Do vascular headaches exist?

The Term "Vascular Headache" Is Outdated and No Longer Used in Modern Headache Classification

The concept of "vascular headache" as a distinct diagnostic entity has been abandoned in contemporary neurology. While historically migraine and other headaches were attributed primarily to vascular mechanisms, current understanding recognizes these as complex neurovascular disorders where vascular changes are secondary phenomena rather than the primary cause 1, 2.

Historical Context and Evolution

• The term "vascular headache" was widely used in the 1980s-1990s to describe headaches thought to originate from blood vessel changes, particularly migraine 3, 4
• This classification was based on the observation that migraine headaches have a throbbing, pulsating quality and that successful treatments often act on blood vessels 2
• Over the past 20 years, emphasis has shifted to neural imbalances as the primary mechanism, with vascular changes now viewed as epiphenomena that are neither sufficient nor necessary to induce migraine 2

Why the Term Is No Longer Valid

• Modern headache classification systems do not include "vascular headache" as a category 1
• Current evidence points to an underlying neurogenic etiology, with associated vascular changes believed to be secondary phenomena 3
• The International Headache Society and major neurology organizations have moved away from this terminology in favor of more specific diagnoses like migraine, cluster headache, and other primary headache disorders 1

What Clinicians Should Use Instead

When evaluating headaches with vascular features, consider these specific diagnoses:

• Migraine with or without aura - the most common condition historically labeled as "vascular headache" 1
• Cerebral venous thrombosis - presents with headache in nearly 90% of cases and represents true vascular pathology requiring urgent diagnosis 1, 5
• Moyamoya vasculopathy - causes headaches with migraine-like features but represents actual cerebrovascular disease 1
• Arterial dissection - can present with sudden severe headache and represents true vascular emergency 1
• Subarachnoid hemorrhage - the classic "thunderclap headache" from vascular rupture 1

Critical Clinical Distinction

• The key is distinguishing between headaches that are symptoms of actual vascular pathology versus primary headache disorders 1, 5
• When headache is accompanied by focal neurological signs, papilledema, fever, or sudden onset, imaging and vascular evaluation are essential to exclude true vascular disease like cerebral venous thrombosis, stroke, or hemorrhage 1, 5
• Isolated headache without these features, even if throbbing or "vascular" in character, should be classified according to modern headache criteria (typically migraine) rather than as "vascular headache" 1

Important Caveats

• While the term "vascular headache" is obsolete, migraine does carry increased vascular risk, particularly migraine with aura, which is associated with increased risk of ischemic stroke in women under 55 years 1, 6
• Medications that cause vasoconstriction (triptans, ergots) remain effective migraine treatments, but this doesn't validate the old "vascular headache" concept - it reflects the complex neurovascular nature of migraine 1, 7, 8
• The success of CGRP-targeted therapies, which act peripherally on blood vessels, has prompted re-evaluation of vascular contributions to migraine, but this doesn't resurrect the outdated "vascular headache" classification 2