Tag Archives: Headache

Cavernous Sinus Syndrome

Diagnosis: This is a clinical diagnosis. Dysfunction of cranial nerves III, IV, and VI, and the superior divisions of cranial nerve V. Investigations to consider: Blood tests: FBC, U&E, fasting Glucose Vasculitic screen, ESR, CRP, ANCA, ANA, ENA SPEP, ACE Tests for infections: Borrelia serology, HIV MRI pre and post contrast: Pituitary tumors, meningioma, metastasis … Continue reading Cavernous Sinus Syndrome

Raised Intracranial Pressure, raised ICP

This is an abnormality that can occur due to multiple potential causes. It is treated based on the underlying cause and severity. Diagnosis: Intracranial pressure monitoring: Ventriculostomy (external ventricular drain EVD) Implantable ICP monitor Lumbar drain Raised opening pressure on Lumbar puncture (e.g. in cases of pseudotumor cerebri or meningitis). This should not be performed … Continue reading Raised Intracranial Pressure, raised ICP

Chiari Malformation

Synonyms: Arnold Chiari malformation Chiari I malforamation: Diagnosis: MRI Clinical features: May be asymptomatic (usually this is the case) In some cases can be associated with headaches and transient brainstem dysfunction Findings on Investigations: MRI: Low lying cerebellar tonsils extending below the foramen magnum Treatment: Usually no treatment Medications for headache (but avoid overuse) In … Continue reading Chiari Malformation

Empty Sella Syndrome

Diagnosis: An imaging finding that may or may not be associated with clinical features Clinical features: Mild headache, CSF rhinorrhea, hypertension, obesity Findings on Investigations: CT: empty sella i.e. sella turcica that is completely or partially filled with CSF, MRI: empty sella i.e. sella turcica that is completely or partially filled with CSF, TSH, gonadotrophin: … Continue reading Empty Sella Syndrome

Burning mouth syndrome

Diagnosis: Burning sensation in the mouth or tongue for which there is no identifiable cause Diagnosis of exclusion Related articles: Approach to headache,

Persistent Idiopathic Facial Pain

Synonyms: formerly atypical facial pain Diagnosis: A diagnosis by exclusion Facial pain not meeting criteria for other neuralgias or secondary causes Treatment: Amitriptyline +/-phenelzine or Phenytoin PHT Related articles: Approach to headache, trigeminal neuralgia,

Temoporomandibular joint TMJ syndrome

Diagnosis: Clinical: Pain around the TMJ +one of the following: Noise from TMJ on jaw opening Tenderness at TMJ joint capsule Pain occurs with chewing or moving the jaw Reduced jaw range or irregular opening +Imaging: CT X-ray MRI Bone scintigraphy Treatment: Nocternal bite guard Local heat application Jaw exercises NSAIDs Related articles: Approach to … Continue reading Temoporomandibular joint TMJ syndrome

Post-Herpetic Neuralgia

Synonyms: Post zoster neuralgia VZV: Diagnosis: Persistence of the pain of herpes zoster more than 3 months after resolution of the rash. Zoster-associated pain: the continuum of pain from acute herpes zoster to the development of postherpetic neuralgia. Treatment: Best medications: Tricyclic antidepressants: Nortriptyline, amitriptyline, desipramine, and maprotiline Antiepileptics: Gabapentin GBP, pregabalin Opioids: Oxycodone or … Continue reading Post-Herpetic Neuralgia

Glossopharyngeal Neuralgia

Diagnosis: Clinical: Pain in: ear, base of tongue, tonsillar fossa, beneth the angle of the jaw +Pain <2 minutes +reproducing the pain through trigger zone stimulation Primary or secondary Investigations to consider: MRI+contrast, MRA Treatment: Treat the cause if identified Carbamazepine CBZ, three times a day, controls the pain & syncope or Phenytoin PHT Related … Continue reading Glossopharyngeal Neuralgia

Trigeminal Neuralgia

Synonyms: formerly tic douloureux Diagnosis: Clinical: Brief electric shock like pains or stabbing +last 1 second to 2 minutes +in the distribution of the trigeminal nerve +attacks are stereotyped May be triggered by light touch of areas supplied by the trigeminal nerve Primary (classic) or secondary forms Electrophysiology: trigeminal nerve reflexes can distinguish between primary … Continue reading Trigeminal Neuralgia

Idiopathic Stabbing Headache

Synonyms: a.k.a. primary stabbing headache a.k.a. idiopathic Ice pick pain a.k.a. jabs and jolts syndrome: Diagnosis: Clinical: Sharp ice pick like pain, lasting less than 1 second Within the distribution of trigeminal nerve, especially V1 division. Rarely it is outside this distribution May cause flinching & may occur in a series Note: Ice pick like … Continue reading Idiopathic Stabbing Headache

Medication Overuse Headache

Synonyms: Analgesic use headache: Treatment: Withdraw responsible medication Stop caffeine intake For headaches during withdrawal consider: Topiramate up to 200mg (moderate evidence base) Prednisone 60mg (weak evidence base) Amitriptyline up to 50mg (weak evidence base) Teat underlying headache after a few weeks Related articles: Approach to headache,

New Daily Persistent Headache

Diagnosis: Similar to Chronic daily headache but is daily from the outset (within 3 days) >3 months, daily. Exclusion of other primary headaches, analgesic use headache, secondary headaches Related articles: Approach to headache,

Chronic Daily Headache

Diagnosis: >15 days per month for >6 months. Subtypes: Chronic tension type headache Chronic migraine (see under migraine) Transformed migraine: chronic daily headache that has evolved from migraine not meeting criteria for chronic migraine. Believed to be the late stage of chronic migraine. Treatment: Behavioural psychotherapy Physical therapy for myofascial symptoms Consider trigger point botulinum … Continue reading Chronic Daily Headache

Hypnic Headache

Diagnosis: Clinical: Similar to cluster headache but bilateral, lacks autonomic components & occurs in the elderly. Treatment: Consider Lithium Related articles: Approach to headache,

Hemicrania Continua

Diagnosis: Clinical: Unilateral headache, +Unremitting (no pain free periods) daily for >3months, but with exacerbations +1 autonomic feature: Conjunctival injection or lacrimation Nasal congestion or rhinorrhea Ptosis or miosis +response to indomethacin Treatment: Indomethacin 25 mg TID up to 200 mg/day (strong evidence base) Related articles: Approach to headache, SUNCT headache,

Short-lasting Unilateral Neuralgiform headache attacks with Conjunctival injection and Tearing (SUNCT)

Diagnosis: Clinical: similar to cluster headache (character) except: Much shorter duration Only has eye autonomic symptoms Doesn’t meet criteria for other headache disorder Treatment: Lamotrigine (weak evidence base) Related articles: Approach to headache, Cluster headache,

Paroxysmal Hemicrania

Diagnosis: Clinical, similar to cluster headache (character & associated symptoms) except: No male predominance Attacks are shorter, more frequent Complete resolution with Indomethacin Episodic & chronic forms Treatment: Prophylaxis: Indomethacin up to 200mg (strong evidence base) Verapamil (weak evidence base) NSAIDs (weak evidence base) Topiramate (weak evidence base) Related articles: Approach to headache, Cluster headache, … Continue reading Paroxysmal Hemicrania

Cluster Headache

Diagnosis: Clinical: Always unilateral. Usually periorbital pain. M>F +15-180 minutes, multiple times per day for weeks +long (month) headache free period +associated with ipsilateral autonomic features: Conjunctival injection or lacrimation Nasal congestion or rhinorrhea Ptosis or miosis Eyelid or forehead swelling Treatment: Acutely: 100% Oxygen inhaled, 7-10 L/min for 15 min (strong evidence base) Sumatriptan … Continue reading Cluster Headache

Familial Hemiplegic Migraine

  Diagnosis: Genetics: Autosomal dominant Ca++ CACNA1A, a P/Q-type of calcium channel. Clinical: 1st & 2nd decade Migraine with aura associated with hemiplegia (hemiparesthesia, hemianopia, dysphagia) Lasts >24 hours Related articles: Approach to headache,

Slit Ventricle Syndrome

Diagnosis: Clinical: a syndrome that occurs when VP shunts fail without enlargement in ventricles. intermittent symptoms of increased intracranial pressure. Raised CSF pressure CT/MRI: Subnormal ventricular size Related articles: Approach to headache,

Spontaneous Intracranial Hypotension

Synonyms: a.k.a. sinking brain syndrome a.k.a. Spontaneous CSF leak Diagnosis: Clinical: Orthostatic headache a.k.a. postural headache (improves on lying down): Worsened by standing in <15 minutes Associated symptoms: tinnitus, hypacusia, photophobia, nausea, neck stiffness May present with thunderclap headache Later stages: drowsiness, coma No history of dural puncture or LP MRI: Postcontrast: enhancement of thickened … Continue reading Spontaneous Intracranial Hypotension

Idiopathic Intracranial Hypertension

Synonyms: a.k.a. Benign intracranial hypertesion a.k.a. Pseudotumor cerebri Diagnosis: Clinical: Headache +Visual disturbances e.g. peripheral visual field loss or diplopia, “transient visual obscurations”. +Papilloedema, +/-VI palsy +Imaing MRI, MRV or CTV: No ventricular dilation No venous sinus thrombosis Transependymal oedema may occur +lumbar puncture opening pressure: 25—40 cm H2O Visual fields, by perimetry: nasal step … Continue reading Idiopathic Intracranial Hypertension

Post Lumbar Puncture Headache

Diagnosis: Clinical: Post lumbar puncture, worse on standing, better on lying down Treatment: Usually self limited Caffeine sodium benzoate P.O. or I.V. 300-500mg If persistent consider autologous blood injection into the puncture site ‘blood patch’: Using Tuohy needle 20-30ml of blood Related articles: Approach to headache,

Primary Thunderclap Headache

Diagnosis: Clinical +exclude secondary causes (see list below e.g. subarachnoid hemorrhage, venous sinus thrombosis & others): Sudden onset, maximum intensity within 1 minute Lasts 1hr to 10 days Doesn’t recur within months Note: Secondary causes to exclude: SAH, intracranial hematoma, arterial dissection, venous sinus thrombosis, reversible cerebral vasoconstriction syndrome (RCVS), Other primary headaches to exclude: … Continue reading Primary Thunderclap Headache

Primary headache associated with sexual activity

Synonyms: a.k.a. Orgasmic headache a.k.a. Postcoitus Headache Diagnosis: Clinical +exclude subarachnoid hemorrhage Investigations to consider: To exclude subarachnoid hemorrhage Treatment: Prophylactic indometacin prior to intercourse

Perimesenchphalic Subarachnoid Hemorrhage

Diagnosis: CT or MRI: blood in CSF space around the midbrain i.e. peri-mesencephalic. Usually in prepontine cistern or quadrageminal cistern. +Catheter Angiography: that excludes any cause of SAH. Especially posterior circulation aneurysm. +absence of trauma DDx. Aneurysmal subarachnoid hemorrhage due to ruptured posterior  inferior cerebellar artery (PICA) aneurysms 7% of Posterior circulation aneurysms may present … Continue reading Perimesenchphalic Subarachnoid Hemorrhage

Subarachnoid Hemorrhage

Synonyms: Subarachnoid haemorrhage Diagnosis: Findings on Investigations: Diagnosis is established by neuroimaging (CT or MRI) or by lumbar puncture Non-contrast CT: Demonstrates subarachnoid hemorrhage in the acute phase. May be negative, but is positive in the majority of cases. If CT is negative LP is indicated. Blood in CSF spaces: sulci & cisterns. May also … Continue reading Subarachnoid Hemorrhage

Intracerebral Hemorrhage

This section will discuss intracerebral hemorrhage; the commonest type of hemorrhagic stroke. Hemorrhagic stroke is a broad category of stroke and includes intracerebral hemorrhage and subarachnoid hemorrhage. Together these two conditions represent 13-20% of stroke cases with the rest being due to ischemic stroke. Intracerebral hemorrhage is more common than subarachnoid hemorrhage with the later … Continue reading Intracerebral Hemorrhage

Viral Encephalitis

Viral encephalitis is the commonest cause of encephalitis. The general features and causes of encephalitis are described in a separate section. Here we discuss the various viral encephalitides.   HSV Encephalitis: Diagnosis: Clinical findings combined with MRI features and isolation of virus by PCR or pathology Findings on investigations: CT: Low density in: Insular regions, … Continue reading Viral Encephalitis

Tension-Type Headache

Tension-type headache (TTH) is the commonest headache. It has a very high incidence with most people experiencing a tension-type headache at some point in their lives. There are many subtypes of Tension-type headache. The commonest one is the infrequent episode variant which tends to be mild and self-limiting. However, other people may experience more frequent … Continue reading Tension-Type Headache


Encephalitis is the term used to describe an inflammatory process of the substance of the brain. This distinguishes it from meningitis which is an inflammatory process of the coverings of the brain. There are patients who have inflammation of both areas and this is described as meningo-encephalitis. Patients with encephalitis and those with meningitis present … Continue reading Encephalitis

Viral Meningitis

Diagnosis: Clinical features plus confirmation by CSF analysis & isolation of the virus or PCR or antibody tests Findings on Investigations: CSF analysis: Early LP may show: Increased neutrophils, Glucose normal Later: White cell counts: moderately high, <1000/mL (usually 25-500/microL) Lymphocytes or monocytes RCC: raised in HSV encephalitis Glucose normal Protein: Usually normal Or slightly … Continue reading Viral Meningitis

Bacterial Meningitis

Diagnosis: Clinical features plus confirmation by CSF analysis Findings in Bacterial meningitis: High opening pressure >180 mmH2O, turbid/purulent appearance White cell count: high, 10-10,000/microL Mainly neutrophils (usually >100), but monocytes are suggestive of Listeria monocytogenes Protein: High, >0.45 g/L (>45 mg/dL) Glucose: low, <0.4 of serum (roughly <1/2 serum), or <2.2 mmol/L (<40 mg/dL) Borrelia … Continue reading Bacterial Meningitis


Clinical features: Patients present with headache and necks stiffness. They typically have a fever, unless they are immunosupressed, and may have a rash. The classic triad in bacterial meningitis is headache, fever and rash. It is a serious life-threatening medical emergency that often results in significant disability. However, the commonest cause of meningits overall is … Continue reading Meningitis


Diagnosis: The diagnosis is clinical: after history & physical exam. On occasion imaging and other tests should be obtained to exclude competing differential diagnoses. Adapted from International Headache Society IHS Criteria, used mainly in research: Migraine without aura a.k.a. Common Migraine: A.     At least 5 attacks fulfilling criteria B through D B.     Headache lasting from … Continue reading Migraine