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Clinicians caring for patients with headache need to be aware that there are numerous secondary causes of headache related to a wide range of disorders of homeostasis, and these headaches can mimic the phenotype of common primary headache disorders (ie, migraine, tension-type headache, and primary exertional headache).
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Failure to recognize a secondary cause of headache attributed to a disorder of homeostasis can lead to significant morbidity due to an unrecognized (and untreated) underlying
Metabolic Headaches
Section snippets
Key points
Headache attributed to hypoxia or hypercapnia
This group of headache disorders is caused by hypoxia and/or hypercapnia and occurs in conditions of exposure to one or both of those conditions (Box 2). According to the ICHD-2, it is difficult to separate the effects of hypoxia and hypercapnia.3 The ICHD-2 criteria for headache secondary to hypoxia state that headache begins within 24 hours after acute onset of hypoxia with PaO2 less than 70 mm Hg or in chronically hypoxic patients with PaO2 persistently at or below these levels.3 Diseases or
Dialysis headache
Dialysis headache is a type of secondary headache disorder with no specific characteristics occurring during and caused by hemodialysis (Box 7). It resolves spontaneously within 72 hours after the hemodialysis session has ended or headache episodes may stop altogether after a successful kidney transplantation and termination of hemodialysis.2 This type of headache has been recognized for years as a known emerging symptom of hemodialysis treatment.36 Dialysis headache occurs in 30% to 70% of
Headache attributed to hypertension
Headache attributed to hypertension is often bilateral and pulsating, caused by arterial hypertension, usually during an acute rise in systolic (to ≥180 mm Hg) and/or diastolic (to ≥120 mm Hg) blood pressure (Box 8). It remits after normalization of blood pressure.2 Mild (140–159/90–99 mm Hg) or moderate (160–179/100–109 mm Hg) chronic arterial hypertension does not seem to cause headache. Ambulatory blood pressure monitoring in patients with mild and moderate hypertension has shown no
Headache attributed to hypothyroidism
Headache attributed to hypothyroidism is usually bilateral and nonpulsatile headache and remits after normalization of thyroid hormone levels (Box 14).2, 63 Approximately 30% of patients with hypothyroidism suffer from headache.63 In migraineurs with subclinical hypothyroidism, treatment of borderline hypothyroidism is sometimes followed by dramatic improvement in the control of the headache.64 The headache begins within 2 months after the onset of hypothyroidism and lasts less than 3 months
Headache attributed to fasting
Headache attributed to fasting is a diffuse nonmigrainous headache that begins during a fast of at least 8 hours and is relieved after eating (Box 15).2 Even though the typical headache attributed to fasting is diffuse, nonpulsating, and mild to moderate in intensity, in those with a prior history of migraine the headache may resemble migraine without aura.67
One of the most commonly reported migraine triggers is hypoglycemia. Headache attributed to fasting is significantly more common in people
Cardiac cephalalgia
Cardiac cephalalgia is migraine-like headache, usually but not always aggravated by exercise, occurring during an episode of myocardial ischemia that is relieved by nitroglycerin (Box 16).2 Lipton and colleagues70 proposed that this type of headache is a rare and treatable form of exertional headache. During stress test in 2 subjects, typical headaches were correlated with electrocardiogram changes indicative of myocardial ischemia. In both patients, coronary angiography revealed 3-vessel
Headache attributed to other disorder of homeostasis
Headache attributed to other disorder of homeostasis is a headache caused by any disorder of homeostasis not described previously (Box 17). Although relationships between headache and a variety of systemic and metabolic diseases have been proposed, systematic evaluation of these relationships has not been performed and there is insufficient evidence on which to build operational diagnostic criteria.2
Summary
The metabolic headaches are secondary headaches that appear as a consequence of metabolic disturbances. Treatment of the underlying disease is associated with headache improvement.
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Funding Sources: Dr A.M. Lagman-Bartolome: Canadian Headache Society.
Conflict of Interest: Nil.