Management of Headache 1

By Dr. Thilak Jayalath



Headache is pain felt in the neck, scalp or head. Seven in 10 people have at least one headache a year. The majority of headaches last for only a few hours, but some can persist for weeks. Headache disorders are not perceived by the public as serious illness since they are mostly episodic, do not cause death, and are not contagious.

Headache disorders are extremely common, painful and disabling. They can cause substantial personal suffering, impaired quality of life and financial loss. Many health care professionals tend to perceive headache as a minor or trivial complaint. As a result, the physical, emotional, social and economic burdens of headache are poorly acknowledged.

For the vast majority of people suffering from headache, effective treatment requires no expensive equipment, tests or specialists. Headache disorders are mostly, and rightly, managed in primary health care. The essential components of effective management are awareness of the problem, correct diagnosis, avoidance of mis-management, appropriate lifestyle modifications and informed use of cost-effective pharmaceutical remedies.

Because of lack of knowledge among health-care providers, very large numbers of people troubled by headache do not receive effective care. An updated knowledge on common causes of headache, and how to identify sinister causes of headache are mandatory.

For practical clinical purposes, however, all headaches can be classified as one of the primary headache syndromes or as a headache that is caused by or secondary to an underlying disease process or medical condition.



Primary headaches account for more than 90% of all headache complaints. The primary headache syndromes are migraine, tension-type, and cluster headaches. Migraine and cluster headaches are episodic and recurring conditions. Tension-type headache is usually episodic but like migraine, it can become chronic, occurring daily. None of these primary headaches are associated with demonstrable organic disease or structural neurologic abnormality. Laboratory and imaging test results are generally normal. Similarly, the physical and neurologic examinations are also usually normal.

Episodic type of tension headache is the most common primary headache disorder seen in the clinical practice. Migraine is the second most common primary headache type and the cluster headache is not very common in clinical practice.

Secondary headaches are usually of recent onset and associated with abnormalities found on clinical examination. Laboratory testing or imaging studies confirm the diagnosis. Recognizing headaches related to an underlying condition or disease is critical not only because treatment of the underlying problem usually eliminates the headache but also because the condition causing the headache may be life-threatening.


Diagnosis of Primary Headache Disorders

The three common primary headache disorders are Migraine, Cluster headache and Tension headache. The diagnosis of each of these conditions is made on clinical grounds and do not need investigations generally. The primary care providers, with a sound knowledge of clinical features of these common headache types, should be able to make the diagnosis.


Migraine attacks commonly occur when the person is awake. The typical headache of migraine is throbbing or pulsatile in nature. The headache is initially unilateral and localized in the frontotemporal and ocular area, but pain can be felt anywhere around the head or neck. The pain typically builds up over a period of 1-2 hours, progressing posteriorly and becoming diffuse.

The headache typically lasts from 4-72 hours. Among females, more than two thirds of patients report attacks lasting longer than 24 hours.

Pain intensity is moderate to severe and intensifies with movement or physical activity. Many patients prefer to lie quietly in a dark room. The pain usually subsides gradually within a day and after a period of sleep; a majority of patients report feeling tired and weak afterwards.

Nausea and vomiting usually occur later in the attack, along with anorexia and food intolerance. Photophobia and/or phonophobia are also commonly associated with the headache.

Other neurological symptoms that may be observed include hemiparesis (this symptom defines hemiplegic migraine), aphasia, confusion, and paresthesias or true numbness.


Cluster headache

Cluster Headache is more common in men, with a male-to-female ratio of 3:1. Although it is more common in the third decade of life, cluster headache has been reported in patients as young as 1 year and as old as 79 years.

Cluster headache is a neurovascular primary headache disorder characterized by severe strictly unilateral, typically retro-orbital or periorbital, short-lasting headaches accompanied by prominent craniofacial parasympathetic autonomic features.

Attacks usually are severe and unilateral, and typically are located at the temple and periorbital region. The pain is typically associated with ipsilateral lacrimation, nasal congestion, conjunctival injection, miosis, ptosis, and lid edema. Each headache is brief in duration, typically lasting a few moments to 2 hours. Cluster refers to a grouping of headaches, usually over a period of several weeks. To fulfill criteria for diagnosis, patients must have had at least 5 attacks occurring from 1 every other day to 8 per day and no other cause for the headache.

The 2 existing forms of cluster headache are

Episodic clusters with at least 2 cluster phases lasting 7 days to 1 year separated by a cluster-free interval of 1 month or longer, and

Chronic form, in which the clusters occur more than once a year without remission or the cluster-free interval is shorter than 1 month.


Tension type headache

Tension-type headache (TTH) represents one of the most costly diseases because of its very high prevalence. TTH is the most common type of headache, and it is classified as episodic (ETTH) or chronic (CTTH). The International Headache Society (IHS) defines TTH more precisely and differentiates between the episodic and the chronic types. The following is a modified outline of the IHS diagnostic criteria:


Episodic tension-type headache

At least 10 previous headaches fulfilling the following criteria; number of days with such headache fewer than 15 per month.

Headaches lasting from 30 minutes to 7 days

At least 2 of the following pain characteristics:

pressing/tightening (non-pulsating) quality

mild or moderate intensity (may inhibit but does not prohibit activities)

bilateral location

no aggravation from climbing stairs or similar routine physical activity

Both of the following:

No nausea or vomiting

Photophobia and phonophobia absent or only one present

Secondary headache types not suggested or confirmed


Chronic tension-type headache

Average headache frequency of more than 15 days per month for more than 6 months fulfilling the following criteria

1. At least 2 of the following pain characteristics:

Pressing/tightening (nonpulsating) quality

Mild or moderate intensity (may inhibit but does not prohibit activities)

Bilateral location

No aggravation from climbing stairs or similar routine physical activity

2. Both of the following:

No vomiting

No more than one of the following: nausea, photophobia, or phonophobia

3. Secondary headache types not suggested or confirmed




Sri Lanka Association for the Study of Pain

The Sri Lankan Chapter of the International Association for the Study of Pain

January 2014. Sri Lanka Association for the Study of Pain (SLASP). All Rights Reserved.

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 Physiology of Pain

 Pharmacological Management of Pain

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 Abdominal Pain

 Orofacial Pain: An Overview

 Pain: Psychological Correlates

 Assessment of Pain

 Management of Acute Post-Surgical Pain

 Management of Pain in Obstetrics

 Management of Musculoskeletal Pain and Chronic Pain Syndromes

 Management of Pain in Children

 Management of Pain in Neonates

 Management of Acute Pain in Trauma

 Management of Cancer Pain

 Management of Headache




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