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150 Siu Lun TSUI, Chi Wai CHEUNG
essential for their management. It is emphasised
that effective control of these discomforts and
distress are as important as pain control. e
efficacy of pain control can be significantly
enhanced with effective control of other physical
symptoms. e best example is illustrated by the
ability to take oral analgesics when nausea and
emesis are effectively treated. Management of pain
and physical symptoms is often emphasised by
most clinicians. Paying attention to the patient’s
psychological, familial and social well-being is
of equal importance, particularly when the aim
is to encourage home care if feasible rather than
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Table 9.12 Other causes of distress in cancer
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Introduction
Headache is a common presenting complaint in medical and
dental practice. e true incidence of headache is unknown
as many afflicted with minor disorders often resort to self-
treatment. In a population study of 25 to 64 year-olds in
Denmark [78], the lifetime prevalence of headache was 99%
in women and 93% in men. In another survey of elderly
rural residents in Italy, the 1-year prevalence for migraine
and tension headache was 4.6% and 16% respectively [13].
e prevalence of migraine in Canada was 3.8% in men and
11.7% in women [59]. Locally in Hong Kong, the estimated
prevalence rates for migraine and tension headache are 12.5%
and 18.7% respectively [18].
An important objective in evaluation of such patients is to
differentiate organic (secondary) from functional (primary)
disorders. Headache can be a presenting symptom secondary
to diseases affecting the intracranial and extracranial structures
of the head. is is organic craniofacial pain and the warning
leak headache of subarachnoid haemorrhage is an example. In
primary or functional craniofacial pain, the pain is not only a
symptom but a disease in itself. Diagnosing headaches poses
a challenge. Treatment varies widely for different aetiologies.
An early diagnosis may result in better outcome for organic
disorders. However, different pathologies may coexist in the
same patient making diagnosis more difficult. Moreover,
doctors from different disciplines manage craniofacial pains.
Referral to an inappropriate specialist delays the diagnosis and
the appropriate treatment. For example, trigeminal neuralgia
has been mistaken for dental problems and teeth extractions
performed unnecessarily [32, 47]. e fact that a patient may
suffer from multiple pain syndromes stresses the importance
of a systematic approach in the diagnostic workup of headache
and facial pain.
INTRODUCTION
CLASSIFICATION AND
DIAGNOSTIC APPROACH
Clinical History
Physical Examination
Investigations
MIGRAINE
CLUSTER HEADACHE
TENSION-TYPE HEADACHE
CERVICOGENIC HEADACHE
REFERENCES
Headache
10
Chi Tim HUNG, Steven H.S. WONG
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158 Chi Tim HUNG, Steven H.S. WONG
Classication and Diagnostic
Approach
Terminology and diagnostic criteria for craniofacial
pains have been confusing in the past. e
Headache Classification Committee of the
International Headache Society (IHS) developed
the first internationally acceptable classification
in 1988 [37]. A revised classification, now
referred to as the International Classification of
Headache Disorders, second edition (ICHD-
II) was published in 2004 (Table 10.01) [38].
Headache disorders are classified into primary
and secondary headaches. Primary headaches
are classified into four categories (1–4), namely
migraine, tension-type headache, cluster headache
and other trigeminal autonomic cephalalgias, and
other primary headaches. Categories 5–14 refer to
all the secondary headaches. Cranial neuralgias,
e.g. trigeminal neuralgia, and central causes of
facial pain are classified as secondary headaches.
Diagnostic criteria using both clinical features and
laboratory tests are available. New subcategories
with their diagnostic criteria are constantly being
proposed [31, 89].
Careful history taking and paying special attention
to the details of the pain plus a comprehensive
physical examination are the most important steps
in the diagnostic workup. e general approach
(Fig. 10.01) is to actively look for features in the
history and physical examination that are suggestive
of ominous organic diseases (Table 10.02). Apart
from space occupying lesions due to neoplasm or
bleeding, organic diseases can also be infective,
traumatic, vascular or degenerative in origin. ese
secondary headaches will then need to be further
investigated or referred to other disciplines for
treatment. After excluding potential secondary
causes, diagnosis and treatment of the four primary
categories are more straightforward. It is important
Table 10.01 International Classification of
Headache Disorders, second edition (ICHD-II) [38]
Primary Headaches:
Code Diagnosis
1 Migraine
2 Tension-type headache
3 Cluster headache and other trigeminal
autonomic cephalalgias
4 Other primary headaches
Secondary Headaches:
Code Diagnosis
5 Headache attributed to head and/or neck
trauma
6 Headache attributed to cranial or cervical
vascular disorder
7 Headache attributed to nonvascular
intracranial disorder
8 Headache attributed to a substance or its
withdrawal
9 Headache attributed to infection
10 Headache attributed to disorder of
homeostasis
11 Headache or facial pain attributed to
disorder of cranium, neck, eyes, ears,
nose, sinuses, teeth, mouth, or other facial
or cranial structures
12 Headache attributed to psychiatric
disorder
13 Cranial neuralgias and central causes of
facial pain
14 Other headache, cranial neuralgia, central
or primary facial pain
Table 10.02
Sinister features of headache
• Headache of late onset in life (after age 50)
• New or different headache
• Worst headache ever experienced
• Intensity of headache peaks rapidly (except
cluster, trigeminal neuralgia)
• Onset of subacute headache that worsens over
time
• Headache occurring mainly at night
• Headache associated with
• exertion, sexual activity, Valsalva’s
manoeuvre or sneezing
• focal neurological signs or dysfunction,
other than aura, e.g. seizures
• systemic illnesses or abnormal physical
examination
e.g. fever, stiff neck, hypertension,
papilloedema, weight loss,
tenderness, poorly pulsatile temporal
arteries
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Headache 159
Patient with headache, facial pain
Clinically exclude organic causes,
look for sinister features
Differentiate
primary headaches
or neuralgias
CT, MRI, other
investigations
Appropriate
treatment
Appropriate
treatment
Successful
Unsuccessful
Absent Present
Organic cause not
apparent
Unlikely
Organic cause
apparent
Likely
Review for new
symptomatology
Figure 10.01 Diagnostic approach to headache disorders
to review the diagnosis at intervals if response to
treatment is not satisfactory. Organic causes may
have been overlooked [1].
Clinical history
History is indispensable in evaluation since the
vast majority of headache patients have no physical
signs. Every detail about the pain, the premonitory
and associated symptoms, family history, effect
of pregnancy and menstruation, medical history,
surgical history and responses to past treatment are
important [107].
e mnemonic PQRST [83] is a useful aid to history
taking about the pain. It stands for provocation,
quality, region, strength and time course. Time
course refers to age of onset, chronicity, pattern,
duration and frequency of pain. Childhood
headaches are often primary in origin [110]. e
onset of migraine ranges from childhood to young
adulthood. Organic diseases such as temporal
arteritis or space occupying lesions have to be
excluded in late-onset headaches occurring in those
more than 50 years old. Long-standing headaches
experienced for more than 20 years are usually
not associated with life-threatening neurological
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