Secondary Headaches

Headache is among the most common health concerns that bring individuals to seek medical care. This is highlighted by the fact that the World Health Organization’s Global Burden of Disease (GBD) study lists headache as the third leading cause of years lived with disability worldwide. Very frequently, the final diagnosis ends up as migraine, as this disease is very prevalent, affecting over 1 billion people globally, and very disabling, having been identified by the GBD as the primary cause of disability in women age 15 to 49.

There are, however, many other headache diagnoses that also need to be considered, including several secondary headache conditions that can have serious consequences if not managed appropriately. Because of the complexity of headache diagnoses and their varied presentations, this chief complaint can often be overwhelming to clinicians, particularly without a proper framework to approach the topic. With these considerations in mind, we hope to provide some practical tips for navigating the waters when evaluating headache and highlight several important secondary diagnoses not to miss.

I am honored to serve as this month’s guest editor for Practical Neurology. In this role, I have had the distinct pleasure of curating this list of secondary headache disorders by carefully selected headache medicine specialists from around the US. These experts are outstanding clinicians who are role models for a person-centric approach to medicine; they are known leaders in the headache medicine community. I am grateful that they have so graciously shared their knowledge with us.

Drs. Chia-Chun Chiang and Juliana VanderPluym begin with the very practical and systematic Diagnosing Secondary Headache, with some specific recommendations for the history and examination to help ensure secondary causes are thoroughly considered. Secondary headaches caused by disorders of cerebrospinal fluid (CSF) pressure can be very challenging both to diagnose and to treat, sometimes masquerading as intractable daily headache. Because of this complexity, we have an article on Idiopathic Intracranial Hypertension by Drs. Karissa Arca and Amaal Starling and an article on Spontaneous Intracranial Hypotensionby Dr. Jennifer Robblee and her colleagues. We then turn to serious time-sensitive vascular causes of headache. Dr. Deena Kuruvilla discusses Cardiac Cephalgia, a situation when headache presents essentially as an anginal equivalent. Drs. Britany Klenofsky and Huma Sheikh provide a comprehensive review on the diagnosis and initial management of Giant Cell Arteritis. Next we consider headaches in specific populations. Posttraumatic Headaches in Children are the most common in that population, and Drs. Elizabeth Ackley and Marcy Yonker share an excellent management overview. There have been several recent papers published on Secondary Headaches During Pregnancy and Postpartum; indeed, a new headache during this time is a red flag in itself, and Dr. Katherine Hamilton does an outstanding job synthesizing this literature and providing guidance. Finally, we conclude with Dr. Jessica Ailani explaining an extremely important secondary headache, that is not widely well-understood, is often mismanaged, and yet, has been listed among the top 20 causes of years lived with disability in the world—Medication-Overuse Headache.

From a humanities in medicine standpoint, we have chosen to highlight the works of cover artist Priya Rama. As a person who experiences chronic migraine, she does a beautiful job of transforming her headache pain into breathtaking works of art. We are truly privileged to be welcomed into her space.

We hope that these articles will provide clinicians with guidance and the necessary tools to think broadly and systematically when someone presents for a headache consultation. By asking careful details when obtaining their history, appropriately screening for red flags, and pausing to consider common as well as serious secondary causes of headache before settling on a diagnosis, we can more confidently approach what often first appears as a complex problem.