Dr Pyari Bose is a neurologist with special interest in headache disorders. He did headache research at King's College London, looking into the postdrome (recovery) phase of migraine using functional brain imaging.
Credits: Health Navigator Editorial Team. Reviewed By: Dr Pyari Bose, Consultant Neurologist, Auckland City Hospital
Last reviewed: 04 Nov 2021
Information for healthcare providers on headache
The content on this page will be of most use to clinicians, such as nurses, doctors, pharmacists, specialists and other healthcare providers.
Key information about headache provided by Dr Pyari Bose, neurologist, Auckland
Primary headache disorders
Primary headache disorders like migraine and cluster headache form the major bulk of referrals to a neurologist. Every year it is estimated that 3 billion people worldwide are affected. Though these disorders are not life threatening, they canlead to major disability with heavy socioeconomic consequences.
Patients sometimes find it hard to access resources for diagnosis, management and supportand hence raising medical awareness is paramount.New advances in the understanding of the disorders and novel therapeutic developments takes us to an exciting era in management.New acute therapies for migraine attackslikegepants, calcitonin gene-related peptide (CGRP) receptor antagonists, and serotonin 5-HT1F receptor agonists, offer novel approaches to the treatment.
See the following for more information about specific primary headache disorders:
These are headaches caused by an underlying condition. Clinicians who evaluate patients with headache should be alert to signs that suggest a serious underlying disorder. Missing a secondary headache disorder can have devastating consequences for the patient. The disorders that fall in this category include brain tumours, brain bleeds, brain infections.
Red flag signs
The presence of the following red flag signs in the context of headache could indicate a serious underlying disorder and warrants an urgent medical review:
Headache with systemic symptoms including fever.
Headache in apatient with prior history of cancer.
Headache with clinical signs on examination including decreased consciousness.
Onset of headacheis sudden or abrupt(i.e.,headache peaks in intensity over few minutes rather than several minutes or hours).
New onset headache after age 50 years- this would be unusual for a primary headache disorder like migraine.
Pattern change of usual headachesor recent onset ofdifferent type ofheadache.
Positional headache i.e.,headaches that worsen onlyingflat or come on within few minutes of standing up.
Headaches precipitated by sneezing, coughing, or exercise.
Headache with evidence of swelling behind the eye (papilledema) detected at the opticians.
Headache onset during pregnancy or following delivery.
Headache associated with a painful eye, eye swelling or with autonomic features like watering from the eye, redness of the eye, running nose.
Headache that developed following head trauma,\.
Headache onset in the context of an immune deficiency state such as HIV.
Post-traumatic headache (PTH)is the most frequent symptom after mild traumatic brain injury (mTBI). It is estimated that annually 69 million suffer from TBI worldwide, mostly attributable tomTBI.InNew Zealand it is estimated that up to 36,000 people suffer TBIs each year, of which 95% are mild.
The leading causes of TBI in New Zealand are falls,mechanical forces, driving-related accidents andassaults.Just over 20% of all TBIs in New Zealand are sustained through sport-related activity.(7)
The underlying cause of PTH is not fully known. It is thought thatmechanisms related toboth migraine and traumatic brain injury (TBI) are implicated. These include impaired descending paincontrol networks in thebrain,neurochemicalchanges, neuroinflammation, cortical spreading depression, and release of thepain protein-calcitonin gene-related peptide (CGRP).
The treatment would be determined by evaluation of the underlying headache phenotype. Common patterns of PTH include migraine type and tension type headache patterns. Part of the management also includes addressing if patients are overusing pain medications.
Headachesmay resolve within 3 months of the traumatic brain injury but in some patients this may last longer.
Medication overuse (or rebound) headache is a secondary headache disorder caused by using too much pain relief medicine to treat headaches.
It may feel like a tension-type headache or migraine-like attack.
Headaches often improve within 2–4 weeks of withdrawal of the overused medicine, but you can feel worse before you feel better.
To avoid this, limit the use of pain relief medication. Use them for the shortest possible time, only when you have pain. For example, paracetamol and NSAIDs should not be taken for headache on more than 15 days per month and triptans for migraine should not be used for more than 10 days per month.
Post-traumatic headache (PTH) is a secondary headache disorder caused by mild traumatic brain injury (mTBI).
It is the most common symptom of mTBI.
Your headaches may go away within 3 months of the mTBI, but in some people this may last longer.