A headache or cephalgia is pain anywhere in the region of the head or neck. It can be a symptom of a number of different conditions of the head and neck.[1] The brain tissue itself is not sensitive to pain because it lacks pain receptors. Rather, the pain is caused by disturbance of the pain-sensitive structures around the brain. Several areas of the head and neck have these pain-sensitive structures, which are divided in two catego
ries: within the cranium (blood vessels, meninges, and the cranial nerves) and outside the cranium (the periosteum of the skull, muscles, nerves, arteries and veins, subcutaneous tissues, eyes, ears, sinuses and mucous membranes).
There are a number of different classification systems for headaches. The most well-recognized is that of the International Headache Society. Treatment of a headache depends on the underlying etiology or cause, but commonly involves analgesics.
ries: within the cranium (blood vessels, meninges, and the cranial nerves) and outside the cranium (the periosteum of the skull, muscles, nerves, arteries and veins, subcutaneous tissues, eyes, ears, sinuses and mucous membranes).There are a number of different classification systems for headaches. The most well-recognized is that of the International Headache Society. Treatment of a headache depends on the underlying etiology or cause, but commonly involves analgesics.
Classification
Headaches are most thoroughly classified by the International Headache Society's International Classification of Headache Disorders (ICHD), which published the second edition in 2004.[2] This classification is accepted by the WHO.[3]
Other classification systems exist. One of the first published attempts was in 1951.[4] The National Institutes of Health developed a classification system in 1962.[citation needed]
Headaches can also be classified by severity and acuity of onset. Headaches that are sudden and severe are known as thunderclap headaches.[5]
ICHD-2
Main article: International Classification of Headache Disorders
The International Classification of Headache Disorders (ICHD) is an in-depth hierarchical classification of headaches published by the International Headache Society. It contains explicit (operational) diagnostic criteria for headache disorders. The first version of the classification, ICHD-1, was published in 1988. The current revision, ICHD-2, was published in 2004.[6]
The classification uses numeric codes. The top, one-digit diagnostic level includes 14 headache groups. The first four of these are classified as primary headaches, groups 5-12 as secondary headaches, cranial neuralgia, central and primary facial pain and other headaches for the last two groups.[7]
NIH
Main article: NIH classification of headaches
The NIH classification consists of brief definitions of a limited number of headaches.[8]
[edit] Differential diagnosis
There are over 200 types of headache, and the causes range from harmless to life-threatening. The description of the headache, together with findings on neurological examination, determines the need for any further investigations and the most appropriate treatment.[9]
Other classification systems exist. One of the first published attempts was in 1951.[4] The National Institutes of Health developed a classification system in 1962.[citation needed]
Headaches can also be classified by severity and acuity of onset. Headaches that are sudden and severe are known as thunderclap headaches.[5]
ICHD-2
Main article: International Classification of Headache Disorders
The International Classification of Headache Disorders (ICHD) is an in-depth hierarchical classification of headaches published by the International Headache Society. It contains explicit (operational) diagnostic criteria for headache disorders. The first version of the classification, ICHD-1, was published in 1988. The current revision, ICHD-2, was published in 2004.[6]
The classification uses numeric codes. The top, one-digit diagnostic level includes 14 headache groups. The first four of these are classified as primary headaches, groups 5-12 as secondary headaches, cranial neuralgia, central and primary facial pain and other headaches for the last two groups.[7]
NIH
Main article: NIH classification of headaches
The NIH classification consists of brief definitions of a limited number of headaches.[8]
[edit] Differential diagnosis
There are over 200 types of headache, and the causes range from harmless to life-threatening. The description of the headache, together with findings on neurological examination, determines the need for any further investigations and the most appropriate treatment.[9]
Typical causes
The commonest types of headache are the "primary headache disorders", such tension-type headache and migraine. They have typical features; migraine, for example, tends to be pulsating in character, affecting one side of the head, associated with nausea, disabling in severity, and usually lasts between 3 hours and 3 days. Rarer primary headache disorders are trigeminal neuralgia (a shooting face pain), cluster headache (severe pains that occur together in bouts), and hemicrania continua (a continuous headache on one side of the head).[9]
The commonest types of headache are the "primary headache disorders", such tension-type headache and migraine. They have typical features; migraine, for example, tends to be pulsating in character, affecting one side of the head, associated with nausea, disabling in severity, and usually lasts between 3 hours and 3 days. Rarer primary headache disorders are trigeminal neuralgia (a shooting face pain), cluster headache (severe pains that occur together in bouts), and hemicrania continua (a continuous headache on one side of the head).[9]
Secondary causes
Headaches may be caused by problems elsewhere in the head or neck. Some of these are not harmful, such as cervicogenic headache (pain arising from the neck muscles). Medication overuse headache may occur in those using excessive painkillers for headaches, parodoxically causing worsening headaches.[9]
A number of characteristics make it more likely that the headache is due to potentially dangerous secondary causes; some of these may be life-threatening or cause long-term damage. A number of "red flag" symptoms therefore means that a headache warrants further investigations, usually by a specialist. The red flag symptoms are a 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 woken by headache, headache that worsens with changing posture, headache worsened by exertion or Valsalva manoeuvre (coughing, straining), visual loss or visual abnormalities, jaw claudication (jaw pain on chewing that resolves afterwards), neck stiffness, fever, and headaches in people with HIV, cancer or risk factors for thrombosis.[9]
"Thunderclap headache" may be the only symptom of subarachnoid hemorrhage, a form of stroke in which blood accumulated around the brain, often from a ruptured [[Intracranial berry aneurysmbrain aneurysm. Headache with fever may be caused by meningitis, particularly if there is meningism (inability to flex the neck forward due to stiffness), and confusion may be indicative of encephalitis (inflammation of the brain, usually due to particular viruses). Headache that is worsened by straining or a change in position may be caused by increased pressure in the skull; this is often worse in the morning and associated with vomiting. Raised intracranial pressure may be due to brain tumors, idiopathic intracranial hypertension (IIH, more common in younger overweight women) and occasionally cerebral venous sinus thrombosis. Headache together with weakness in part of the body may indicate a stroke (particularly intracranial hemorrhage or subdural hematoma) or brain tumor. Headache in older people, particularly when associated with visual symptoms or jaw claudication, may indicate giant cell arteritis (GCA), in which the blood vessel wall is inflamed and obstructs blood flow. Carbon monoxide poisoning may lead to headaches as well as nausea, vomiting, dizziness, muscle weakness and blurred vision. Angle closure glaucoma (acute raised pressure in the eyeball) may lead to headache, particularly around the eye, as well as visual abnormalities, nausea, vomiting and a red eye with a dilated pupil.[9]
Headaches may be caused by problems elsewhere in the head or neck. Some of these are not harmful, such as cervicogenic headache (pain arising from the neck muscles). Medication overuse headache may occur in those using excessive painkillers for headaches, parodoxically causing worsening headaches.[9]
A number of characteristics make it more likely that the headache is due to potentially dangerous secondary causes; some of these may be life-threatening or cause long-term damage. A number of "red flag" symptoms therefore means that a headache warrants further investigations, usually by a specialist. The red flag symptoms are a 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 woken by headache, headache that worsens with changing posture, headache worsened by exertion or Valsalva manoeuvre (coughing, straining), visual loss or visual abnormalities, jaw claudication (jaw pain on chewing that resolves afterwards), neck stiffness, fever, and headaches in people with HIV, cancer or risk factors for thrombosis.[9]
"Thunderclap headache" may be the only symptom of subarachnoid hemorrhage, a form of stroke in which blood accumulated around the brain, often from a ruptured [[Intracranial berry aneurysmbrain aneurysm. Headache with fever may be caused by meningitis, particularly if there is meningism (inability to flex the neck forward due to stiffness), and confusion may be indicative of encephalitis (inflammation of the brain, usually due to particular viruses). Headache that is worsened by straining or a change in position may be caused by increased pressure in the skull; this is often worse in the morning and associated with vomiting. Raised intracranial pressure may be due to brain tumors, idiopathic intracranial hypertension (IIH, more common in younger overweight women) and occasionally cerebral venous sinus thrombosis. Headache together with weakness in part of the body may indicate a stroke (particularly intracranial hemorrhage or subdural hematoma) or brain tumor. Headache in older people, particularly when associated with visual symptoms or jaw claudication, may indicate giant cell arteritis (GCA), in which the blood vessel wall is inflamed and obstructs blood flow. Carbon monoxide poisoning may lead to headaches as well as nausea, vomiting, dizziness, muscle weakness and blurred vision. Angle closure glaucoma (acute raised pressure in the eyeball) may lead to headache, particularly around the eye, as well as visual abnormalities, nausea, vomiting and a red eye with a dilated pupil.[9]
Pathophysiology
The brain in itself is not sensitive to pain, because it lacks pain receptors. However, several areas of the head and neck do have nociceptors, and can thus sense pain. These include the extracranial arteries, large veins, cranial and spinal nerves, head and neck muscles and the meninges.[10]
Headache often results from traction to or irritation of the meninges and blood vessels. The nociceptors may also be stimulated by other factors than head trauma or tumors and cause headaches. Some of these include stress, dilated blood vessels and muscular tension. Once stimulated, a nociceptor sends a message up the length of the nerve fiber to the nerve cells in the brain, signaling that a part of the body hurts. [11]
It has been suggested that the level of endorphins in one's body may have a great impact on how people feel headaches. Thus, it is believed that people who suffer from chronic headaches or severe headaches have lower levels of endorphins compared to people who do not complain of headaches.
The brain in itself is not sensitive to pain, because it lacks pain receptors. However, several areas of the head and neck do have nociceptors, and can thus sense pain. These include the extracranial arteries, large veins, cranial and spinal nerves, head and neck muscles and the meninges.[10]
Headache often results from traction to or irritation of the meninges and blood vessels. The nociceptors may also be stimulated by other factors than head trauma or tumors and cause headaches. Some of these include stress, dilated blood vessels and muscular tension. Once stimulated, a nociceptor sends a message up the length of the nerve fiber to the nerve cells in the brain, signaling that a part of the body hurts. [11]
It has been suggested that the level of endorphins in one's body may have a great impact on how people feel headaches. Thus, it is believed that people who suffer from chronic headaches or severe headaches have lower levels of endorphins compared to people who do not complain of headaches.
Headaches in children
Children can suffer from the same types of headaches as adults do although their symptoms may vary. Some kinds of headaches include: tension headaches, migraines, chronic daily headaches, cluster headache and sinuses headaches. [12] It is actually common for headaches to start in childhood or adolescence, for instance, 20% of adults who suffer headaches report that their headaches started before age 10 while 50% report they started before age 20. The incidence of headaches in children and adolescents is very common. One study reported that 56% of boys and 74% of girls between 12 and 17 indicated having experienced a form of headache within the past month. [13]
The causes of headaches in children include either one factor or a combination of factors. Some of the most common factors include: genetic predisposition, especially in the case of migraine; head trauma, produced by accidental falls; illness and infection, for example in the presence of ear or sinus infection as well as colds and flu; environmental factors, which include weather changes; emotional factors, such as stress, anxiety, and depression; foods and beverages, caffeine or food additives; change in sleep or routine pattern; loud noises. Also, excess physical activity or sun may be a trigger specifically of migraine. [14]
Although most cases of headaches in children are considered to be benign, when they are accompanied with other symptoms such as speech problems, muscle weakness, and loss of vision, a more serious underlying cause can be suspected. They include: hydrocephalus, meningitis, encephalitis, abscess, hemorrhage, tumor, blood clots, and head trauma. In these cases, the headache evaluation may include CT scan or MRI in order to look for possible structural disorders of the central nervous system. [15]
Some measures can help prevent headaches in children. Some of them are: drinking plenty of water throughout the day avoiding caffeine; getting enough and regular sleep; eating balanced meals at the proper times; and reducing stress and excess of activities. [16]
Children can suffer from the same types of headaches as adults do although their symptoms may vary. Some kinds of headaches include: tension headaches, migraines, chronic daily headaches, cluster headache and sinuses headaches. [12] It is actually common for headaches to start in childhood or adolescence, for instance, 20% of adults who suffer headaches report that their headaches started before age 10 while 50% report they started before age 20. The incidence of headaches in children and adolescents is very common. One study reported that 56% of boys and 74% of girls between 12 and 17 indicated having experienced a form of headache within the past month. [13]
The causes of headaches in children include either one factor or a combination of factors. Some of the most common factors include: genetic predisposition, especially in the case of migraine; head trauma, produced by accidental falls; illness and infection, for example in the presence of ear or sinus infection as well as colds and flu; environmental factors, which include weather changes; emotional factors, such as stress, anxiety, and depression; foods and beverages, caffeine or food additives; change in sleep or routine pattern; loud noises. Also, excess physical activity or sun may be a trigger specifically of migraine. [14]
Although most cases of headaches in children are considered to be benign, when they are accompanied with other symptoms such as speech problems, muscle weakness, and loss of vision, a more serious underlying cause can be suspected. They include: hydrocephalus, meningitis, encephalitis, abscess, hemorrhage, tumor, blood clots, and head trauma. In these cases, the headache evaluation may include CT scan or MRI in order to look for possible structural disorders of the central nervous system. [15]
Some measures can help prevent headaches in children. Some of them are: drinking plenty of water throughout the day avoiding caffeine; getting enough and regular sleep; eating balanced meals at the proper times; and reducing stress and excess of activities. [16]
Diagnosis approach
The American College of Emergency Physicians have guidelines on the evaluation and management of adult patients who have a nontraumatic headache of acute onset.[10]
While, statistically, headaches are most likely to be primary (non serious and self-limiting), some specific secondary headache syndromes may demand specific treatment or may be warning signals of more serious disorders.[citation needed] Differentiating between primary and secondary headaches can be difficult.
As it is often difficult for patients to recall the precise details regarding each headache, it is often useful for the sufferer to fill-out a "headache diary" detailing the characteristics of the headache.
The American College of Emergency Physicians have guidelines on the evaluation and management of adult patients who have a nontraumatic headache of acute onset.[10]
While, statistically, headaches are most likely to be primary (non serious and self-limiting), some specific secondary headache syndromes may demand specific treatment or may be warning signals of more serious disorders.[citation needed] Differentiating between primary and secondary headaches can be difficult.
As it is often difficult for patients to recall the precise details regarding each headache, it is often useful for the sufferer to fill-out a "headache diary" detailing the characteristics of the headache.
Imaging
When the headache does not clearly fit into one of the recognized primary headache syndromes or when atypical symptoms or signs are present then further investigations are justified.[17] Neuroimaging (noncontrast head CT) is recommended if there are new neurological problems such as decreased level of consciousness, one sided weakness, pupil size difference, etc. or if the pain is of sudden onset and severe, or if the person is known HIV positive.[10] People over the age of 50 years may also warrant a CT scan.[10]
When the headache does not clearly fit into one of the recognized primary headache syndromes or when atypical symptoms or signs are present then further investigations are justified.[17] Neuroimaging (noncontrast head CT) is recommended if there are new neurological problems such as decreased level of consciousness, one sided weakness, pupil size difference, etc. or if the pain is of sudden onset and severe, or if the person is known HIV positive.[10] People over the age of 50 years may also warrant a CT scan.[10]
Acute headaches
Not all headaches require medical attention, and most respond with simple analgesia (painkillers) such as paracetamol/acetaminophen or non-steroidal anti-inflammatory drugs like aspirin, ibuprofen, or diclofenac.[citation needed]
Not all headaches require medical attention, and most respond with simple analgesia (painkillers) such as paracetamol/acetaminophen or non-steroidal anti-inflammatory drugs like aspirin, ibuprofen, or diclofenac.[citation needed]
Chronic headaches
See also: Management of chronic headaches
In recurrent unexplained headaches keeping a "headache diary" with entries on type of headache, associated symptoms, precipitating and aggravating factors may be helpful. This may reveal specific patterns, such as an association with medication, menstruation or absenteeism or with certain foods. It was reported in March 2007 by two separate teams of researchers that stimulating the brain with implanted electrodes appears to help ease the pain of cluster headaches.[18]
Acupuncture has been found to be beneficial in chronic headaches[19] of both tension type[20] and migraine type.[21] Whether or not there is a difference between true acupuncture and sham acupuncture however is yet to be determined.[21]
One type of treatment, however, is usually not sufficient for chronic sufferers and they may have to find a variety of different ways of managing, living with, and seeking treatment of chronic daily headache pains. [22]
There are however two types of treatment for chronic headaches meaning acute abortive treatment and preventive treatment. Whereas the first is aimed to relieve the symptoms immediately, the latter is focused on controlling the headaches that are chronic. From this reason, the acute treatment is commonly and effectively used in treating migraines and the preventive treatment is the usual approach in managing chronic headaches. The primary goal of preventive treatment is to reduce the frequency, severity, and duration of headaches. This type of treatment involves taking medication on a daily basis for at least 3 months and in some cases, for over 6 months. [23] The medication used in preventive treatment is normally chosen based on the other conditions that the patient is suffering from. Generally, medication in preventive treatment starts at the minimum dosage which increases gradually until the pain is relieved and the goal achieved or until side effects appear.
To date, only amitriptyline, fluoxetine, gabapentin, tizanidine, topiramate, and botulinum toxin type A (BoNTA) have been evaluated as "prophylactic treatment of chronic daily headache in randomized, double-blind, placebo-controlled or active comparator-controlled trials. Antiepileptics can be used as preventative treatment of chronic daily headache and includes Valproate. [24]
Psychological treatments are usually considered in comorbid patients or in those who are unresponsive to the medication
See also: Management of chronic headaches
In recurrent unexplained headaches keeping a "headache diary" with entries on type of headache, associated symptoms, precipitating and aggravating factors may be helpful. This may reveal specific patterns, such as an association with medication, menstruation or absenteeism or with certain foods. It was reported in March 2007 by two separate teams of researchers that stimulating the brain with implanted electrodes appears to help ease the pain of cluster headaches.[18]
Acupuncture has been found to be beneficial in chronic headaches[19] of both tension type[20] and migraine type.[21] Whether or not there is a difference between true acupuncture and sham acupuncture however is yet to be determined.[21]
One type of treatment, however, is usually not sufficient for chronic sufferers and they may have to find a variety of different ways of managing, living with, and seeking treatment of chronic daily headache pains. [22]
There are however two types of treatment for chronic headaches meaning acute abortive treatment and preventive treatment. Whereas the first is aimed to relieve the symptoms immediately, the latter is focused on controlling the headaches that are chronic. From this reason, the acute treatment is commonly and effectively used in treating migraines and the preventive treatment is the usual approach in managing chronic headaches. The primary goal of preventive treatment is to reduce the frequency, severity, and duration of headaches. This type of treatment involves taking medication on a daily basis for at least 3 months and in some cases, for over 6 months. [23] The medication used in preventive treatment is normally chosen based on the other conditions that the patient is suffering from. Generally, medication in preventive treatment starts at the minimum dosage which increases gradually until the pain is relieved and the goal achieved or until side effects appear.
To date, only amitriptyline, fluoxetine, gabapentin, tizanidine, topiramate, and botulinum toxin type A (BoNTA) have been evaluated as "prophylactic treatment of chronic daily headache in randomized, double-blind, placebo-controlled or active comparator-controlled trials. Antiepileptics can be used as preventative treatment of chronic daily headache and includes Valproate. [24]
Psychological treatments are usually considered in comorbid patients or in those who are unresponsive to the medication
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