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Headache is one of the most common presenting symptoms of neurological disorders. Whereas the majority of them are innocuous and need only symptomatic treatment, some can be a sign of serious underlying disorders and therefore headaches should always be taken seriously. A headache is a pain in the head radiating above the eyes or the ears, behind the head or in the back of the upper neck.Primary headaches are not associated with any underlying major disease. Examples of primary headaches are tension headaches, migraine and Cluster headches. Secondary headaches are caused due to some other underlying disease. These may be minor ones such as uncorrected ophthalmic refractory error, sinusitis, withdrawal from caffeine and discontinuation of analgesics. They may also be symptomatic of major illnesses such as brain tumors, strokes, meningitis, and subarachnoid hemorrhages.

Common types of Headaches

It is the most common type of headache and occurs due to muscle tension producing ischemia of the scalp and facial muscles. It may have a band like discomfort and is not associated by any other symptom, patient is able to continue his/her normal activity. This type of headache builds slowly and may become These are generalized headaches of gradual onset and can be of mild to moderate severity. They are described by the patients as aching or pressure type of headache and are always non pulsatile. They last from one to two hours and occur during the later part of the day. They may be associated with grinding of the teeth, lack of sleep and difficulty in concentration. There is always some major underlying emotional or psychological cause which may be family or work related. Neurological examination does not reveal any abnormality.

Migraine is an inflammatory disorder of the brain and its blood vessels, which results in hyper reactivity of the cerebral blood vessels. It is classified as a common migraine (migraine without aura), classical migraine (migraine with aura) and complex migraine. Classical migraine headaches are throbbing in nature, mostly unilateral and often associated with flashes of light. Aura, nausea and vomiting, photo/phonophobia, scalp tenderness may be present in some of the cases. In the complicated migraine there are associated neurological signs and symptoms caused by vasoconstriction of intracranial vessels such as confusion, amnesia, transient monocular blindness, hemiparesis and limb paraesthesias. Migraine can be precipitated by red wine,menses,hunger,insomnia,perfumes, etc. A migraine typically lasts from 4 to 72 hours.

These are episodic pain attacks at periorbital region it is usually excrutiating and deep and pulsatile in nature,pain is unilateral and lasts for 30 minutes to 2 hours.there are associated symptoms like lacrimation,redness of eye,nasal stuffiness,ptosis,and nausea.Alcohol provokes the attack.

Headache due to Sinusitis

These are bifrontal headaches which are gradual in onset, moderate in severity, dull and boring in nature and associated with pain or pressure in the face. There is history of frequent cold with nasal discharge. Presence of tenderness on the sinuses (frontal,maxillary), sides of the nose is noticed on examination.

Headaches due to Hypertension

One of the early signs of Hypertension are Headaches. The classical feature of Hypertension headaches is that they occur early in the morning. They may present as pressure just behind the eyes or as headaches at the back of the head. They are sometimes associated by dizziness and palpitations . The headache may be mild or severe and occur more commonly in women than men. Any patient over 50 presenting with morning headaches should always have their blood pressure checked.

Trigeminal Neuralgia

Unilateral severe lancinating pain around the face, lips, gums. It is aggravated by a tickle or touch, pain burst happen over seconds to minutes with a refractory period afterwards. There may be associated flushing, salivation or lacrimation.

Headache due to uncorrected refractory error

The headache comes as after watching TV, reading for long. Is dull, aching, bilateral and may be bifrontal or generalized.

Headaches due to serious underlying conditions

Conditions causing secondary headaches are brain stroke, subarachnoid intracranial hemorrhage , brain tumors, meningitis, severe high blood pressure. These can cause Neurological Disorders – A Handbook for Family Physicians serious brain damage or even death. Thus, timely and accurate diagnosis of secondary headaches is crucial. Special blood tests, brain scans, and lumbar puncture (spinal tap) are necessary to establish these diagnoses. One should rely upon information obtained from the initial patient history and physical examination.

Common causes of serious headache

Sentinel headache due to subarachnoid haemorrhage

Sentinel headache (SH) is characterized as sudden (thunderclap headache), intense, and persistent headache, preceding spontaneous subarachnoid hemorrhage (SAH) by days or weeks. It is often described as the “worst headache of my life”. It is the most common symptom to manifest 10-20 days before rupture of an aneurysm. In addition to headaches, sentinel leaks may produce nausea, vomiting, photophobia, malaise, or neck pain. These symptoms can easily be ignored by a physician. Therefore, a high index of suspicion is necessary to diagnose this type of headache due to subarachnoid haemorrhage. The possibility of SAH should be suspected if any one or more of these is present along with acute nontraumatic headache which reaches maximum intensity within one hour, and the patient be referred to a neurophysician and hospitalized immediately.

Acute severe type of headache with neck stiffness and fever suggests meningitis. Meningitis may be mistaken as migraine sometimes due to the chief symptoms like pounding headache, photophobia, nausea, vomiting, etc. This requires hospitalisation and so patient should be referered to neurology department.

Profound pounding dull, aching, or throbbing headache of medium intensity which worsens with exertion and change of position and may be associated with nausea or vomiting may suggest an intracranial tumour. The headaches may become more frequent, increasing in severity, and not easily relieved. Patient gets disturbed from sleep. They can also be worsened by coughing or sneezing and persistently occur on the same side often. Vomiting that precedes headache is a characteristic of posterior fossa tumours. This type of headache should be immediately investigated and brought to the concern of a neurophysician or neurosurgeon.

Headache with symptoms such as acute weakness and numbness in the limbs and/or face, nausea, vomiting, an altered level of consciousness, may indicate increased intracranial pressure and are more common with hemorrhagic strokes and large ischemic strokes.

It is an inflammatory condition of arteries which involves the extracranial carotid circulation. Temporal arteritis presents with classical symptoms - headache, jaw claudication, scalp tenderness, and visual disturbances. Fever, myalgia, anorexia, weight loss, anemia, and malaise may also occur as systemic inflammatory response.
Temporal arteritis usually occurs in older people and is extremely rare in individuals younger than 50 years of age, and present with visual changes. If not treated, patient may develop partial or complete blindness due to involvement of ophthalmic artery or its branches.

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