All of us would have suffered from severe headache at some point in our lives. It is one of the most common symptoms for which a doctor’s consult is sought. Fortunately most headaches are not serious and resolve spontaneously or can be easily treated.

Types of Headache
Headache can be primary or secondary. Primary headaches are not associated with any underlying illness or condition.

Primary headache – Causes

Tension headache – most common type of headache. Occurs across the forehead and although uncomfortable and painful, does not disrupt normal activities. Tends to be worse as the day progresses and may be associated with increased sensitivity to bright light and noise.

Migraine – Migraine headaches are less common but more severe than tension headaches. Occur as throbbing pain on the front and side of the head. Associated symptoms include nausea, vomiting and heightened sensitivity to light and sound. The headaches may be preceded by aura. They can be severe enough to disrupt daily routine and last longer up to a couple of hours.

Cluster headaches – Cluster headache is a rare form of headache and tends to occur in clusters for a month or two at a time, often around the same time each year. They are very painful, causing severe pain around one eye, and occurrence of other symptoms, such as a blocked or runny nose or a watering or red eye.

Secondary Headache – Causes
Secondary headache refers to headache occurring due to underlying disease condition or medication that the person may be taking for another condition.

Causes of Secondary Headache

Concerning Features Associated With Headache That Warrant Medical Attention
As mentioned earlier, most headaches are not serious and can be easily treated.
Presence of any of the following features may be a sign of something more serious and have to be further evaluated without delay
• History of recent fall with head injury
• Worsening headache and associated with high fever or neck stiffness
• Sudden onset severe headache that peaks within seconds (thunderclap headache)
• Headache onset above the age of 50 years
• Associated with slurred speech and limb weakness
• Headache associated with confusion, fits or altered consciousness
• Headache associated with visual disturbances such as blurring or double vision
• Headache associated with memory disturbances or personality changes
• Headache that comes on coughing, sneezing or straining
• Headache is associated with red or painful eyes
• Unusually severe headache
• Associated unexplained vomiting with the headache.
• Known history of cancer or immunosuppression

EVALUATION OF HEADACHE
History and Examination
Aim of evaluating headache symptom is to look for a secondary cause for the headache and ruling out any serious underlying disease. If no secondary cause can be found, a primary cause has to be looked for.
A complete history including drug history, family history, headache triggering and relieving factors, location and severity of pain, associated symptoms, and any underlying illness;
History taking should be followed by detailed examination including general examination, eye examination, examination of the ear, nose and throat, neurological examination and examination of scalp.

Diagnostic Tests
• Eye testing to rule out refractive errors and glaucoma should be done if history is suggestive
• If points in the history or examination (see concerning symptoms), suggest something more serious, then an immediate CT or MRI
scan of the brain will be done to look for any bleeding, clot, abscess, hematoma or tumor
• If history and clinical examination suggests brain infection (fever, neck stiffness, altered consciousness etc), a spinal tap (lumbar
puncture) may be done to obtain CSF. The cerebrospinal fluid (CSF) is sent for cytological, biochemical and microbiological
examination to confirm the diagnosis. Before a spinal tap is done a CT/MRI scan is advised to rule out raised intracranial pressure
• In suspected giant cell arteritis, biopsy of the temporal artery may be done to confirm the diagnosis

Treatment of Headache
• For most primary tension headaches, rest and over-the-counter pain relief medication are recommended such as aspirin,
paracetamol and ibuprofen
• For migraines and cluster headaches triptans may be prescribed to relieve acute symptoms
• Occasionally, preventive medication, such as tricyclic antidepressants, anti-epileptic drugs and beta blockers and triptans may be
advised for certain recurrent headaches
• Treatment of secondary headache depends on addressing the underlying cause such as infection, raised intracranial pressure,
tumor or correction of refractive error.
• Drug induced headaches should be treated by stopping the drug and prescribing an alternative
• Trigeminal neuralgia may be treated with anti-epileptic medications, deep brain stimulation or surgery if resistant to medical
treatment

Tips On Prevention of Primary Headaches
• Coping with stress through relaxation techniques and meditation
• Regular exercise
• Healthy diet rich in fresh fruits and vegetables
• Adequate sleep at least 8 hours every night
• Sleeping with two pillows or fewer
• Staying well hydrated
• Application of heat or ice pack to head and neck
• Avoiding extremes of temperatures
• Cognitive behavioral therapy to reduce stress headache stress cycle

Key Points To Remember
• Most headaches are not serious, especially in the young and they are not progressive and examination by the doctor is largely
normal
• Seek immediate attention if you have any concerning signs or symptoms
• Most headaches do not need further diagnostic testing
• Simple lifestyle changes and stress management will help improve most headache symptoms
• History taking and examination by the doctor will usually point to the correct diagnosis
• Tests such as CT/MRI scan and lumbar spinal tap will only be done if something serious is suspected