Headaches

Ninety percent of persons who seek medical advice for headache have migraine or tension-type headaches, and only 10% of all people have anything else wrong with them. Although there are many types of headaches, the overwhelming majority of people fit into only a very small category of headaches.

Let’s discuss what doesn’t cause headaches, because these are things which are commonly blamed on causing headaches, which aren’t very important. The first is: refractive errors of the eye. Whether you need glasses or you don’t need glasses is nice, but usually doesn’t have a whole lot to do with why you have chronic recurring headaches. The second is: chronic sinus disease. We know that acute sinusitis causes headaches but that’s easy to recognize, but chronic sinus disease, whether your sinuses are a little thickened or not, generally has very little to do with whether you have, or why you have chronic recurring headaches. Then there are allergies. Allergies are not a very important cause of chronic recurring headaches. They can be a non-specific trigger of headaches in people, particularly migraineurs but by themselves, allergies don’t cause chronic recurring headaches.

The overwhelming majority of headaches are in the eye. People come in and they say, “My eye hurts in here” so they run off to the eye doctor. So the question that then comes up is, if the headache is in the eye, how do you know if you should see your eye doctor? Well, the answer is really simple. One is, you almost never to see your eye doctor because very few causes of headache have anything to do with the eye. The reality is that virtually everything that is sensitive to pain within the brain is supplied by the first division of the trigeminal nerve. V1 fibers are ubiquitous within the anterior middle fossa and even the superior part of the tentorium, so virtually everything that hurts in the head refers pain to the eye. Here’s a rule. All the ocular causes of pain cause changes in the external appearance of the eye. In other words, if you have a red eye, that’s acute glaucoma for example, the first few minutes of acute angle closure glaucoma and very few of these cases are going to be seen in the office, acutely. So basically, if someone comes into the office and they have a white eye and they say the pain is in the eye, forget about their eye doctor.

Now the IHS, International Headache Society, classified headaches a number of years ago and they put out a very, very long doctrine about hundreds and hundreds and causes of headache. Here’s the Green simplification of the IHS classification, which is probably all it’s worth – one slide. It’s basically worth dividing headaches into primary and secondary headaches. Primary headaches are those in which the headache is the problem, and secondary headaches are those in which the headache is a symptom of another organic neurological disease.

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