Headache

Almost all headaches have a vascular character (throbbing sensation) which is elicited only when the patient describes the symptoms properly and a competent physician listen to the patient carefully. Vascular headache is only a symptom (like fever); look for an underlying illness or precipitating cause/causes.

If, after proper evaluation,

• One fails to find a precipitating cause for vascular headache and if it keeps on recurring and has a familial predisposition, one can call it as Migraine.
• In Migraine, there can be symptoms and signs due to vasospasm also in contrast to other vascular headaches.
• Hypertension usually is not a cause for headache. The site of vascular headache is often decided by the precipitating factor.
• Neuralgic facial pains (Trigeminal neuralgia) can be easily differentiated from vascular headache because of the distinct character

Causes of Vascular Headache

1. Fever: Due to any cause; Enteric fever very often is preceded by severe vascular headache mistaken for migraine, many times patient had gone to ENT specialist/ neurologist before the onset of fever. Headache in a febrile patient most often is not due to CNS infection but one has to exclude it.
2. Nasal obstruction: Very often due to allergic rhinitis or viral infection. Upper respiratory infections (URI) produces blocked ostia leading to vacuum in the sinuses which precipitates vascular headache; misdiagnosed as sinusitis, in fact this headache is relieved once the rhinitis is controlled along with use of drugs effective in migraine— no need of antibiotics unless there is evidence of infection in the sinus (like warmth, edema and severe tenderness over sinus and fever. Mild tenderness is nonspecific often).
3. Eye strain: Commonest cause of which is refractive error.
4. Painful lesions in and around the head
5. Anxiety, Depression.
6. Drugs like isosorbide dinitrate (which cause vasodilatation).
7. Increased intracranial pressure

• Meningitis
• Encephalitis
• ICSOL
• Subarachnoid hemorrhage/Intracranial hemorrhage
• Malignant hypertension
• Accelerated hypertension
• Arteriovenous malformations. Vascular headache due to 3,4 and 5 are diagnosed as Tension headaches which is a confusing term.

Management of Headache

1. Find out the cause(s) of headache

• Treat the cause of fever
• Relieve rhinitis
• Correct refractive error
• Treat painful lesions in head and neck region
• Treat depression preferably with Amitriptyline, as it is useful in migraine also
• Reassure the patient: Often the patient wants only this, as he/she is afraid whether there is a brain tumor or not.

​2. Treatment of the cause alone may not relieve the headache in patients who are prone for migraine headaches. They require drugs to relieve the acute attack like:

• Paracetamol 500 mg SOS
• Ibuprofen + Paracetamol (400 mg + 325 mg) SOS
• Ergot alkaloids SOS (should be used early to be effective (avoid in IHD, HTN, PVD and pregnancy)
• Sumatriptan 25-50 mg SOS (5-HT receptor agonist, avoid in HTN, IHD, PVD) Usually one dose is enough to relieve the acute attack.

​3. In those patients with repeated attacks over long periods (i.e. more than 2-3/week) prophylaxis is given, especially when it persists even after correcting all possible precipitating factors

Drugs used for prophylaxis

a. Propranolol 10 to 40 mg 8th hourly. Avoid in asthmatics, ideal if patient has hypertension also.

b. Amitryptyline 10 to 75 mg HS, avoid in those with hypertension and IHD. Ideal in those with depression and migraine, can cause weight gain.

c. Flunarazine 5 to 10 mg HS, use when other drugs are contraindicated or may be combined with Amyline (Amitriptyline) or Inderol (propranolol) in severe cases, can cause weight gain.