Developments in distinguishing secondary vascular headache from primary headache disorders in clinical practice

ABSTRACT

Introduction

Vascular headaches are secondary headache disorders with potentially devastating consequences if missed. Clinicians often struggle to distinguish these from primary headache disorders whereby there is no underlying structural pathology. Here, the authors describe the advancement in our understanding of vascular headache disorders, their clinical presentation and the developments in neuroimaging that facilitate diagnosis.

Areas covered

Here the authors discuss the definition of primary and secondary headache disorders. They review the literature on the presentation, choice of neuroimaging and diagnostic tools that can be used to diagnose specific vascular headaches including Carotid or Vertebral artery dissection, Stroke, Temporal Arteritis, subarachnoid hemorrhage, cerebral venous thrombosis, Reversible Cerebral Vasoconstriction syndrome, Primary angiitis, AV malformation and Genetic vasculopathy. The authors discuss the influence of Covid-19 on the management of patients with headache.

Expert opinion

Whilst developments in neuroimaging have been of paramount importance in the diagnosis of vascular headache disorders, there is no substitute for meticulous history taking and examination. Research has aided our understanding of clinical presentation, however further studies are needed as well as increased education of neurologists and acute physicians.

KEYWORDS:

• Primary headaches
• vascular headaches
• secondary headaches

Article highlights

• Headaches are broadly classified into primary and secondary headache disorders. Most headaches are primary headache disorders including migraine and tension type headache. A very small percentage are secondary to an underlying pathology that could be life threatening and a cause of litigation.

• Red flags are good clinical pointers in differentiating primary from secondary headache disorders.

• The ICHD-3 gives a comprehensive list of secondary headache disorders with secondary vascular disorders described in section 6. These are sub classified into headaches attributed to stroke disease, non-traumatic intracranial haemorrhage, Vascular malformation, cranial venous disorders, Temporal arteritis, Vasculopathy including genetic vasculopathies and other cranial vascular disorders such as reversible vasoconstriction syndrome and arterial dissection.

• History taking remains the mainstay of differentiating primary headache disorder from secondary vascular disorders and guides choice of investigation. In the current climate of Covid-19 history taking regarding previous infection and vaccination is paramount

• Advancements in neuroimaging with techniques such as MRI and CT angiography have removed the need for invasive imaging in a large proportion of patients. Whilst positive, we need to be mindful not to over investigate as a result, particularly during the current climate whereby remote consultations are more prevalent.

• In the next 5 years, we will see more robust guidelines in when one should consider vascular headache to inform imaging. We hope to also see an expansion and increased availability of interventional radiology services.

Declaration of interests

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.