Chapter

113

Clinical Approach to a Patient

with Headache
Gurubax Singh, Pritam Gupta, Ankur Gupta, Manoj Khanal

Every head has its own headache

The above sums up the clinical approach to the headache in the
sense that majority of diagnostic and treatment modalities in the
management of headache are at best a generalized approach and
each individual patient might be a different experience by itself.
However, a good clinical algorithm helps us to reach at a reasonably
good diagnosis.

CLINICAL APPROACH
The brain tissue itself is not sensitive to pain because it lacks
pain receptors. Nine areas of head and neck have pain sensitive
structuresperiosteum of the skull, muscles, nerves, arteries, veins,
subcutaneous tissues, eyes, ears, sinuses and mucous membranes.
Headache often results from traction/irritation of the meninges and
blood vessels.
Headache disorders are classified as primary or secondary.1 The
primary headache disorders do not have an underlying structural
cause. The diagnosis of headache depends upon three elements: the
history, examination and appropriate investigations.

History1,2
The gold standard for diagnosis and management of headache is a
careful interview and clinical examination. In majority of patients,
clinical examination is expected to be normal and hence, diagnosis
is based entirely on history. Hence, a great deal of time is expected
to be spent on history. The history is on standard lines, but certain
questions, which are of relevance, are: types 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, details of the
treatment, etc.

Onset of Headache
A stable headache disorder of many-year duration would almost
always be a benign headache. Migraine headache often begins in
childhood, adolescence or adulthood, and not in old age. A headache
of recent onset can be a headache of benign origin or due to a more
sinister cause but that would be evident only with the passage of
time. In general, the more recent the headache, more worrisome
it is. Thumb of rule is that following features point to possible nonbenign pathologies:1,2 the worst ever headache, increasingly severe
headache or change for worse in an existing headache, instantaneous

headache and onset of headache in a patient older than 55 years of

age.

Temporal Profile
A chronic daily headache without migrainous or autonomic features
is likely to represent a chronic tension-type headache. Migraine pain
usually peaks within 12 hours of onset and typically lasts for 472
hours. Cluster headache is typically at its peak at onset or within
minutes. These generally last for 15180 minutes. Headache similar
to cluster headaches but lasting only for 230 minutes and occurring
several times a day are typical of episodic or chronic paroxysmal
hemicrania. Primary stabbing headaches are transient, momentary,
lasting only for seconds in absence of any organic disease. A chronic
headache that is continuous, unilateral, is of moderate severity and
is superimposed by attacks of more intense pain, associated with
autonomic features suggests hemicrania continua, an indomethacinresponsive headache. Occipital and trigeminal neuralgia manifest as
brief electric shock-like pains.

Time of the Day

Cluster headaches often awake the patient from sleep and have
almost clock-like periodicity. Hypnic headaches also awake the
patient from sleep with periodicity, but they are usually diffuse and
not associated with autonomic phenomenon. Migraine can occur
at any time, but usually start in the morning. Chronic tension-type
headache is typically present during day and is most severe in the
later part of the day. A headache of recent onset that disturbs sleep
or is worse on waking may be caused by increased intracranial
pressure.

Location
Location of the pain gives some clue to the possible diagnosis.
Migraine commonly is unilateral and may confine to the front or
the back of head. Alternatively, the pain can start on one side and
then can spread to the other side. Occasionally, the pain can be
global at onset. Cluster headaches are unilateral during the attack
and are typically located in and around the eyes. The tension-type of
headache is generalized; although it may begin in the neck and affect
chiefly the occipital region or predominate frontally. Trigeminal
neuralgia is confined to one or more branches of trigeminal nerves.

Quality of Pain
Migraine pain often has a pulsating quality that may be superimposed
on a more continuous pain. The pain of cluster headache is severe,

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Chapter 113 Clinical Approach to a Patient with Headache

boring and steady. Short-lasting unilateral neuralgiform headache

with conjunctival injection and tearing (SUNCT) produces more
moderately severe pain in the orbital or temporal region and may
be described as sharp or stabbing pain. Tension-type headache
is generally described as steady feeling of tightness or pressure.
Trigeminal neuralgias produce severe brief sharp, electric shock-like
or stabbing.

Aggravating Factors
The worsening of headache as a result of coughing or physical jolt
suggests an intracranial component to pain. Sufferers of cluster
headache tend to endure their patience in an agitated state, pacing
and moving about. On the contrary, patients with migraine prefer
to lie still. Precipitation or worsening in upright position suggests
intracranial hypotension. Routine physical activity, light, sound and
smell aggravates migraine attacks.

Physical Examination2,3
Vital signs including temperature are measured. General appearance
(e.g. whether restless or calm in a dark room) is noted. A general
examination, with a focus on the head and neck, and a full neurologic
examination are done. The body habitus should be seen. Patient with
pseudotumor cerebri tend to be obese females. The scalp is examined
for areas of swelling and tenderness. The ipsilateral temporal artery
is palpated for thickness and tenderness. Both temporomandibular
joints are palpated for tenderness and crepitance while the patient
opens and closes the jaw. The area over the infected sinus may be
tender. The scalp may be tender in both migraine and tensiontype headache. A short neck or low hairline may indicate basilar
invagination or Chiari malformation. The eyes and periorbital area
are inspected for lacrimation, flushing and conjunctival injection.
Pupillary size and light responses, extraocular movements and
visual fields are assessed. The fundi are checked for spontaneous
venous pulsations and papilledema. If patients have vision-related
symptoms or eye abnormalities, visual acuity is measured. If the
conjunctiva is red, the anterior chamber and cornea are examined
with a slit lamp if possible, and intraocular pressure is measured. The
nares are inspected for purulence (infected sinuses). The oropharynx
is inspected for swellings, and the teeth are percussed for tenderness.
Neck is flexed to detect discomfort, stiffness or both, indicating
meningismus. The cervical spine is palpated for tenderness.

Investigations
Most patients can be diagnosed without testing. However, some
serious disorders may require urgent or immediate testing. Some
patients require tests as soon as possible. Computed tomography
(CT) or magnetic resonance imaging (MRI) should be done in
patients with any of the following findings:1-3
Thunderclap headache
Altered mental status
Meningismus
Papilledema
Signs of sepsis (egg, rash, shock)
Acute focal neurologic deficit
Severe hypertension (egg, systolic blood pressure > 220 mm Hg or
diastolic pressure > 120 mm Hg on consecutive readings).
In addition, if meningitis, subarachnoid hemorrhage or
encephalitis is being considered, lumbar puncture and cerebrospinal
fluid (CSF) analysis should be done if not contraindicated by imaging
results. Tonometry should be done if findings suggest acute narrowangle glaucoma (e.g. visual halos, nausea, corneal edema, shallow
anterior chamber). Other testing should be done within hours or
days, depending on the acuity and seriousness of findings and
suspected causes. Erythrocyte sedimentation rate (ESR) should be

done if patients have visual symptoms, jaw or tongue claudication,

temporal artery signs or other findings suggesting giant cell
arteritis. CT of the paranasal sinuses is done to rule out complicated
sinusitis if patients have a moderately severe systemic illness (e.g.
high fever, dehydration, prostration, tachycardia) and findings
suggesting sinusitis (e.g. frontal, positional headache, epistaxis,
purulent rhinorrhea). Lumbar puncture and CSF analysis are done if
headache is progressive and findings suggest idiopathic intracranial
hypertension (e.g. transient obscuration of vision, diplopia, pulsatile
intracranial tinnitus) or chronic meningitis (e.g. lethargy, vomiting,
focal neurologic deficits).

CLASSIFICATION OF HEADACHE
(BY INTERNATIONAL HEADACHE SOCIETY)4,5
Primary Headaches
The most common types of headache are the primary headache
disorders. Primary headaches are usually recurrent. They have
typical features as described in Table 1.

Secondary Headaches
The causes are as described in Table 2 and their characteristics are
described in Table 3.

RED FLAG SYMPTOMS

A red flag symptom means that a headache warrants further
investigations.
New or different headache in someone over 50 years old
Headache that develops within minutes (thunderclap headache)
Inability to move a limb or abnormalities on neurological
examination
Mental confusion
Being awakened by headache
Headache that worsens with changing posture
Headache that worsens by exertion or Valsalva maneuver
(coughing, straining)
Visual loss or visual abnormalities
Jaw claudication
Neck stiffness
Fever
Headaches in people with HIV
Headaches in people with cancer or risk factors for thrombosis.

TREATMENT APPROACHES IN HEADACHE

The treatment of patients with headache requires a great deal of
understanding of the causative factors and understanding of the
lifestyle attributes of the patient. Depending on the headache type,
one would be prescribed medicines to terminate the headache
episode (abortive treatment) or to prevent the occurrence of
headache (prophylactic treatment). Not all patients require
prophylactic treatment. The decision is largely based on frequency
of headache and also the perceived disability. One should not
overlook the possibility of analgesic abuse. Prevention of triggers is
an important factor in the treatment protocol. Lifestyle modification
especially regular diet, reduction in smoking, alcohol, avoidance
of estrogen contraceptives if possible, etc. go long way in the
overall management. Medical treatment of more common primary
headache types is summarized below.

Drug Therapy
Analgesic and Abortive Medications
The most common chronic treatment method is the use of medicine.
Many people try to seek pain relief from analgesic medicines

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Section 16

TABLE 1Primary headache disorders characteristics

Cause

Clinical findings

Diagnostic approach

Migraine

Frequently unilateral, pulsating/throbbing, lasting for 472 hours, occasionally with aura,
photophobia, phonophobia, osmophobia, worse with activity, preference to lie in the dark,
resolution with sleep

Clinical evaluation

Tension-type
headache

Frequent or continuous, mild, bilateral, ban-like holocranial, occipital or frontal pain that spreads
to entire head, worse at the end of the day

Clinical evaluation

Cluster headache

Unilateral orbitotemporal attacks at the same time of day, deep, severe lasting 30180 min,
often with lacrimation, facial flushing, Horners syndrome, restlessness, cannot sit still in a place

Clinical evaluation

TABLE 2Disorders causing secondary headache

Cause

Examples

Extracranial
disorders

Carotid or vertebral artery dissection (associated

neck pain)
Dental disorders (infection, temporomandibular joint
dysfunction
Glaucoma
Sinusitis

Intracranial
disorders

Brain space occupying lesion (SOLs)

Chiari Type 1 malformation
Cerebrospinal fluid leak with low-pressure headache
Hemorrhage (intracranial, subdural, subarachnoid)
Idiopathic intracranial hypertension
Infections (meningitis, encephalitis, abscess,
subdural empyema)
Noninfectious meningitis (carcinomatous, chemical)
Obstructive hydrocephalus
Vascular disorders (e.g. vascular malformations,
vasculitis, venous sinus thrombosis)

Systemic
disorders

Acute severe hypertension

Fever
Giant cell arteritis
Hypercapnia
Viral infections

Drugs and
toxins

Analgesics overuse
Caffeine withdrawal
Carbon monoxide
Hormones (estrogen)
Nitrates
Proton pump inhibitors

(commonly termed pain killers), such as aspirin, acetaminophen,

aspirin compounds, ibuprofen and narcotics. However, medical
professionals advise that abuse of analgesics and abortive
medications can actually lead to an increase in headaches. The
painkiller medicines relieve headaches temporarily, but gradually
headaches become more recurrent and grow in intensity (rebound
headaches). There are certain specific treatments for migraines,
which are given as follows:
Analgesics: Aspirin, acetaminophen
NSAIDs: Naproxen, ibuprofen
5-HT1 agonists-oral: Ergotamine, rizatriptan, naratriptan,
zolmitriptan
5-HT1 agonists-nasal: Dihydroergotamine, sumatriptan,
zolmitriptan
5-HT1 agonists-parenteral: Dihydroergotamine, sumatriptan
Dopamine antagonists: Metoclopramide, prochlorperazine.

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unresponsive, if attack frequency is more than five a month, or in

migraine variants such as hemiplegic migraine or rare headache
attacks producing profound disruption or risk of permanent
neurological injury.

Treatment: Chronic Tension-Type Headache1,2

Since tension-type headache is considered to be related to
disorder of central nervous system pain modulation, relaxation
techniques can be useful in patients with tension-type headache.
The usual abortive treatment can be any simple analgesic (aspirin,
NSAIDs, acetaminophen). The most effective prophylactic drug is
amitriptyline in the dosage of 50150 mg per day. Lower dosage may
be tried initially. Other drugs are tricyclic antidepressants (TCAs),
gabapentin, mirtazapine, topiramate. Botulinum toxin has been
tried but is not of proven benefit.

Cluster Headache1-3
Since the time to peak is rapid, fast-acting symptomatic treatment
is imperative. Options are nasal oxygen (810 L/min), sumatriptan
(subcutaneous 6 mg) and dihydroergotamine (subcutaneous or
intramuscular). Preventive therapy could be transitional prophylaxis
(short-term use of drugs to tide over the crisis (with steroids or
dihydroergotamine) or maintenance prophylaxis with agents
throughout the entire expected duration of cluster headache. The
maintenance prophylactic agents include calcium channel blockers
(verapamil 80 mg three times a day to a maximum dose of 720 mg
per day; monitor with ECG if total daily dose is more than 480 mg/
day), methylsergide, lithium (300 mg three times daily; monitor
with lithium levels), topiramate (100400 mg/day), gabapentine
(1,2003,600 mg/day), melatonin (912 mg/day) (Table 4).
Neurostimulation strategies have been employed in patients who fail
on above prophylactic therapies.

Nonpharmacological Treatment1,2,6-9
Physical Therapy
In addition to medicines, physical therapy is a treatment to help
improve chronic headaches. In physical therapy, a patient works
together with a therapist to help identify and change physical habits
or conditions that affect chronic headaches. Therapists use manual
therapy, such as a massage, stretching or joint movement to release
muscle tension. Other methods to relax muscles include heat packs,
ice packs and electrical stimulation. In physical therapy, the patient
must take an active role to practice exercises and make changes to his
or her lifestyle for there to be improvement.

Preventive Therapy in Migraine1,2

Acupuncture

One should consider preventive therapy in patients with migraine

if patient has increasing frequency of headache, if attacks are

Another nonmedicinal treatment, which does not require athome exercises, is acupuncture. Acupuncture involves a certified

Chapter 113 Clinical Approach to a Patient with Headache

Section 16
TABLE 3Secondary headache disorders characteristics
Cause

Clinical findings

Diagnostic approach

Acute angle-closure
glaucoma

Unilateral, halos around lights, decreased visual acuity, conjunctival injection,

vomiting

Tonometry

Encephalitis

Fever, altered mental status, seizures, focal neurological deficits

MRI brain (contrast), CSF analysis

Meningitis

Fever, meningismus, altered mental status

MRI brain (contrast), CSF analysis

Giant cell arteritis

Age > 55 years

Unilateral throbbing pain when combing hair, visual symptoms or jaw claudication,
fever, weight loss, sweats, temporal artery tenderness, proximal myalgia

MRI brain (contrast),

ESR, temporal artery biopsy

IIH

Migraine-like headache, diplopia, pulsatile tinnitus, loss of peripheral vision,

papilledema

MRI brain + MRV followed by

measurement of CSF opening
pressure

Intracerebral
hemorrhage

Sudden onset vomiting, focal neurological deficits, altered mental status

NCCT head

Sinusitis

Positional, facial or tooth pain, fever, purulent rhinorrhea

Clinical evaluation
CT PNS

SAH

Thunderclap headache
Vomiting
Syncope
Obtundation
Meningismus

NCCT head
CSF if imaging nondiagnostic)

Chronic SDH

Sleepiness, focal neurological deficits, altered mental status, papilledema

Presence of risk factors (old age, coagulopathy, dementia, anticoagulant use,
ethanol abuse)

NCCT head
MRI brain

Brain tumor or mass

(SOLs)

Focal neurological deficits, altered mental status, papilledema, seizures, vomiting,

diplopia when looking laterally

MRI brain (contrast)

Abbreviations: MRI, Magnetic resonance imaging; CSF, Cerebrospinal fluid; ESR, Erythrocyte sedimentation rate; IIH, Idiopathic intracranial hypertension;
MRV, Magnetic resonance venography; NCCT, Non-contrast computed tomography; PNS, Paranasal sinuses; SAH, Subarachnoid hemorrhage; SDH, Subdural
hematoma; SOLs, Space occupying lesions

TABLE 4Preventive drugs for headache

Drug

Dosage

Selected side effects

Beta-blocker: Propranolol
Tricyclics: Amitriptyline
Tricyclics: Nortriptyline
Anticonvulsants: Topiramate
Anticonvulsants: Valproate
Anticonvulsants: Gabapentin
Serotonergic drugs: Methysergide
Serotonergic drugs: Flunarizine

40120 mg bid
1075 mg at night
2575 mg at night
25200 mg/day
400600 mg bid
9003,600 mg/day
14 mg/day
515 mg/day

Tiredness, postural hypotension

Drowsiness, urinary retention
Drowsiness, urinary retention
Paraesthesias, cognitive symptoms, glaucoma, weight loss
Tremors, weight gain, drowsiness
Dizziness, sedation
Drowsiness, leg cramps, hair loss, retroperitoneal fibrosis
Drowsiness, parkinsonism, depression

acupuncturist picking particular points on the body to insert

acupuncture needles; these points may differ on an individual basis.
With chronic headache patients, the acupuncturist may needle
tender points at or near the site of maximal headache. Some studies
have shown benefits of acupuncture but are not unequivocal.

Relaxation Training
Relaxation training helps to reduce internal tension, allowing
a person to control headache triggered by stress. The different
relaxation methods are normally taught by a psychologist or a
therapist. Relaxation training works as people become in tune with
their own body, allowing them to realize when it is necessary to
decrease tension before a headache occurs. The point of relaxation
training is to teach people an attitude of consciously setting out to
relax but not trying too hard, enabling people to relax in everyday

situations. Relaxation training includes two different types of

methods: (1) physical and (2) mental.

Biofeedback
Biofeedback is often used to evaluate the effectiveness of
relaxation training, because it feeds back information to the
chronic headache sufferer about the bodys (biological) current
state. Common biofeedbacks used are electromyograph (EMG),
electroencephalograph (EEG), thermograph, etc. Biofeedback
methods have been proven to work. They allow headache sufferers to
identify problems and then seek to reduce them.

Changes in Diet
Many chronic headache sufferers fail to recognize foods or beverages
as headache factors, because the consumption may not consistently

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cause headaches or the headaches may be delayed. Many of the
chemicals in certain foods can cause chronic headaches, including
caffeine, monosodium glutamate (MSG), nitrites, nitrates, tyramine
and alcohols. Some of the foods and beverages that chronic headache
sufferers are advised to avoid include caffeinated beverages,
chocolate, processed meats, cheese and fermented dairy products,
fresh yeast-risen baked goods, nuts and alcohol as well as certain
fruits and vegetables. Additionally, people may have differing dietary
triggers on an individualized basis.

Behavioral Therapy and Psychological Therapy

Also, behavioral therapy and psychological therapy are suggested
treatments to reduce chronic headaches. These include a combination
of identifying headache stressors, biofeedback, relaxation training
and cognitive-behavioral therapy. Psychological and behavioral
therapies identify stressful situations and teach chronic headache
patients to react differently, change their behavior, or adjust attitudes
to reduce tension that leads to headaches. Treatments especially
focus on emotional, mental, behavioral and social factors. It is
important to look at the psychological status of a chronic headache
sufferer to identify conditions that might interfere with headaches
and treatments, such as depression. Also, psychological therapy
suggests training in self-hypnosis. While hypnotized, patients are
given suggestions to relax and use visual imagery to control headache
mechanisms. Psychological therapists also analyze personal issues
making him or her unable to make changes in lifestyle to improve
headaches.
To sum up, headache management involves multimodality
treatment especially in chronic patients. Every individual patient
is a challenge in himself/herself. The most important component
is careful patient listening and reaching a correct diagnosis.

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Investigations are at best ancillary and should not be the primary
focus in reaching a diagnosis.

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