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Secondary Headaches

Key Features of Secondary Headaches

Secondary Headaches Overview

The vast majority of patients entering neurology office and complaining of headaches are concerned about… having a brain tumor. Basically, they want to know if “it is just a headache” or “something bad”, like a “tumor”. Using medical terms, everyone is concerned about having secondary headaches. Whether the headache is primary or secondary is the first question in neurologist’s mind as well. Why? Because primary headaches cause nothing more than misery, but they come and go with no harm.

Secondary headaches, by definition, are secondary to other disease and the headache is just a symptoms. Secondary headaches may lead to grave consequences, such as disability or even death. Please, don’t expect some Brain MRI to resolve all the diagnostic hurdles. Sometimes normal Brain MRI will only lead to a false sense of security. Yes, tumors are seen on MRI pretty well. But… in headache diagnostic work up “a tumor” is the last thing to worry about.

So, what makes neurologist suspicious about some headache being secondary?  The main feature is lack of specific pattern typical for primary headaches. There is a limited number of primary headache types. Every single one has a very specific set of associated symptoms. Lack of such is always suspicious for secondary headaches.

There is one “primary” headache, which I refuse to call primary. It’s tension headache. I have never seen a tension headache without particular cause. Even though, in tension headache the cause is outside the head, it is still secondary to… something. The most common reason is a chronic sleep deprivation or poor sleep quality.

The most concerning secondary headaches are:  sudden “worst of life headache” because it might be caused by subarachnoid hemorrhage, which is often deadly or disabling; constant localized scalp pain in temporal arteritis, because it might cause a complete loss of vision in one and later in another eye; chronic daily headache in pseudotumor cerebri because of threat to vision as well. Secondary headache is a part of many other diseases, such as meningitis, but there are usually specific findings on examination helping to make the right diagnosis.

Secondary headaches might mimic primary headaches and vice versa. Classical migraine with aura might be simulated by an arteriovenous malformation, or be a part of rear genetic disorder, CADASIL. Some primary headaches are sometimes hard to differentiate from trigeminal neuralgia.

Secondary headaches do have specific patterns too. Secondary headache diagnosis is based on gender, age, precipitating factors, length, localization, pain onset intensity, associated symptoms, neurological examination findings, diagnostic imaging and blood work results, and preexisting medical conditions.

Level of neurologist expertise is, probably, the main factor in the timely and correct diagnosis and management of secondary headaches.

Key Features of Secondary Headaches

Unlike primary headaches, which have predictable type, duration, frequency, and location of pain, as well as specific set of associated symptoms, secondary headache phenomenon is much more elusive. Secondary headaches often look alike. In primary headaches, the diagnosis is mostly based on the set of symptoms alone. In secondary headaches, identification of the underlying disease is the goal.

The approach to the diagnosis in secondary headaches is also different. In primary headaches the diagnosis is always with a “plus” sign. It is definite. For example, “migraine” and “hypnic headache” are statements. Why? – You can’t “rule out migraine” because there is no way to do this.

In secondary headaches, the diagnosis is almost always “rule out… something”. Headache symptom is a sign of some disease, which has to be either ruled in or ruled out by additional examination, questioning, and diagnostic testing.

Below are typical secondary headache syndromes occurring in association with specific disorders.

  • Sudden excruciating pain in the whole head – Subarachnoid Hemorrhage it is, unless proven otherwise.
  • Similar sudden headache associated with vision problems – Rule out Pituitary Apoplexy
  • Sudden pain in one side of the head or neck lasting for a few days followed by a stroke within a couple of weeks – Vertebral or Carotid Dissection
  • Constant annoying moderate one sided or the whole head pain in a person after age 60 – Giant Cell (Temporal) Arteritis must always be considered in this age group.
  • Strongly position-dependent pain in the mid-to-upper face and orbit. It is worse at night. Face might be puffy on one side or both – Acute Sinusitis is the first possibility to be ruled out.
  • Constant heavy sensation in the head or dull headache, which is often worse at night in a young overweight lady. Episodic head motion dependent transient visual obscuration, like looking through a ground glass, is typical. – Pseudotumor Cerebri, or Idiopathic Intracranial Hypertension is a prime suspect.
  • Frequent or constant headache for months or years associated with dizziness, difficulty concentrating, fatigue, lack of refreshment upon awakening, daytime sleepiness, falling asleep during inactivity. Naps bring no relief. – Chronic Sleep deprivation due to Sleep Apnea is the most likely offender.
  • Frequent or daily headaches of variable intensity, quality and location; irritability, anxiety, depressed mood, memory problems, fatigue but no daytime sleepiness. Inability to nap even if attempted. Night sleep is shallow, interrupted by frequent awakenings, early awakenings in the morning. – Chronic Daily Headache caused by Sleep Deprivation due to Anxiety Disorder and/or Depression
  • Strong pounding headache exclusively in upright body position, which is relieved shortly after laying down – Intracranial Hypotension is almost certain.
  • Chronic daily headache of variable quality and location, temporarily relieved by one or a combination of the following medications, which are taken on a regular basis (multiple times per week): Tylenol, Excedrin, Fioricet/Fiorinal (Butalbital containing), any of Triptans or narcotics, Paracetamol, Analgin/Baralgin (Russia/Eastern Europe) – Analgesic Rebound Headache must always be considered.
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