All you need to know about Headaches

On 11 May, 2024, Seniors Today hosted their weekly Health Live webinar with Dr Ishant Rege who spoke on and answered questions about Headache. He demystified the common complaint of a headache and gave a neurosurgeon’s opinion on the same. 

About Dr Ishant Rege:

Dr Ishant Rege is a Consultant Brain and Spine Surgeon with varied experience of managing operative and non-operative conditions of the brain and the spine. He has completed a postdoctoral Fellowship in Vascular and Endovascular Neurosurgery which involves minimal invasive treatment of vascular disorders like stroke, carotid stenosis, brain aneurysms, arterio-venous malformations and arteriovenous fistulas, among others.

After completing his MCh in Neurosurgery as a university topper from the St John’s Medical College, Bengaluru, he secured a Fellowship  in Vascular and Endovascular Neurosurgery at the Amrita Institute of Medical Sciences, Kochi. 

With an experience of more than 3000 routine and complex neurosurgical procedures including a wide range of neurological conditions like brain tumours, traumatic brain injuries, stroke, vascular disorders and spine care, his focus remains strongly on patient safety and outcomes.

Headache is a very common condition, an important one, yet often one that is easily neglected. 

It all starts with a headache, which is why it is important to know the kind and cause for the headache so it can be evaluated and treated accordingly. 

Headache is a very common complaint that most of us have experienced. It consists of pain in the head and neck which arises from the pain sensitive structures in the head. It is one of the most common disorders of the nervous system. And it ranks 3rd in the world in neurological diseases after stroke and dementia. 

But only a minority of people with headache are correctly diagnosed and treated, which is a cause for concern. 

The brain parenchyma is interestingly insensitive to pain, but the structures around it are, which cause the pain in a headache. These structures include:

• The protective layer around it- called the meninges
• Veins and arteries around the brain
• Structures outside the skull such as the scalp, subcutaneous layers, muscles around it are all sensitive to pain.

Usually, patients come to the hospital for a headache when it is

• Acute onset, sudden headache 
• Episodic or recurrent headache 
• Non subsiding pain
• Headache persisting despite taking medication 
• Chronic headache 

Invariably, at the onset of a headache the first step is to go to a pharmacy and consume an over the counter medication, if it works, it’s well and good, but sometimes it does not work which is when the individual reports to a physician who will then prescribe stronger medication and diagnose it. This diagnosis helps in treating it the pain well. 

If the pain still persists, the patient is then sent to other specialists to rule out other causes for a headcahe, such as:

• An ophthalmologist to rule out far/ near sightedness
• ENT specialist to rule out sinusitis which can also be the cause for the headache. 
• General physician- the headache could also be due to hypertension 
• Orthopaedic surgeon- to treat and rule out for spasm in the neck/ spondylosis 
• Neurologist/ neurosurgeon

A scan/ radiodiagnostic imaging is not always required for all patients with a headache. It is advised in patients with 

• headache associated with neurological signs and symptoms such as- headache associated with double vision, loss of consciousness, seizure, imbalance withal walking 
• Progressively worsening headache 
• New onset severe headache 
• Headache associated with multiple episodes of vomiting and fever 

Investigations are needed in secondary headache. They are not of much value for primary headache. 

Headache is a symptom and not a disorder in itself. 

Primary headache is one wherein the headache is the disorder itself. 

– It constitutes 98% of all the headaches. Which means that 98% of the times you might not need any investigations or scans. 

• This is the commonest type. 
• Of all the primary headaches, tension headache constitutes 60- 80% of them
• Migraine makes up 15% 
• The lesser common ones include cluster headache 

Secondary headache is one where the headache is due to an underlying disorder. 

• This can be due to a space occupying lesion such as a tumours, infection in the brain, bleed in the brain. 
• Causes can include: 

• Trauma to the head 
• Bleed ninth brain 
• Vascular causes such as a stroke, aneurysm, venous thrombosis, hepatoma in the brain 

• Underlying cause for the headache need to be ruled out when:
• The headache is associated with other systemic symptoms such as fever, significant amount of weight loss, cancer/ tumour elsewhere in the body
• Immunocompromised states 
• You also have impaired consciousness/ alertness 
• Neurological deficits 
• Headache associated with seizures
• Thunderclap kind of headache- sudden and severe headache 
• Headache associated with trauma to head 
• Headache precipitated by coughing, sneezing, etc
• Progressively worsening headache  

Patient history is very important when it comes to diagnosing a patient with a headache. Which means that the patient giving the right and correct history is very important. Most of the time primary headaches are diagnosed correctly based on the correct history itself. 

For example:

1. A patient with tension headache will also have/ give a history of palpitations and anxiety, which in turn helps us come to the correct diagnosis. 
2. A patient with migraine will give a history of aggravation of pain when the patient is pacing/ moving and is relieved on rest/ lying down.
3. A patient with cluster headache, on the contrary will present with relief in pain on movement and aggravation of pain on lying down/ rest. 

Common types of primary headaches include:

1. Tension type headache: band of pressure on the head

• Bilateral (both sides of the head)
• Dull aching/ nagging type of pain which is present throughout the day (upto 4-5 hours/ day)
• Often associated with shoulder, neck and scalp tenderness 
• Risk factors include:

• Stress 
• Anxiety 
• Poor sleep 
• Younger population 

• Treatment includes:
• Taking less stress 
• Getting adequate amount of sleep 
• Regular exercise 
• Over the counter analgesics such as paracetamol, initially. 
• If the pain still persists, wherein the pain in chronic or more than 15 episodes are seen per month, the patient may then need to be started on antidepressants like amitriptyline, fluoxetine 

2. Migraine: it is a moderate to severe intensity of headache 

• Throbbing/ pulsating kind of pain 
• Mostly unilateral (90%)
• 1/3rd of these patients suffer from an aura. Aura is a warning sign which comes before the acute onset of this headache. Most of the time it is a visual aura. The aura usually comes about 30-60 mins prior to the onset of the migraine headache. There can also be sensory aura.
• These can be episodic and chronic 
• Patients with migraine should keep a headache diary- to help identify triggering factors such as bright light, loud sounds, less sleep, some dietary triggers like wine/ cheese 
• Treatment: 
• Over the counter analgesics- paracetamol, NSAIDs like ibuprofen, diclofenac 
• Tryptans is another group of medicines which can be used 
• For chronic headache (more than 8 episodes/ month)- these patients require preventive therapy for example- propranolol, antidepressants, stronger anti seizure medicines such as gabapentin, sodium valproate 

3. Cluster headache: not a very common type of headache 

•  The pain is severe and excruciating 
• Pain is felt behind the eye, usually 
• Lasts for about 4 hours 
• It is called “cluster” headache, because it keeps appearing in bouts with periods of remission 
• Triggering/ precipitating factors include- alcohol and smoking 
• Common in men than women 
• Treatment:

• 100% oxygen- this reduces the amount of headache significantly 
• Following this, other medicines such as triptans, paracetamol, ibuprofen are started 

Space occupying lesions are  any kinds of lesions that grow in and around the brain including the protective layers of the brain. It can occur anywhere in the brain. 

These lesions can be of various types:

• Benign- locally growing 
• Malignant- spreading
• Infection/ abscess 
• Cyst 

The space occupying lesions, cause stretching of the layers of the brain which is a pain sensitive structure 

Early morning type of headache which is associated with nausea and vomiting and it improves as the day progresses. 

This kind of a headache is aggravated when lying down or bending over and valsalva like maneuvers 

This is a moderate intensity pain which has been present for quite sometime and is gradually progressive in nature.