Headache secondary to medical conditions (2)

Reviewing other medical conditions

There are a number of other medical conditions that can cause secondary headaches. Three of the most common are:

• Cerebral sinus thrombosis
• Head injury
• Infection

Cerebral venous sinus thrombosis

Cerebral venous sinus thrombosis (CVST) involves clots within the brain’s venous system which slow or halt the flow of venous blood. Although rare, obstruction of venous outflow can lead to bilateral venous infarcts with hemorrhage and focal neurologic deficit.

Women who are postpartum or pregnant, and those taking oestrogen or oral birth control pills, are more prone to CVST.

Cerebral venous sinus thrombosis is treated with anticoagulants. This sounds counterintuitive since haemorrhages can occur from the condition, but the system is one of low pressure, so bleeding does not worsen.

Head Injury

Over 70% of patients with moderate to severe head injury, and over 90% of patients with mild head injury report post-traumatic headaches.

A post-traumatic headache is defined as one of the following:

• A headache that occurs within seven days of injury.
• A headache that occurs within seven days of regaining consciousness.
• A headache that occurs within seven days of stopping medications which might alter perceptions.

Risk factors include a prior history of headache, milder injury, and being less than 60 years old.

Migraine headache characteristics are most common with post-traumatic headaches, but tension-type headache characteristics also occur. Other symptoms include dizziness, cognitive changes, anxiety, insomnia, and personality changes.

Treatments are identical to those used for the primary headache type that the post-injury headache mimics. In other words, if it resembles a migraine, we treat it like a migraine.

Infection

Patients presenting with headache due to infection will have associated fever and nuchal rigidity.Nuchal rigidity is demonstrated with the Brudzinski or Kernig signs. The Brudzinski sign is elicited if the stretching of the meninges achieved while flexing the head forward produces pain. The Kernig sign is elicited if extension of the knees while the hips are flexed up produces pain.

Imaging with computed tomography (CT) or magnetic resonance imaging (MRI) is necessary. Lumbar puncture should also be performed, unless contraindicated due to the presence of a mass (e.g., an abscess).Empiric antibiotic therapy should be started while awaiting the results of a lumbar puncture.

References

• The International Classification of Headache Disorders 3rd edition
• Chou DE. Secondary Headache Syndromes. Continuum (Minneap Minn). 2018 Aug;24(4, Headache):1179-1191
• Green MW. Secondary headaches. Continuum (Minneap Minn). 2012 Aug;18(4):783-95.
• Tsakadze, N, Antonovich N, Rossi F. Medication-overuse headache. Practical Neurology. 2018; 17: 50–52.

Neurology Library: Secondary headaches

• Coni R. Secondary headaches. LITFL
• Coni R. Sinus headaches. LITFL
• Coni R. Muskuloskeletal pain and headache. LITFL
• Coni R. Temporomandibular joint and headache. LITFL
• Coni R. Medication overuse headache. LITFL
• Coni R. Thunderclap headache. LITFL