HEADACHE CLASSIFICATION

1. Headache

2. International headache society
(HIS) classification of headache

3. HEADACHE
Part I: The Primary Headaches
Part II: The Secondary Headaches
Part III: Cranial Neuralgias, Central and Primary
Facial Pain And Other Headaches

4. PRIMARY HEADACHE
1. Migraine
2. Tension-type headache (TTH)
3. Cluster headache and other trigeminal
autonomic cephalalgias (TAC)
4. Other primary headaches

5. SECONDARY HEADACHE
1.
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Post traumatic Headache
Vascular Headache of cranial or cervical origin
Non vascular headache intracranial origin
Post infective headache
Headache due to substance abuse/withdrawal
Headache due to disorder of homoeostasis
Headache due to non cranial causes
Headache attributed to psychiatric disorders

6. PART IPRIMARY HEADACHE

7. MIGRAINE
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6.
Migraine without aura
Migraine with aura
Childhood periodic syndromes
Retinal migraine
Complications of migraine
Probable migraine

8. MIGRAINE WITH AURA

9. CHILDHOOD PERIODIC SYNDROME

10. COMPLICATIONS OF MIGRAINE

11. PROBABLE MIGRAINE

12. TENSION TYPE HEADACHE

13. Cluster headache and other trigeminal
autonomic cephalalgias (TAC)
1. Cluster headache
2. Paroxysmal hemicrania
3. Short-lasting unilateral neuralgiform
headache attacks with conjunctival injection
and tearing (SUNCT)
4. Probable TAC

14. Other primary headaches
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Primary stabbing headache
Primary cough headache
Primary headache associated with sexual activity
Primary exertional headache
Primary thunderclap headache
Hypnic headache
Hemicrania continua
New daily-persistent headache

15. PART IISECONDARY HEADACHE

16. 1. POST TRAUMATIC HEADACHE
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Acute post-traumatic headache
Chronic post-traumatic headache
Acute whiplash headache
Chronic whiplash headache
Traumatic intracranial hematoma
Other head and/or neck trauma
Post-craniotomy headache

17. 2. Vascular headache
of cranial or cervical origin
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Nontraumatic intracranial hemorrhage
Ischemic stroke or TIA
Unruptured vascular malformation
Arteritis
Carotid or vertebral artery pain
Cerebral venous thrombosis
Other intracranial vascular disorder

18. 3. Nonvascular headache
of intracranial origin
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High CSF pressure (intracranial hypertension)
Low CSF pressure (intracranial hypotension)
Non-infectious inflammatory disease
Intracranial neoplasm
Intrathecal injection
Epileptic seizure
Chiari malformation type I
Transient headache and neurological deficits with
CSF lymphocytosis (HaNDL)
• Other nonvascular intracranial disorder

19. 4. Headache due to a substance
abuse/ withdrawal
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Acute substance use or exposure
Medication-overuse headache (MOH)
Adverse effect of chronic medication
Substance withdrawal

20. 5. Headache attributed to infection
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Intracranial infection
Systemic infection
HIV/AIDS
Chronic post-infection headache

21. 6. Headache due to to disorder of
homoeostasis
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Hypoxia and/or hypercapnia
Fasting
Arterial hypertension
Dialysis headache
Cardiac cephalalgia
Hypothyroidism
Other disorder of homoeostasis

22. 7. Headache or facial pain due to
extracranial causes
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Disorder of cranial bone
Disorder of neck
Disorder of eyes
Disorder of ears
Rhinosinusitis
Disorder of teeth, jaws, or related structures
Disorder of temporomandibular joint(TMJ)
Other disorder of cranial, facial, or cervical
structures

23. PART III
Cranial neuralgias and central causes
of facial pain and other headaches

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Trigeminal neuralgia
Glossopharyngeal neuralgia
Nasociliary neuralgia
Superior laryngeal neuralgia
Supraorbital neuralgia
Occipital neuralgia
Other terminal branch neuralgias
Neck−tongue syndrome
Nervus intermedius neuralgia
External compression headache
Cold-stimulus headache
Optic neuritis
upper cervical roots lesions
Herpes zoster
Ocular diabetic neuropathy
Tolosa-Hunt syndrome
Ophthalmoplegic “migraine”
Central causes of facial pain
Constant pain caused by compression irritation, or distortion of cranial
N

27. History in headache
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Duration of headache
Nature of headache
Site
Severity of headache
Continuous / episodic
Duration of episodes
Frequency of episodes
Associated features
Relieving features
Diurnal variations

28. Intensity
• Throbbing pulsatile- migraine
• Thunderclap – subarachnoid hmge

29. LOCATION
• Migraine headache
– is unilateral in two thirds of attacks
– commonly associated with nausea, vomiting, and
sensitivity to light, sound, and smells.
• Less sharply localized pain:
– Paranasal sinuses, teeth, eyes, and upper cervical
vertebrae induce a less sharply localized pain

30. • Occipitonuchal pain :
– Posterior fossa lesion localised to the homolateral side of
lesion
• Frontotemporal pain:
– Supratentorial lesions induce, or approximate the site of
the lesion.
• Frontal regions :
– Glaucoma
– Sinusitis
– Increased intracranial pressure
– Thrombosis of the vertebral or basilar artery,
– Pressure on the tentorium,

31. • Periorbital and supraorbital pain,
– indicative of local disease
– dissection of the cervical portion of the internal carotid
artery.
• Vertex or Biparietal regions:
– are infrequent
– sphenoid or ethmoid sinus disease
– thrombosis of the superior sagittal venous sinus

33. MIGRAINE

34. CLUSTER HEADACHE

36. TRIGEMINAL NEURALGIA

37. Mode of onset, the variation of the pain
over time, and duration
• subarachnoid hemorrhage
– (caused by a ruptured aneurysm) occurs as an abrupt attack
that attains its maximal severity in a matter of seconds or
minutes;
– Thunder clap headache
• Meningitis
– it may come on more gradually, over several hours or days.
• Migraine
– Ophthalmodynia :
• Brief sharp pain, lasting a few seconds,in the eyeball or
– cranium (“ice-pick”pain) and “ice-cream headache” caused
by pharyngeal cooling is more common in migraineurs.

38. • Migraine of the classic type
– onset in the early morning hours or in the daytime,
– reaches its peak of severity typically over several to 30
min,
– and lasts, unless treated, for 4 to 24 h, occasionally for
as long as 72 h or more.
– Often it is terminated by sleep
• Cluster headache:
– unbearably severe unilateral orbitotemporal pain
– Coming on within an hour or two after falling asleep or
at predictable times during the day
– recurring nightly or daily for a period of several weeks to
months is typical of cluster headache;
– usually an individual attack of “cluster” dissipates in 30
to 45 min

39. • Intracranial tumor:
– may appear at any time of the day or night;
– it will interrupt sleep, vary in intensity,
– last a few minutes to hours; as the tumor raises
intracranial pressure.
– With posterior fossa masses, the headache tends to be
worse in the morning, on awakening.
• premenstrual tension:
– occur regularly in the premenstrual period
– are usually generalized and mild in degree
• catamenial migraine:
– attacks of migraine may also occur at this time

40. • Headaches of cervical spine disease
– origin after a period of inactivity, such as a night’s sleep,
– movements of the neck are stiff and painful.
• Sinusitis :
– often face ache, with clock-like regularity, upon awakening or
in midmorning
– is characteristically worsened by stooping
– and changes in atmospheric pressure;
– there is associated midfrontal or maxillary tenderness.
• Eyestrain headaches,
– follow prolonged use of the eyes,
– as after long-sustained periods of reading, peering into
glaring headlights, or exposure to the glare of video displays.
• alcohol, intense exercise (such as weight lifting),
stooping, straining, coughing, and sexual intercourse
are known to initiate a special type of bursting
headache,

41. Pain-Sensitive Cranial Structures
• (1) skin, subcutaneous tissue, muscles, extracranial
arteries, and periosteum of the skull;
• (2) delicate structures of the eye, ear, nasal cavities, and
paranasal sinuses;
• (3) intracranial venous sinuses and their large
tributaries, especially pericavernous structures;
• (4) parts of the dura at the base of the brain and the
arteries within the dura, particularly the proximal parts
of the anterior and middle cerebral arteries and the
intracranial segment of the internal carotid artery;
• (5) the middle meningeal and superficial temporal
arteries; and
• (6) the optic, oculomotor, trigeminal, glossopharyngeal,
vagus, and first three cervical nerves.

42. Pain insensitive structure
• Much of the pia-arachnoid and dura over the
convexity of the brain,
• parenchyma of the brain,
• ependyma
• Choroid plexuses lack sensitivity.

43. Pain pathway in headache
• V1 and V2 division
– Fore head
– Orbit
– Anterior & middle cranial fossa upto superior surface of
tentorium :
• sphenopalatine branches of the facial nerve
– impulses from the nasoorbital region
• Ninth and tenth cranial nerves and the first three
cervical nerves
– impulses from the inferior surface of the tentorium and
– All of the posterior fossa.

44. • Sympathetic fibers from the three cervical ganglia
and parasympathetic fibers from the
sphenopalatine and otic ganglia are mixed with the
trigeminal and other sensory fibers.
• The tentorium roughly demarcates the trigeminal
from the cervical–vagal–glossopharyngeal
innervation zones.
• To summarize,
– pain from supratentorial structures is referred to the
anterior two-thirds of the head, i.e., to the territory of
sensory supply of the first and second divisions of the
trigeminal nerve;
– pain from infratentorial structures is referred to the
vertex and back of the head and neck by 9th 10th and the
upper cervical roots.

45. Referred pain
• Trigeminal and cervical sensory inputs converge on
the second order neurons at the C2 level. Permitting
pain from the neck and occipital regions to be
referred to the forehead, and vice versa
• The 7,9,10th cranial nerves refer pain to the
nasoorbital region, ear, and throat. There may be
local tenderness of the scalp at the site of the
referred pain
• With the exception of the
– cervical portion of the internal carotid artery, from
which pain is referred to the eyebrow and supraorbital
region
– the upper cervical spine, from which pain may be
referred to the occiput, pain because of disease in
extracranial parts of the body is not referred to the head.

46. Mechanisms of Cranial Pain
• Intracranial mass lesions
– cause headache only if they deform, displace, or exert
traction on vessels and dural structures at the base of
the brain,
– and this may happen long before intracranial pressure
rises.
• High intracranial pressure
– bioccipital and bifrontal headaches
– that fluctuate in severity,
– probably because of traction on vessels or dura.

47. • Dilatation of intracranial or extracranial arteries
– follow seizures, infusion of histamine,
– ingestion of alcohol
– Nitroglycerin.
– headache that accompanies febrile illnesses
– rises in blood pressure
• as occurs with pheochromocytoma, malignant hypertension,
sexual activity,
– cough and exertional headaches

48. Cerebrovascular diseases causing head pain
• extracranial temporal and occipital arteries,
– when involved in giant cell arteritis (cranial or
“temporal” arteritis), give rise to severe, persistent
headache,
– at first localized on the scalp and then more diffuse
• Vertebral artery,
– occlusion or dissection produce pain in the upper neck
or postauricular area;
• Basilar artery thrombosis
– causes pain to be projected to the occiput and
sometimes to the forehead

49. • carotid artery
– Occlusion/dissection may produce ipsilateral eye and
brow and the forehead also produced by
– occlusion of the stem of the middle cerebral arteries.
• PCA/ DISTAL ICA:
– Aneurysm /dilatation produce pain projected to the eye

50. • Sinusitis :
– frontal and ethmoidal sinusitis,
• the pain tends to be worse on awakening
• gradually subsides when the patient is upright;
– Maxillary and sphenoidal sinusitis
• the opposite happens
– pain is ascribed to filling of the sinuses and its relief to
their emptying, induced by the dependent position of
the ostia.
– Bending over intensifies the pain by causing changes in
pressure, as does blowing the nose and air travel,
especially on descent,

51. Headache of ocular origin,
• Site :
– orbit, forehead, or temple, is of the steady,
– aching type
– follow prolonged use of the eyes in close work.
• Hypermetropia and astigmatism (rarely myopia),
– which result in sustained contraction of extraocular as
well as frontal, temporal, and even occipital muscles.
– Correction of the refractive error abolishes the
headache.
• Iridocyclitis and in acute angle closure glaucoma,
– in which raised intraocular pressure causes steady,
aching pain in the region of the eye, radiating to the
forehead

52. Headache of upper cervical spine
• Headaches that accompany disease of ligaments,
muscles,and apophysial joints in the upper part of the
cervical spine
• are referred to the occiput and nape of the neck on the
same side and sometimes to the temple and forehead.
• Degenerative changes in the cervical spine
• Arthritic
– Pain on first movements after prolonged rest for some hours
are
– stiff and painful.
• Pain of fibromyalgia:
– a controversial entity, is putatively characterized by tender
areas near the cranial insertion of cervical and other
muscles.

53. Headache of meningeal irritation
• (infection or hemorrhage) is acute in onset, usually
severe, generalized, deep seated, constant,
• associated with stiffness of the neck, particularly on
forward bending.
• dilatation and inflammation of meningeal vessels
• chemical irritation of pain receptors in the large
vessels and meninges by endogenous chemical
agents, particularly serotonin and plasma kinins,
• are probably more important factors in the
production of pain and spasm of the neck
extensors.

54. Spontaneous/post LP low CSF
pressure headache,
• steady occipitonuchal and frontal pain coming
on within a few minutes after arising from a
recumbent position
• is relieved within a minute or two by lying down
• this type of headache is increased by
compression of the jugular veins but is unaffected
by digital obliteration of the carotid artery.
• Headache caused by caudal displacement of the
brain, with traction on dural attachments and
dural sinuses

55. Exertional headaches
• are usually benign but sometimes related to
• pheochromocytoma,
• arteriovenous malformation, or other
intracranial lesions,
• in addition to the aforementioned
subarachnoid hemorrhage from ruptured
aneurysm