (acute).
Tension headache often described as a normal or ordinary headache felt as a band of tightness or pressure around the head.
Migraine: a severe headache often associated with nausea, vomiting and discomfort in bright lights.
Combination headache (combination of tension/depression, migraine, cervical dysfunction, and drugs).
Cervical dysfunction (referred pain from the back bones in the upper neck).
Cluster headache: an extremely unpleasant condition affecting 1 in 1000 men and 1 in 6000 women characterised by 6-12 week bouts (clusters) of pain around the eye, runny nose and eye watering.
Drugs (eg. caffeine, alcohol, high blood pressure tablets, stopping analgesics).
Depression.
Sinusitis.

In addition, the following causes are serious and must not be missed:

Subarachnoid haemorrhage, intracerebral haemorrhage (acute, sudden).
Extradural/Subdural haematomas.
Temporal arteritis.
Malignancies (brain tumours, other cancers eg. lung that have spread to the brain).
Severe infections (meningitis).
Benign intracranial hypertension.
Glaucoma.

Of course the above will vary with the age of the patient. Children are more likely to suffer from respiratory infections, while older people of glaucoma, temporal arteritis, malignancies etc.

Progression of Headache

The natural history of the headache largely depends on the cause. Acute causes, such as subarachnoid haemorrhage, meningitis, and epidural and subdural haematomas (after trauma) can occur suddenly (especially subarachnoid haemorrhage) and require immediate management, but will not cause repeated episodes.On the other hand, headache due to other causes, eg. tension headache, migraine, Depression, Cervical dysfunction will often recur and may lead to a chronic or recurrent headache. In addition, the chronic use of analgesics by patients may lead to a drug rebound headache (where the headache recurs when they discontinue the medications) which can also complicate matters.

How is Headache Diagnosed?

A clinical diagnosis is often possible of most causes of headache and investigations are usually not required. However, investigations are important for ruling out more serious causes of headache in selected patients.

Full blood count (FBC): A low Haemoglobin due to anaemia may be found or elevated white cells due to infection.
ESR: An elevated ESR is in keeping with temporal arteritis.

Prognosis of Headache

The prognosis is highly variable as well, which is why a careful history and examination is required to rule out serious causes.Causes such as subarachnoid haemorrhage and meningitis have high fatality rates, and causes such as glaucoma and temporal arteritis can result in blindness unless treated early. On the other hand, causes such as tension headache, migraine and Cervical dysfunction can cause long-term morbidity but are not life threatening.

How is Headache Treated?

Appropriate treatment is dependent on obtaining an accurate diagnosis. Treatment may vary from:

Urgent neurosurgical referral and treatment for epidural or subdural haematomas, subarachnoid haemorrhage and brain tumours.
Urgent IV antibiotics and supportive treatment for meningitis.
Corticosteroids for temporal arteritis.
Referral to an opthalmologist and measures to lower the pressure in the eye for glaucoma.
Psychotherapy, anti-depressants, and possible psychiatrist referral for depression.

Through to:

Simple analgesics and relaxation therapies for tension headache;
Simple analgesics, general measures, avoidance of precipitants, and specific medications and preventative medications for migraine.
Physical rehabilitation for cervicogenic headache.

The use of Spinal Cord Stimulation is currently being investigated for treatment of headaches.For more health information on Headache consult your local doctor.

Headache References

Bal S, Hollingworth G, 10-minute consultation- Headache, BMJ 2005;330:346.
Dodick D, Chronic Daily Headache, NEJM 2006;354;2: 158-165.
Kumar P, Clark M. Clinical Medicine. WB Saunders 2002.
Longmore, Wilkinson, Torok. Oxford Handbook of Clinical Medicine, 6th ed, Oxford University Press, United Kingdom 2004.
Murtagh, J. General Practice. Second Ed. McGraw-Hill, 1998.
Steiner T, Fontebasso M, Headache, BMJ 2002;325:881-886.