Secondary Causes

Approach to Patients
Migraine Headache
Primary Headache Syndromes
Secondary Causes
Cranial and Facial Pain Disorders

Table of Contents

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Subarachnoid Hemorrhage (SAH)


1:10,000 in USA, 1% of nontraumatic headache

Up to ¼ of sudden severe headaches

Median age = 50 YO

50% 6-mth survival

58% of survivors regain premorbid state

Clinical Features

½ normal neurological exam : V/S, GCS, no neck stiffness

Severe and sudden onset = m/c

Occipitonuchal location

Resolution of pain doesn’t exclude Dx

Radiation of pain down along the spine


Begins with plain CT scan

  • (Sensitivity = 93% within 24 hours, more if within12 hours)
  • Cannot rule out even within 12 hr
  • Sensitivity falls to slightly over 80%

LP is used when

  • mandatory following a negative CT
  • Low-probability pt : isolated severe headache and absence of neurologic finding (12%)
  • Lone acute sudden headache : acute sudden headache without neck stiffness, normal neuro exam + V/S + GCS

Gold standard = xanthochromia in CSF supernatant

  • 100% sens up to 2 weeks
  • 12 hr or longer after headache
  • Spectrophotometry
  • Naked-eye detection --> 50 % FN



All forms of meningitis can cause headache

LP is required

CT need not if

  • normal neurologic examination,
  • normal level of consciousness and
  • no papilledema

Antibiotics should be started immediately


Intraparenchymal Hemorrhage and Cerebral Ischemia

55 % report headaches at the onset of intraparenchymal hemorrhage

17% in ischemic stroke

6% in TIA


Subdural Hematoma

Hx of remote trauma

Low threshold for initiating Ix is appropriate for high-risk patient

  • On anticoagulants
  • Chronic alcoholics
  • elderly


Brain tumor

Up to 70% complain headache

Classic headache = few

Worse in the morning

Associated with position


If 24 hr F/U can be ensured, reliable Pt with normal neurologic examination including papilledema --> OPD


Temporal Arteritis


Exclusively in Pts over 50 YO


15-30 : 100,000 in this age group


Systemic panarteritis that selectively involves arterial walls with significant amount of elastin

Clinical Features

Headache = m/c symptom (60-90%)

Most often severe, throbbing

Fromtotemporal region

Strong evidence

  • Jaw claudication
  • Polymyalgia rheumatica

Nonpulsatile or tender artery

Most serious C/P = ischemic optic neuritis

Temporal Arteritis : Dx = 3 in 5

  • Age over 50 YO
  • New-onset localized headache
  • Temporal artery tenderness or decreased pulse
  • ESR over 50 mm/hr


Abnormal arterial Bx finding



Begin immediately in order to prevent loss of vision

40 – 60 mg/D prednisolone

Refer urgently for definitive Dx + F/U


Ophthalmic Disorder

Acute glaucoma

  • Nausea and vomiting are severe with associated orbital pain.
  • Decreased visual acuity and conjunctival injection.
  • Patient usually greater than 50 years of age.


Optic neuritis



Higher DBP ass with more severe headache

DDx with

  • other secondary headache condition
  • Stroke
  • Pheochromocytoma
  • Preeclampsia
  • Secondary to pain and anxiety

Most Pt can be D/C following complete resolution of symptoms and BP reduction

F/U next 24-28 hr



Maxillary sinusitis – commonest type

Headache varies with head position

Symptom predictive of sinusitis

  • Colored nasal discharge
  • maxillary toothache
  • poor response to decongestant

Reliable sign

  • Purulent nasal discharge
  • abnormal transillumination

>4 --> very likely, <2 --> unlikely


Drug-related and Toxic or Metabolic Headaches

Nitrates, MAOI, chronic use of analgesics

Hypoxia, hypercapnia, hypoglycemia

Monosodium glutamate, CO

Fever greater than 38.8 C is the m/c cause


Benign Intracranial Hypertension (Pseudotumor Cerebri)

Rare entity

Young, obese Pt with long-standing headache

N/V, visual disturbance

Ass with OCP, vit A, tetracycline, thyroid

Character : papilledema, normal LOC and CT, markedly elevated CSF pressure

Acatazolamide or steroid = initial Rx

Repeated LP if fail

Sx : shunt or optic nerve sheath fenestration


Post-Lumbar Punture Headache

10-36 % within 24-28 hr after LP

Persistent CSF leak from dura

Minimized by smaller-bore needle with noncutting tips

Responsive to simple analgesics

If fail --> blood patch


Posttraumatic Headache

Vertiginous sensation, N/V

Markedly improved by recumbency

If unrelieved by lying down --> neuroimaging

Yield is extremely low if cognitive function esp short-term memory is completely intact

Usu self-limited, NSAIDs may be beneficial


Coital Headache

Before, during, or after orgasm

Severe, persist for several hours

Sentinel subarachnoid hemorrhage must be excluded

Indomethacin 50 mg orally 1-2 hr before intercourse


Summarized By Thirayost Nimmanon

โดย ธีรยสถ์ นิมมานนท์


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