• Trauma-Induced
• Tumor-Related Increased ICP
• Idiopathic Intracranial Hypertension (IIH)
• Infections
• Cranio-Facial Disorders
• Vascular Disorders
• and Others . . .

Self explanatory: They are the result of head or neck trauma.

Thirty percent (30%) of patients with a brain tumor have a mild headache which is typically intermittent, dull, aching, unilateral, and worsening over time. The classic brain tumor headache (seen in only 17%) is a severe headache that wakes up the patient in the middle of the night, accompanied by nausea. More typical is a headache that is worse in the morning or with a change in body position, coughing, or straining. Pain can be frontal or located at the site of the lesion. A tumor-related headache often mimics a migraine. Neurological symptoms such as dizziness, tinnitus, tingling, and visual disturbances often occur (over time).

IIH (formerly known as pseudotumor cerebri) is the most common cause of papilledema seen by eye doctors. It is usually found in young, stressed, overweight females and may be associated with oral medications such as tetracycline and birth control pills.

The patient will complain of a diffuse, mild to moderate headache that is worse in the morning. Transient visual obscurations are very common. Papilledema and possibly diplopia occur (from compression of the abducens nerves). The patient experiences nausea, vomiting, and tinnitus (a swishing sound or ringing in the ears). Symptoms worsen with changing position.

Treatment involves lowering intracranial pressure (ICP) with diuretics or steroids, lumbar punctures, behavior modification, or shunts. IIH may be related to anemia, and does occasionally affect children.

A patient with meningitis or encephalitis can present with a moderate to severe, generalized, throbbing headache. The patient experiences fever, vomiting, nausea, rash, and changes in mental status. Photophobia and blurred vision often occur. Some report diplopia. Stiffness of the neck can also occur.

Temporal mandibular joint (TMJ) syndrome causes pain in trigeminal and facial nerve areas. It occurs in five percent (5%) of the population usually between the ages of 15 and 40 years. It is more prevalent in females than males. The pain originates from the jaw joint and is worse with chewing. Patients report jaw clicking or locking. Manage with dental devices and analgesics.

Stroke
Stroke can be the cause of recent onset headache in the elderly. The headache is on the same side as the infarct or hemorrhage. It precedes the attack and can last minutes to days.

Aneurysmal headache
A patient will describe an aneurysmal headache as the worst headache of his/her life. Extremely severe pain occurs at the site of the rupture. Fifty percent (50%) of patients with arterio-venous malformations (AVM) will have dull headaches for weeks leading up to the rupture. Other signs and symptoms include a stiff neck, change in mental status, third nerve palsy usually involving the pupil, hemiparesis, papilledema, and visual field defect. A patient experiencing an aneurysmal headache usually ends up in the ER, not the eye doctor's office.

Hypertension
Headaches caused by hypertension are rare. Blood pressure must be sustained above 140 diastolic. Vision loss from severe papilledema with macular edema can occur. Pheochromocytoma, nephritis, and malignant hypertension are possibilities. Headaches caused by hypertension present as pounding headaches with nausea, tachycardia, sweating, pallor, and anxiety.

Systemic disease

• Giant cell arteritis (GCA)
  Temporal arteritis can be a true emergency when the eye is involved! It occurs in 1 in 1000 persons over age 60--most common in females and Caucasians. You must rule out temporal arteritis in older patients with headache and vision loss. Other symptoms include scalp tenderness, jaw claudication, malaise, anorexia, and low grade fever. Order stat Westergren sed rate and CBC. Normal is age/2 for males and age + 10 / 2 for females. Also order C-reactive protein which is not specific for GCA but is 100% sensitive. Biopsy of temporal artery should be done if you strongly suspect temporal arteritis, but testing is negative. Treat with high dose steroids. Ocular complications of GCA include ischemic optic neuropathy, artery occlusions, and cotton-wool spots.
• Sinus disease
  In acute cases of sinus disease, pain is almost always present. In chronic, pain is almost always absent. Headache is frontal and can effect the malar area of the face, the teeth, and between or behind the eyes. Patients report a congested feeling with nasal drainage, worsened by changing posture. Treat with decongestants and OTC analgesics.

Ophthalmodynia
Patients experiencing ophthalmodynia often have a history of migraines. The complain of sharp, stabbing, fleeting pain localized to one eye. It probably occurs along CN V ophthalmic branch. Ophthalmodynia is benign, and the cause is unknown.

Ocular causes of headache

• Angle closure glaucoma
• Uveitis, keratitis, scleritis
• Optic neuritis
• Refractive disorders and muscle imbalance
• Metastatic orbital tumors