Cephalalgia: Definition, Types, and Management
Cephalalgia is the medical term for headache, referring to pain in the head region that can vary in intensity, duration, and location depending on the underlying cause. 1
Types of Cephalalgia
Cephalalgia can be classified into several major categories based on clinical features:
1. Migraine Headache
- Diagnostic features (at least two of the following):
- Unilateral location
- Throbbing/pulsating character
- Moderate to severe intensity
- Worsening with routine physical activity
- Associated symptoms (at least one):
- Nausea and/or vomiting
- Photophobia and phonophobia
- May include aura - visual distortions, scotomas, or other sensory phenomena preceding the headache 1
2. Tension Headache
- Diagnostic features (at least two):
- Pressing/tightening (non-pulsatile) quality
- Mild to moderate intensity
- Bilateral location
- No aggravation with routine activity
- Absence of:
- Nausea and vomiting
- May have either photophobia OR phonophobia (but not both) 1
3. Cluster Headache
- Diagnostic features:
- Severe unilateral pain (orbital, supraorbital, temporal)
- Pain lasting 15-180 minutes untreated
- Frequency of 1-8 attacks daily during cluster periods
- Associated symptoms (same side as pain):
- Lacrimation
- Nasal congestion/rhinorrhea
- Forehead/facial sweating
- Ptosis/miosis
- Eyelid edema 1
4. Other Trigeminal Autonomic Cephalalgias
- Paroxysmal hemicrania
- SUNCT (Short-lasting Unilateral Neuralgiform headache attacks with Conjunctival injection and Tearing)
- SUNA (Short-lasting Unilateral Neuralgiform headache attacks with cranial Autonomic symptoms) 2
Evaluation of Cephalalgia
When evaluating a patient with cephalalgia, it's important to assess:
Headache characteristics:
- Location, quality, intensity, duration
- Pattern (episodic vs. continuous)
- Triggers or alleviating factors
- Associated symptoms
Red flags requiring immediate attention:
- Sudden onset severe headache ("thunderclap")
- New headache after age 50
- Progressively worsening headache pattern
- Headache with systemic illness (fever, neck stiffness)
- Headache associated with neurological deficits
- Headache awakening patient from sleep 1
Management Approaches
1. Migraine Management
- Acute treatment:
- Triptans (sumatriptan, zolmitriptan)
- NSAIDs
- Antiemetics for associated nausea
- Preventive treatment (for frequent or disabling migraines):
2. Cluster Headache Management
- Acute treatment:
- 100% oxygen inhalation
- Subcutaneous sumatriptan (6mg)
- Nasal spray triptans (second-line)
- Preventive treatment:
3. Trigeminal Neuralgia Management
- First-line treatment:
- Carbamazepine (400-800 mg daily in divided doses)
- Oxcarbazepine (alternative with fewer side effects)
- Second-line options:
- Gabapentin (300-3600 mg/day)
- Pregabalin (150-600 mg/day)
- Baclofen (can be combined with carbamazepine)
- Lamotrigine (particularly effective for SUNCT/SUNA) 5
Special Considerations
Coital Cephalalgia
- Acute headache temporally related to sexual activity
- Often confused with more serious conditions like subarachnoid hemorrhage
- Can be effectively treated with propranolol hydrochloride
- Considered a variant of migraine 6
Secondary Cephalalgia
- May result from:
- Infections (meningitis, encephalitis)
- Vascular disorders (subarachnoid hemorrhage, arterial dissection)
- Intracranial pressure abnormalities
- Medication overuse
- Structural lesions 1
Cephalalgia in Older Adults
- Consider age-related changes affecting pain perception
- Evaluate for secondary causes more aggressively
- Adjust medication dosing (start low, go slow)
- Consider comorbidities and potential drug interactions 1
When to Refer or Investigate Further
Neuroimaging (preferably contrast-enhanced MRI) is indicated for:
- New or changing headache pattern
- Headaches with atypical features
- Neurological deficits
- Failure to respond to appropriate treatment 5
Specialist referral is appropriate for:
- Diagnostic uncertainty
- Treatment-resistant headaches
- Complex comorbidities
- Need for specialized treatments or procedures 1
Remember that accurate diagnosis of the specific type of cephalalgia is crucial for implementing effective treatment strategies and improving patient outcomes.