Headaches-know the red flags

Headache is a common complaint for which patients consult a neurologist like me. While headaches can be disabling in themselves they are also the cause of much concern. Many patients are worried that their headache is a sign of a serious condition such as a brain tumor. So in this post I shall discuss what are the red flags one needs to watch out for when it comes to headaches. What are the symptoms and signs that may be a cause for just concern and should warrant a visit to your doctor for evaluation?

–Age of onset of headaches: most primary headaches such as migraine, tension type headaches, cluster headaches start usually in the late teenage years or in the second decade of life. The usual history is of episodic headaches starting from a young age (migraines usually begin in the late teens or the early/mid 20’s). So what is the red flag when it comes to age? If you have never suffered from headaches in your 20s and 30s and suddenly start experiencing headaches in your (40’s, 50s and later years) one should err on the side of caution and seek medical attention.

–character of headache changes: let us assume you suffer from episodic headaches since your 20s. Headaches are unilateral, throbbing in character and associated with light sensitivity (we call this photophobia) and nausea but you were never formally diagnosed with migraine.  You found over the counter ibuprofen helpful and so never sought out medical attention. Now you are in your 50s and the headache character has changed. What do I mean by headache character? Type of headache (now no more unilateral rather the whole head hurts), severity of headache (the pain is either more severe or constant rather than episodic, wakes you up in the middle of the night, you throw up violently when you have the headache episode, it is causing other symptoms–blurring of vision, double vision , problems with balance, memory problems, changes in behavior and so forth. I would advice again to err on the side of caution and do not just assume that this is still migraine, rather seek medical attention and let your doctor reassure you that indeed that is the case.

–headaches which are accompanied by other signs and symptoms: for example-

—————-severe headache and then you pass out/ suffer loss  of consciousness

—————-headache accompanied by visual symptoms (loss of vision, blurring of vision, double vision, pain in the eye–while many of these symptoms may occur along with migraine headaches, I would again advice that you rather err on the side of seeking a timely medical opinion)

—————-headache accompanied by memory and personality changes

—————-headache accompanied by problems with balance, gait and stance

—————-headache accompanied by weakness or numbness on one side of body

—————-headache accompanied by a seizure or vice versa.


Nitin K Sethi, MD

Post coital headaches: a question and an answer

One of the readers of my blog asked me an interesting question about post coital headaches.  I am reproducing his question here. My reply to it follows:


Recently I too began having pre and post-coital headaches. The first time it happened I was obviously very concerned, so I scheduled an appointment with a doctor who recommended an MRI with and without contrast.

Fortunately, for me the MRI turned up normal, however, I still have the pain and the intensity varies. Occasionally, the pain occurs during arousal although it is not intense. Sometimes there is no pain. Sometimes the pain still occurs days after sex, more as a low throbbing though.

Although perhaps unrelated, years ago I was diagnosed as having a low testosterone level. Nothing that warranted medication, but it was on the low side. A doctor suggested I might want to consider medication since we were trying to conceive and had some difficulty with the second child, but we were successful without it.

My question for the doc is can these types of headaches be associated with low T? Furthermore, should I be concerned that the headaches are a result of a more serious condition, such as a heart condition? Although I am not on medication for high-blood pressure, I noticed the other day at the doctor’s that my blood pressure was 137/75. To me, this seems high for my body. In my 20′s my BP typically ran 100-110/60-65. I am 42 yrs old now.

Should I be put on ow T / BP meds and develop a more regular exercise and diet plan?



Dear B,

                   You ask an interesting question. As I stated in my post on post coital headaches, usually the headache comes on suddenly either at the height of coitus (at the time of orgasm) or soon there after. Patients may use various terms to describe the headache. The headache usually is of a moderate to severe intensity and at times is referred to as a thunderclap headache (basically any headache which on suddenly and is of a severe intensity can be referred to as a thunderclap headache. So a severe sudden attack of migraine can be a thunderclap headache too). Some people may have noticed the temporal attention of the headache to coitus over time and hence do not seek medical attention. It is usually people who have never suffered a post coital headache (or rather I should say who do not suffer from headaches usually) that get sufficiency alarmed and seek medical attention. Now what do I as a physician neurologist or the ER physician who examines you think when you present with a thunderclap headache? Well the think you are most worried about is whether the patient’s severe sudden headache may be on account of something more sinister such as hemorrhage into the brain. There are various causes of hemorrhage (bleeding) into the brain. They can broadly be divided into:

  1. Traumatic (as the name says it, the hemorrhage is on account of head trauma)
  2. Non-traumatic (examples of non-traumatic hemorrhage include: hypertensive intracerebral hemorrhage—the hemorrhage is on account of high blood pressure and non-traumatic subarachnoid hemorrhage (SAH) among various others. Non-traumatic subarachnoid hemorrhage is a special type of hemorrhage and usually occurs in the setting of either a rupture of an intracranial aneurysm or sudden bleeding from a vascular malformation in the brain such as an anteriovenous malformation. As you may well imagine if an aneurysm was to suddenly rupture in the brain, the headache is invariably sudden and of a severe intensity. This the headache can mimic a post coital headache in character. Moreover the headache comes on in the setting of severe exertion and thus further raises concern

So if you present to the ER in this setting, we as physicians want to rule out a subarachnoid bleed. The easiest way to do this is with the aid of a plain (no contrast is used) head CT scan.  The non-contrast head CT is extremely sensitive in ruling out hemorrhage. If you see blood on the CT scan then you treat the patient accordingly (in this post I shall not dwell over the treatment of intracranial and subarachnoid hemorrhage). The problem actually arises if the CT scan comes back negative (meaning no blood is seen). Now in this setting the physician may (after taking a detailed history) just simply reassure you that this is post coital headache (since it occurred in the setting of an orgasm) and there is no reason to be alarmed. If on the other hand the history is atypical or there are other points which raise a red flag (example the patient’s blood pressure is high or he has a prior history of subarachnoid hemorrhage or he has a history of intracranial aneurysm or other vascular malformation), the physician may opt to do other tests. Sometimes after the rupture of an intracranial  aneurysm, no gross blood is seen (meaning the hemorrhage is very small in quantity). In those settings we do a spinal tap (lumbar puncture) to see if there is any blood in the spinal fluid. As you may be aware of, the spinal fluid is usually clear and colorless (it does not have any blood in it). In the setting of a subarachnoid hemorrhage, blood is found in the spinal fluid (xanthochromia in CSF) thus confirming the diagnosis of a subarachnoid bleed. In this setting further tests may be carried out such as a MRI of the brain and a MRA (magnetic resonance angiography) to better visualize the aneurysm or the vascular malformation in the brain. Sometimes a formal angiogram is carried out.

So in reply to your question B, to my knowledge there is no direct correlation between low testosterone levels and post coital headaches. My advise to you would be as follows. Bring the blood pressure to the attention of your Internist. Usually doctors have patients keep a blood pressure diary (meaning they have you chart your blood pressure about a week or two). This helps in determining if you indeed suffer from hypertension or not (as you can imagine a single solitary reading is not sufficient to make this determination). Depending your cardiovascular risk factors (history of smoking, high cholesterol and so forth), your doctor may opt to do more tests to rule out any underlying heart condition.

Regular exercise and dietary modification are seldom ill advised. My advise though would be to run it past your doctor before you embark on a exercise or a dietary modification plan.

Personal Regards,

Nitin Sethi, MD


When a headache is a pain! About primary and secondary headaches

When a headache is a pain! About primary and secondary headaches

Nitin K. Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10065



Headaches are a very common reason that patients consult a neurologist like me.  The intensity of the headache, its character and duration are some of the factors which determine if and when patients seek medical attention. So in this post I shall go over the different types of headaches and list their main differentiating features.

Broadly speaking we can divide headaches into primary and secondary headaches. Primary headaches are those headaches for which there is no structural/ secondary cause.  For example a migraine headache is an example of a primary headache. The migraine may be severe and frequently disabling but if you scan (CT or MRI) the patient’s brain no underlying structural lesion like a tumor is found. Secondary headaches as the name implies are secondary to a another cause. For example headache due to a large brain tumor or headache due to an infection (meningitis) represent secondary headaches.

Types of primary headaches:

1)      Migraine: common migraine and classical migraine

2)      Tension type headache

3)      Cluster headache

Types of secondary headaches:

1)      Headache secondary to a brain tumor or other masses (space occupying lesions) in the brain

2)      Headache secondary to an infectious and inflammatory process in the brain (example headache associated with meningitis)

Headaches can be a cause of concern and distress. Patients frequently worry that may have a brain tumor. So let us go over some of the signs and symptoms which suggest that the headache is due to a secondary cause . These are the signs and symptoms which should make you seek urgent medical attention:

  1. Sudden onset of severe headache. When asked patients rate their headache as the “worse headache of their lives”. I shall be concerned if I encounter such as patient in the ER, more so if the patient tells me that they have never had a  headache in their life before. When accompanied with other signs such as nuchal (neck) rigidity and depressed sensorium (level of alertness), the question of subarachnoid hemorrhage (SAH) comes to mind. A common cause of non-traumatic SAH is the rupture of an aneurysm or arteriovenous malformation (AVH) in the brain. SAH is associated with high morbidity and mortality especially if the patient presents to medical attention late.

Caveat: Not all “worse headaches of my life” are due to SAH due to rupture of an intracranial aneurysm. Many times (especially if there is a past history of migraine headaches) these patients are suffering from a particularly debilitating/ severe attack of migraine. Thunderclap/ explosive headaches have also been reported at the time of coitus. They are referred to as post coital or orgasmic headache.

  1. Headaches in extreme of ages:  headaches which occur in the extreme of ages (such as in a young child or after middle age especially if there is no past history of headaches) deserve a more closer look. Signs such as neck stiffness or depressed level of sensorium may be masked or difficult to elicit in these age groups. As a neurologist my threshold of investigating these patients with tests such as MRI of the brain and more invasive tests such as spinal tap (lumbar puncture) is lower.

Caveat: small children frequently cannot express headache (meaning they cannot tell you that they are bothered by headache).  Primary headaches such as migraine may be missed in children as a result. The child may be agitated and parents may think he is acting up. So a high index of suspicion has to maintained by the physician to timely identify migraines in small children. Also it is well known that migraine is not “typical” in the pediatric age group. Various migraine variants have been identified in children such as abdominal migraine (the child complains of episodic abdominal pain), cyclical vomiting and so forth.

  1. Onset of headache in middle age (especially if there is no prior history of headaches): when a middle aged patient comes to me and says he is bothered by headaches for the past 3-4 months, never had headaches when he was in his teens, I pay close attention to him. A thorough neurological examination shall frequently tell me if there is anything “brewing” inside the brain aka does he have a mass lesion/ tumor? As a neurologist I have several tools to help me in this endeavor. I can look for signs of asymmetry: weakness/ numbness on one side of the body, problems with coordination on one side of the body, is the gait steady, are the reflexes symmetrical and so forth. I can further look into his eyes with an ophthalmoscope to see if there is increased pressure inside the brain (remember the eyes are the window into the brain).  Based on my exam, I may or may not order a MRI scan or CT scan to confirm my suspicion.
  2. Headaches associated with fever: are always a cause of concern. Various disease processes such as meningitis (bacterial, viral or fungal), brain abscesses and so forth come into the differential. Patients are admitted into the hospital and further management depends upon the underlying etiology.
  3. Recent onset of headache in an immunocompromised patient: recent onset of headache in a patient who is immunocompromised (example a HIV positive patient or a patient who is receiving chemotherapy for cancer) always warrant a thorough work-up. Such patients are frequently found to have a secondary cause for their headaches. So again my threshold for imaging such patients is low.  My threshold for doing a spinal tap in these patients is also low (provided I am confident that the pressure in the brain is normal).
  4. Headache/ temporal pain  in a patient past 65: temporal arteritis (Giant cell arteritis) is a disease entity which is seen in the elderly and is due to inflammation of the temporal arteries. Patients may not complain of headache per-se. When you examine them you find they have tenderness over the temporal arteries and the artery may feel beaded and thickened.  It is imperative that temporal arteritis be identified in a timely fashion and treated otherwise the patient may suffer loss of vision.

In the next post I shall talk about the primary headaches.

Analgesic overuse headache

Analgesic overuse headache

Nitin K Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10065


Recently I saw a patient in the hospital who had complaint of constant severe daily headaches. She was a 34-year-old otherwise healthy African American woman who first developed headaches at the age of 15. At that time she used to get throbbing hemicranial (one half of the head) headaches which were accompanied by nausea. At times she used to throw up if the headache was particularly bad. During the headache episode she complained of light sensitivity (bright lights bothered her, we refer to this as photophobia) perferring to lie in a quiet dark room. Sleep usually aborted her headache attack. She was correctly diagnosed as suffering from common migraine (this is migraine which is not associated with aura) and treated with Inderal (propanolol-a beta blocker). Later she started using Imitrex (a triptan) whenever she had an acute migraine attack. Around the age of 18, she developed pelvic inflammatory disease for which she started using ibuprofen.

At the time of her current presentation, she said her headache character had changed. Now instead of having episodic migraine attacks, she had a headache “all the time”. She was taking 4-6 pills of ibuprofen a day and 8 to 10 Imitrex pills a month.

This brings us to the topic under discussion “analgesic overuse headaches” also at times referred to as “medication overuse headaches”. Research has shown that about 1% of the general population experiences medication overuse headache and the condition is thought to occur due to an interaction between a therapeutic agent (in this case an analgesic) used excessively by a suspectible patient.

The overuse of anti-migraine drugs and analgesics gives rise to a mixed picture of migraine-type and tension-type headaches that occur at least 15 days a month. Patients start taking more and more analgesics to treat the headache and this sets up a vicious cycle of headache-analgesic-headache-analgesic.

Chronic daily headaches due to overuse of analgesics are particularly difficut to treat.  Analgesics are discontinued (some patients of course have worsening of their headache during this time). To keep headaches under check during this time (when the analgesics have been discontinued), the doctor may prescribe a low dose tricyclic antidepressant such as Elavil (amitriptyline). The headache usually resolves or reverts to its previous pattern within two months after discontinuation of the drug (analgesic).

Post coital headache

Let us discuss post-coital headache also at times referred to as orgasmic headache. What is post coital headache?  The history is quite typical. This is a throbbing and at times intense headache which comes on at or near the height of orgasm. During coitus as sexual excitement increases, the muscles around the shoulder and neck become tense. There is increased blood flow to the brain and either at the height of the orgasm or soon after the patient complains of throbbing and at times intense holocranial (whole head) headache.

Post coital headache is relatively benign and does not warrant any urgent treatment. As the sexual excitement weans off, the headache too subsides and usually by the time the patient reaches the ER to seek care, the headache is subsiding or already gone. There is though one entity which can mimic a post coital headache in its clinical presentation and which warrants urgent evaluation. This is the headache which occurs when an aneurysm ruptures in the brain. Classically an aneurysmal headache is described by the patient as the ” worst headache of my life“. It is intense, holocranial, throbbing and accompanied by a stiff neck (as you can see the clinical presentation may resemble that of a post coital headache). An aneurysmal bleed though may be accompanied by other neurological signs and symptoms depending upon where the bleed has occurred in the brain and patients are usually obtunded by the time they reach the hospital. An aneurysmal bleed is a medical emergency and needs to be evaluated and treated urgently. Usually a special kind of scan is carried out to localize the site of the aneurysm and then either the aneurysm is coiled or clipped to secure it. I shall discuss the management of aneurysms in a separate post.

Nitin Sethi, MD

Taking control of your migraines: what can you do as a patient

Migraines are among the most common of the primary headaches, the other been tension type headaches and cluster headaches. The etiopathogenesis of migraine headache is thought to be vascular and now there are many effective drugs available both for an acute migraine attack as well as for prophylaxis (read my post on headache at http://braindiseases.info). While these drugs are highly effective, many patients would rather avoid taking a drug if they can help it. Drugs have their own side-effects and cost is always an issue.

So is there anything patients can do themselves so as to make their headaches better? In this post I shall list a few of these simple measures, which if followed shall give you a better control over disabling migraine headache attacks.

 Know your headache

what do I mean by that. Well as a patient who suffers from migraine, the single most important thing that you can do is get to understand your migraine.

When does it come on?

Do you have headaches after a hard day’s work?

Do you get a migraine if you keep a late night out?

Does too much stress bring on a headache?

Does too much alcohol give you a headache?


If yes then what kind of alcohol gives you a headache the next day. People who have migraines usually get headaches if they consume red wine (white wine goes down better with them).

Do you have any other migraine triggers apart from lack of sleep, overindulgence in alcohol, red wine, old and aged cheese, chocolate, nuts etc.

What gives you relief from a headache?

Does sleep abort the headache?

Does regular physical exercise decrease your headache frequency and severity?

What about other complimentary therapies like yoga, tai-chi, meditation?

Keep a headache diary in which you document your headache episodes consistently for about a month or two. How many times did you have a migraine attack? What brought it on? What made the headache go away? If you keep this diary consistently, you shall soon come to know your triggers for migraine and can then take steps to remedy them.

Nitin Sethi, MD

Post Concussive Syndrome

In this post I thought I would talk a little about what is called post concussive syndrome (PCS). Before we discuss PCS, we need to understand just exactly what is a concussion. Unfortunately though there has been realms of data generated on this, the word concussion still remains quite ill-defined in the medical literature. Basically it refers to a brief loss of consciousness. Lets use an example. You are in the ring against Iron Mike. You have your right and left going but walk into one of Iron Mike’s jabs. Boom your legs give away under you and you are on the mat unconscious seeing “stars”. You are “out” for a few seconds and then boom you come out and are looking up at the referee to ask “where am I? what happened to me?”

Concussion may then also be referred to as a minor head trauma or rather a minor closed head trauma accompanied by brief loss of consciousness. Closed since there is no breach in the skull. The head injury occurs but nothing penetrates the skull. Concussions are thus common and they may occur during a MVA, sports related concussions are common (injuries during football, ice-hockey, boxing and other contact sports where blows to the head may occur). The exact mechanism why there is that bried period of unconsciousness which then resolves and the person wakes up is not fully elucidated. The thinking is that during the concussion, the brain is subjected to mechanical and kinetic forces which “shake” the brain inside the rigid cranium. The brain though is free to move inside the skull, it is attached by the brainstem which is relatively immobile. So as the brain turns on its axis, there is transient dysfunction of the brainstem and this leads to loss of consciousness and the person blacks out.

Concussions are usually not life threatening and the patient comes around in a few seconds to a few minutes. Those associated with a prolonged period of unconsciousness though need to be evaluated in the hospital to make sure there is nothing serious or structural such as an intracranial hemorrhage (bleed) into the brain or outside the brain but inside the skull (epidural hematoma).  There are guidelines with respect to sports related concussion injuries and usually the doctor at the side of the play field makes a decision whether it is safe for the player to play again during that game or should he sit out the rest of the game. Multiple concussive injuries increase the risk of sudden death (no one quite knows by what exact mechanism) and hence concussive injuries in professional players like those who play football do deserve special attention.

Let us now turn to what is called PCS. Again there has a lot which has been written about PCS but this syndrome is ill-defined and its etiology is far from clear. Patients who have suffered a concussion frequently complain of memory problems following the concussion. Apart from memory difficulties these patients may complain of mood changes been too irritable or short tempered, balance problems and unsteady gait, dizziness, headaches, fatigue and lack of energy. This constellation of signs and symptoms with a preceeding history of concussion is what has been referred to as PCS. When these patients present to neurologists, we investigate them but most of the time all the tests come back as “normal”. Their imaging studies like CT scan head and MRI brain are normal.

PCS is usually treated symptomatically. If headache is the major complain we treat the headache. If dizziness is the major complaint we treat with an antivertigo drug. At times low dose antidepressants may be helpful. The natural history of this condition is good and most patients recover in due course and are able to go back to their day to day life.

Nitin Sethi, MD