2% or more of emergency department visits, accounting as the fourth leading cause of such visits in the US.

Prevalence of any type of headache in an industrial society is 69% among men and 88% among women.

Headaches are a common problem worldwide, affecting an estimated 50% of adults.

It is estimated that 14% of adults worldwide have migraine.

Headaches can be caused by a variety of factors, and it’s important to identify the underlying cause in order to determine the appropriate treatment.

Some common causes of headaches:

1. Tension headaches: These are the most common type of headache and are often caused by muscle tension or stress.

Common triggers include poor posture, eye strain, lack of sleep, or emotional stress.

2. Migraines: Migraines are severe headaches that are often accompanied by other symptoms such as nausea, sensitivity to light and sound, and visual disturbances.

Migraines can be triggered by various factors, including certain foods (such as chocolate or cheese), hormonal changes, stress, lack of sleep, or environmental factors.

3. Cluster headaches: Cluster headaches are intense headaches that occur in clusters or patterns, typically affecting one side of the head.

They are often described as extremely painful and can be accompanied by symptoms such as red or teary eyes, nasal congestion, or restlessness.

The exact cause of cluster headaches is unknown, but they are thought to be related to abnormalities in the hypothalamus.

4. Sinus headaches: Sinus headaches are typically caused by sinusitis, which is the inflammation of the sinuses due to infection or allergies.

The pain is often localized around the forehead, cheeks, and eyes, and is usually accompanied by nasal congestion and facial tenderness.

5. Medication overuse headaches:

Excessive use or over-reliance on certain medications, such as painkillers or migraine medications, can actually lead to headaches: medication overuse headaches or rebound headaches.

6. Other causes: Headaches can also be caused by other factors, such as dehydration, caffeine withdrawal, head injury, high blood pressure, or certain medical conditions.

Tension headache is the most common type of headache.

It is estimated that 26% of adults worldwide have tension headache.

Headaches can occur at any age, but they are more common in adults.

Women are more likely than men to have headaches, especially migraines.

There is some evidence that headaches may be more common in certain racial groups, such as African Americans and Hispanics.

Headaches are more common in people with lower socioeconomic status.

Headaches are often associated with other medical conditions, such as depression, anxiety, and sleep disorders.

Headaches can have a significant impact on a person’s life, interferng with work, school, relationships, and leisure activities.

Lifetime prevalence of 99% for women and 94% for men.

Prevalence decreases in persons after age 40.

More than 50% of our patient visits for headache occur in primary care

The global prevalence of tension-type headache is approximately 40% and migraine 10%.

The direct and indirect socioeconomic costs of headache is estimated at 14 billion dollars per year.

Approximately 15% of adults report experiencing a headache within a three month period.

More than 300 different types and causes of headache.

All headaches reflect perception of pain via nociceptive information from the head via the nucleus of the trigeminal nerve.

Historical aspects needed to be queried include: medical history, social history, history of alcohol, medication use, specific questions about the headaches associated to onset, character, location,, frequency, duration, radiation, aggravating factors, alleviation factors, relative past history, presence of auras, hallucinations, nausea, vomiting and focal neurological symptoms.

Historical aspects of age of onset is extremely important as is a family history of headaches.

Important lifestyle features of headache include diet, caffeine use, sleep habits, work, and personal stresses.

Historical aspects of associate sleep disorders, depression, anxiety, and underlying medical disorders are important.

Clinical examination in the evaluation of headache is based on a general neurologic examination including examination of the superficial scalp vessels, neck vessels, temporomandibulat joint, bite, dentition, and cervical and shoulder musculature.

Pericranial muscle tenderness can be an important finding in the diagnosis of tension-type headache.

Almost all headaches are benign.

In a cohort of patients with sudden death who presented with headache, 55%were older than 15 years and most of these deaths were secondary to vascular events including aneurysm rupture, intracranial hemorrhage, and cervical artery dissection.

Approximately $1 billion a year is spent on unnecessary brain imaging of primary headache disorders.

A primary headache has no underlying known cause.

Secondary headache is the result of another condition causing traction on or inflammation of pain sensitive structures.

Secondary headache presents because of another condition, such as inflammation , intracranial lesions, structural spinal abnormalities, medications, or other medical comorbid conditions.

In patients with new-onset headache about 15% of those 65 years or older had a secondary headache compared with 1.6% of patients younger than 65 years.

Headache that is related to a psychiatric disease is also considered a secondary process.

Most common causes of primary headache are: migraine, tension type headache, and cluster headache.

Secondary headaches include infection, vascular disease, and trauma.

Only 1% of patients with brain tumor will have a headache is this sole complaint.

Vast majority of patients present for evaluation of a headache have a primary headache disorder.

Only a small subset of patients with acute headache should have imaging or specialist referral.

Radiographic imaging should not be done in patients with uncomplicated headaches.

In evaluation of headaches neuroimaging to rule out a secondary cause of headache should be done when there is an abnormal neurologic exam, atypical headache features, or headaches that do not fit the strict definition of migraine or other primary headache disorder.

Atypical headache features include rapidly increasing headache frequency, history of lack of coordination, history of localized neurological signs, and history of headache causing awakening from sleep.

Red flags: sudden onset or onset during exertion, any abnormality on neurological examination, age greater than 50 years, worsening headache under observation, abnormal vital signs, new-onset headaches in patients with cancer or AIDS, first/worst headache or seizures.

Population prevalence for cluster headaches, migraine or tension headaches are 0.4%, 6-17%, and 38.3%, respectively.

More than 90% of headaches in women are caused by tension and migraine.

Tension headaches affect as many as 69% of the population.

The history is the main determinant of diagnostic testing and the course of treatment.

Undifferentiated type usually is benign and neuroimaging does not reveal neuropathology.

Significant neurologic problems such associated CNS tumors, hemorrhages, abscesses and aneurysms may present with headache and require neuroimaging for diagnoses.

Secondary headaches 1-2% of patients aged less than 65 years compared to 15% of elderly patients.

The overwhelming majority of HA are tension-type and migraine HA, for which imaging provides no benefit for either diagnosis or treatment.

In almost all cases where HA has significant associated pathology other signs and symptoms besides the pain are also present.

Chronic daily headaches of long duration include chronic migraine, chronic tension-type headache, Hemicrania continua, and new daily persistent headache.

Prevalence of chronic daily headache is 3 – 5%, most of which likely represents chronic migraine.

Other types of signs and symptoms besides the pain are also present or precede the HA.

HA associated with underlying pathology that requires further testing includes: Abnormalities on motor or sensory neurologic exams, sudden or explosive HA, and headaches different from ones previously experienced by patients, especially 50 years or older.

With age comes an increased incidence of disease processes that might cause HA, include tumors, stroke, and subdural hematoma.

Temporal arteritis presents with a severe HA without accompanying neurologic abnormalities.

Temporal arteritis almost always occurs in patients over age 55, and diagnosis is based on tests to determine the presence of inflammation, rather than on neuroimaging.

Headaches with a change in mental status, after head trauma or in the presence of fever or nuchal rigidity. may indicate meningitis and a diagnosis usually is made by lumbar puncture: imaging may be required to make sure the LP can be safely performed.

Most post traumatic headaches have the phenotype of migraine.

Prevalence of headache ranges from 12-50%, with frequent headaches from occurring at 17% of people older than age 65 years.

Headache in older adults is most likely caused by a primary headache disorder, such as tension headache or migraine, older age increases the risk of secondary cause of headache.

New-onset headache in older adults requires evaluation for a possible secondary headache disorder and diagnostic evaluation ranging from blood test to neuroimaging.

The presence of comorbid medical conditions in the elderly places them at a higher risk of secondary headache.

The risk of life-threatening secondary headache is increased tenfold in individuals 65 years and older.

New-onset headache evaluation first step is to exclude secondary headache.

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