Headache Classification and Management

Headache Basics & Classification - Head Start

• Primary Headaches: Headache is the illness; no underlying cause. 📌 P: Problem is the headache.
  • Types: Migraine, Tension-Type (TTH), Trigeminal Autonomic Cephalalgias (e.g., Cluster).
• Secondary Headaches: Symptom of another condition (e.g., infection, tumor, bleed). 📌 S: Symptom of something else.
  • Requires identifying and treating the underlying pathology.
• IHS Classification: International Classification of Headache Disorders (ICHD by IHS) is the standard.

⭐ Most common type of primary headache is Tension-Type Headache.

Primary Headaches: Migraine & TTH - Brain Pain Duo

• Migraine:

  • Diagnosis: ≥5 attacks (no aura), ≥2 (aura). Duration 4-72h.
  • 📌 POUND: Pulsatile, Often unilateral, Usually 4-72h, Nausea/vomiting, Disabling.
  • Aura: Reversible CNS sx (visual common); develop ≥5 min, last 5-60 min.
  • Chronic: ≥15 headache days/month (>3 months); migraine on ≥8 days.

  ⭐ Status migrainosus: debilitating migraine >72 hours.

• Tension-Type Headache (TTH):

  • Most common. Bilateral, pressing/tightening (non-pulsatile), mild-moderate. Not aggravated by activity.
  • Duration 30 min-7 days. No N/V; photophobia OR phonophobia (not both).

Migraine vs. TTH Comparison

Primary Headaches: TACs - TACs Attack

• Cluster Headache: Severe unilateral orbital/temporal pain, 15-180 min, up to 8/day.
  • 📌 CLUSTER: Conjunctival injection, Lacrimation, Unilateral, Sweating/autonomic sx, Temporal/orbital, Eight/day, Restlessness.
• Paroxysmal Hemicrania: Shorter (2-30 min), frequent attacks.
  • ⭐ > Absolute indomethacin response (e.g., 25-75 mg tid) is diagnostic.
• SUNCT/SUNA: Shortest (1-600 sec), very frequent, stabbing pain. SUNCT: +conjunctival injection & tearing.

Secondary Headaches & Red Flags - Danger Signals

• 📌 SNOOPPP Red Flags: Systemic symptoms/Secondary risk factors, Neurologic symptoms/signs, Onset sudden/abrupt, Older age of onset >50 years, Pattern change or recent onset, Positional, Precipitated by cough/sneeze/exercise, Papilledema.
• Key Secondary Causes:
  • Subarachnoid Hemorrhage (SAH): Thunderclap headache, neck stiffness.
  • Meningitis/Encephalitis: Fever, nuchal rigidity, altered mental status.
  • Giant Cell Arteritis (GCA): Age >50 years, new headache, jaw claudication, visual sx, tender temporal artery, ↑ESR/CRP.
  • Brain Tumor: Progressive, focal deficits, morning headache, papilledema.
  • Idiopathic Intracranial Hypertension (IIH): Obese young women, papilledema, visual changes, pulsatile tinnitus.

⭐ The 'worst headache of life' or 'thunderclap headache' is a classic presentation of subarachnoid hemorrhage and requires urgent neuroimaging.

Headache Management Approaches - Relief Roadmap

• Principles: Diagnosis, education, lifestyle modification.
• Migraine Management:

- Acute: NSAIDs, triptans (e.g., **sumatriptan 50-100mg PO**), CGRP antagonists (-gepants).
- Prophylactic: β-blockers (propranolol), TCAs (amitriptyline), anticonvulsants (topiramate, valproate), CGRP mAbs (-mabs), Botox (chronic).

• Cluster: Acute (100% O₂ 12-15L/min 15-20min, sumatriptan 6mg SC). Prophylactic: verapamil (1st line), corticosteroids, lithium.
• Tension-Type: Acute (analgesics, NSAIDs). Prophylactic: amitriptyline.

⭐ Verapamil is the first-line prophylactic agent for cluster headache and requires ECG monitoring.

High‑Yield Points - ⚡ Biggest Takeaways

• Tension-type headache (TTH): Most common; bilateral, non-pulsating. NSAIDs first-line.
• Migraine: Unilateral, pulsating, aura. Acute: Triptans, NSAIDs. Prophylaxis: Propranolol.
• Cluster headache: Severe, unilateral, periorbital pain, autonomic features. Acute: 100% Oxygen, Sumatriptan SC.
• Red flags (SNOOP4): Identify secondary headaches; e.g., sudden onset ("thunderclap"), neurological deficits.
• Subarachnoid hemorrhage (SAH): "Worst headache of life"; CT scan is key.
• Medication Overuse Headache (MOH): From frequent acute drug use (>10-15 days/month).