Headache Causes

Aka: Headache Causes, Primary Headache, Headache Central Sensitization

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II. Epidemiology: Prevalence

  1. Episodic Headaches: 50% of U.S. adults suffer from Headaches at any period of time
    1. Progress to chronic Headaches in 3-4% of episodic Headache patients (central sensitization)
  2. Chronic Headaches: 2-4% of U.S. Adults
    1. Chronic daily symptoms in up to 30% of those with chronic Headaches
  3. Headaches are a common trigger for medical care visits
    1. Acute Headache is the fourth most common reason for Emergency Department evaluation
    2. Half of Migraine Headache visits are to primary care

III. Pathophysiology: Headache Central Sensitization

  1. Frequent episodic Headaches may progress to chronic Headaches without management
  2. Results in central sensitization and Neuronal dysfunction
  3. Central sensitization Inappropriate response to low level stimuli
    1. Lower thresholds trigger pain response
    2. Exaggerated stimulus response
    3. Pain persists after trigger is removed
  4. Risk Factors for progression from episodic Headache to chronic Headache are specific to Headache type
    1. See Migraine Headache
    2. See Tension Headache

IV. Causes: Urgent Headaches

  1. Subarachnoid Hemorrhage
  2. Vertebral Artery Dissection
  3. Carotid Artery Dissection
  4. Hypertensive Emergency
  5. Giant Cell Arteritis
  6. Bacterial Meningitis
  7. Acute angle closure Glaucoma

V. Causes: Primary Headaches

  1. See Acute Recurrent Headache
  2. See Chronic Nonprogressive Headache
  3. Common Headaches
    1. Tension Headache (50% of acute Headaches)
    2. Common Migraine Headache (10% of acute Headaches)
  4. Other Primary Headaches
    1. Migraine with Aura (Classic Migraine)
    2. Cluster Headache and other trigeminal autonomic Cephalgias (<1%)
    3. Sexual Headache

VI. Causes: Secondary Headaches

  1. See Headache Red Flag
  2. Acute Localized Headache
    1. Sinus Headache (e.g. Acute Sinusitis)
    2. Myofacial pain
      1. Cervical Spine disorder (Cervical Spondylosis)
      2. Temporomandibular Joint Dysfunction
    3. Ophthalmologic Headache
      1. Acute Angle-Closure Glaucoma (severe Eye Pain)
  3. Generalized Headache
    1. See Acute Generalized Headache
    2. See Chronic Progressive Headache (Organic Headache)
    3. See Headache Red Flags
  4. Life-treatening secondary causes
    1. Meningitis or Encephalitis
    2. Carbon Monoxide Poisoning
    3. Subarachnoid Hemorrhage
    4. Acute or chronic Subdural Hematoma
    5. Cerebellar infarction
    6. Temporal Arteritis
    7. Cerebral or dural venous sinus thrombosis
    8. Cervical Artery Dissection (carotid dissection, Vertebrobasilar Dissection)
    9. Preeclampsia (Pregnancy Induced Hypertension)
    10. Intracranial Mass
    11. Pituitary apoplexy
  5. Miscellaneous secondary causes
    1. Hormonal Headache
      1. Menstrual Migraine
      2. Estrogen in Oral Contraceptive
    2. Benign Intracranial Hypertension: Pseudotumor Cerebri (esp. in women with Obesity)
    3. Post-Traumatic Headache (Postconcussion Syndrome)
    4. Obstructive Sleep Apnea
    5. Temporomandibular Joint Disorder
    6. Frontal Sinusitis

VII. History

  1. See Headache History

VIII. Exam

  1. See Headache Examination

IX. Differential Diagnosis

  1. See Headache Causes
  2. See Headache Red Flag
  3. See Organic Headache

X. Diagnostics

  1. See Headache Diagnostic Testing
  2. See Neuroimaging in Headache

XI. Management

  1. See Nonpharmacologic Headache Treatment
  2. See Chronic Daily Headache
  3. Musculoskeletal Headaches
    1. See Tension Headache
    2. See Occipital Headache
  4. Migraine Headache Management
    1. See Migraine Headache Management
    2. See Migraine Abortive Treatment
    3. See Migraine Headache Prophylaxis
    4. See Migraine Headache Management in Children
    5. See Emergency Department Migraine Headache Care
  5. Iatrogenic Headaches and medication overuse
    1. See Rebound Headache
    2. See Spinal Headache (Post-Dural Puncture Headache)
  6. Trigeminal Nerve Syndromes
    1. See Trigeminal Neuralgia
    2. See Cluster Headache
    3. See SUNCT Syndrome
    4. See Paroxysmal Hemicrania
    5. See Hemicrania Continua
  7. Organic Headaches
    1. See Headache Red Flag
    2. See Subarachnoid Hemorrhage (Thunderclap Headache)
    3. See Pseudotumor Cerebri
    4. See Exertional Headache
    5. See Temporal Arteritis
  8. Headache Management in women
    1. Hypertensive Disorders of Pregnancy
    2. See Migraine Medications in Pregnancy
    3. See Migraine Medications in Breast Feeding
    4. See Headache in Pregnancy
    5. See Menstrual Migraine
  9. Headaches in other specific cohorts
    1. See Headache in HIV

XII. References

  1. Mayans (2018) Am Fam Physician 97(4): 243-51 [PubMed]
  2. Walling (2020) Am Fam Physician 101(7):419-28 [PubMed]
  3. Viera (2022) Am Fam Physician 106(3): 260-8 [PubMed]

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