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Dr. Arindam Mondal

Posted By : Dr. Arindam Mondal - MBBS, MD (Psychiatry)

Posted On : Mar 16, 2010 (Views : 2864)

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Headache is one of the most common complaints seen by general physicians. Though most headaches are harmless, it is very important that a doctor determines if the headache is potentially dangerous or not.

There are two broad categories:

 1) Primary headaches: These are harmless, recurrent headaches having no organic disease as their cause. They comprise of 90% of all headaches. They include tension-type headache, migraine, and cluster headache.

2) Secondary headaches: These are caused by an underlying pathological disease process. Common causes of secondary headaches include glaucoma, sinusitis, meningitis, sub-arachnoid haemorrhage, temporal arteritis, brain tumours and headache following head-injury

A)Tension-type headache:

This is the most common type of headache and characterized by dull, aching, non-pulsating pain, affecting the whole head. About 1 in 7 persons have Tension-type headache.

Symptoms include:

A tight band-like sensation around the head or heaviness of head.

It affects the whole head and may extend to the neck, shoulders & upper back.

It is present continuously and lasts for several months.

Dizziness & tenderness may be present; contact of the scalp with a pillow or comb may increase the pain.


B) Migraine:

This is an episodic (occurs as attacks) throbbing headache, accompanied by nausea and avoidance of light. About 1 in 7 women and 1 in 17 men develop Migraine. It may occur in several members of a family.


Symptoms include:

  • The headache occurs on one or both sides of the head. The pain is of 'throbbing' or 'pulsating' type and of moderate or severe intensity. An attack usually lasts 2-4 hours. Between attacks, the symptoms go away completely.

  • Other symptoms that commonly occur are nausea, vomiting, avoidance of bright lights and loud noises.

  • An “aura” (warning sign) may be present before the attack starts. Common auras are seeing flashes of light or black spots, numbness and 'pins and needles' sensation.

  • Attacks of migraine are usually precipitated by triggers. Common triggers are fasting, missing meals, sleep deprivation, exhaustion,  direct sunlight, bright lights, loud noise, strong smells, psychological stress, menstruation, shift duty, high altitude, food additives (e.g. monosodium glutamate), sweeteners (e.g. Aspartame), some medicines (e.g. Oral Contraceptive Pills), etc.

Mixed Headache: Here Migraine and Tension-type Headache occurs in the same patient. Here, Migraine headaches start several years before the Tension-type headache begins. Usually, these patients have co-existing medical problems (e.g. hypertension) or psychiatric illness (e.g. depression.)

C) Cluster headache:

Cluster headache is a rare type of headache. They are episodic, excruciating, pulsating one-sided headaches in the region of the eye. Pain is accompanied by redness of face, running nose, blurred vision and tears on the same side as the pain. There is no nausea, vomiting and avoidance of light. These occur at a fixed time every day. The headache periods can last for several weeks or months.


D) Secondary Headaches

These headaches can be potentially dangerous and need the immediate attention of a doctor. These warning signs below suggest a serious illness:

    * Headache beginning after 55 years of age

    * Very sudden onset of headache

    * Headaches increasing in frequency and severity

    * Headache with signs of systemic illness (fever, neck stiffness, rash)

    * Headache accompanied by paralysis or loss of sensation

    * Headache following head injury


Are tests required?

Tests are usually not needed. A doctor can be confident that a patient has one of the Primary Headaches if the symptoms are typical. Sometimes tests are done to rule out other causes of headaches. Common tests done are X-Rays, CT Scans, blood tests and sometimes spinal fluid tests.

What are the causes?

The exact cause is not clear. Tension headache is understood to be caused by spasm of muscles of the scalp. Migraine & Cluster headache is thought to be due to rhythmic pulsations of blood vessels (arteries) in the head. 

What are the treatment options?


Most common painkillers like Aspirin and Diclofenac relieve symptoms during attacks. The effect lasts to 4-8 hours. They do not have long-term or preventive effect.

Medications for nausea and vomiting

These are needed for migraine and are usually available in combination with painkillers (e.g. Vasograin, Domcet)

Preventing headache attacks

Prophylactic medications form the mainstay of management of Primary Headaches in addition to patient education about precipitating factors of headaches.

If a patient suffers from more than 2 attacks of headache per month or if the attacks are severe or incapacitating, prophylaxis with one of the medications below are indicated:

    * Anti-epileptics (Sodium Valproate, Topiramate)

    * Anti-depressants (Amitriptyline, Nortriptyline)

    * Beta Blockers (Propranolol)

    * Calcium Channel Blockers (Flunarazine)

    * Miscellaneous (Cyproheptadine)

The medications greatly reduce or stop the headaches in 1-2 weeks. Medications need to be continued for 6-12 months. The course is usually repeated every few years.

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