more commonly affected by migraines than are men (Straube et al., 2019). The onset of tension-type headaches is typically in the 20s and rarely after age 50, and they affect women more than men (Pluta et al., 2011). Cluster headaches have their maximal prevalence at 20–40 years of age and affect men more than wom- en (Straube et al., 2019).
According to Straube et al. (2019), the onset of primary head- aches is age dependent. The onset of migraine headaches is often puberty (Straube et al., 2019). Before puberty, migraines are slightly more common in boys, but with the onset of females’ cyclical hormonal changes, migraines become more common in girls. This difference continues into adulthood, where women are
Evidence-based practice: Age of headache onset can be useful information in differentially diagnosing primary headache types. Migraines typically start in puberty. Tension-type headaches typically start in the 20s and rarely after age 50. Cluster headaches have their maximal prevalence at 20–40 years of age (Straube, 2019).
Systemic origins of headaches Along with understanding the classification of headaches as pri- mary or secondary, differential diagnosis of headaches involves being aware of the many systems and diagnoses that can cause headaches. This is necessary for determining if referral to a physi- cian is warranted and whether physical therapy might be helpful. Systemic origins of headache include the following. Cancer ● Primary neoplasm . The risk of finding a brain tumor in a head- ache patient is rare. According to Do et al. (2019), it is less than 0.1%, with the majority being present in patients over 50 years of age. Metastases to the brain are highest with lung cancer, breast cancer, and malignant melanoma (Do et al., 2019). Relevant accompanying symptoms include emesis, headache duration less than 10 weeks, atypical headache pat- tern, pulsating quality and moderate to severe intensity, gait instability, and extensor plantar response (Do et al., 2019). ● Chemotherapy; brain radiation used in the treatment of cancer . According to the American Cancer Society, head- This condition causes inflammation and destruction of the brain, spinal cord, and meningeal vessels. It can occur as a primary in- flammation within the central nervous system or secondary to a systemic infection. It is considered a rare and severe inflammatory disease (Lu et al., 2020). According to Lu et al. (2020), headache associated with this condition is chronic, moderate, diffuse, and long lasting. Common accompanying symptoms include focal deficits, seizures, altered cognition, and disorders of conscious- Cervical artery dissection is divided into internal carotid artery dis - section and vertebral artery dissection. These conditions lead to blood flow into the wall of the cerebral artery, forming a hema- toma which leads to stenosis, occlusion, or aneurysmal changes in the artery (Lu et al., 2020). The initial symptoms of carotid artery dissection are typically headache and neck pain. It is the cause of stroke in 20% of younger people, with average age of onset of 44 years (Lu et al., 2020). Headache with this condition mimics other headaches such as migraine, cluster headache, or thunderclap headache. The headache is often acute and continuous for days or longer and is located at the same side as the affected cervical vessel (Lu et al., 2020). Cerebrovascular system CNS vasculitis ness (Lu et al., 2020). Arterial dissection Vertebrobasilar insufficiency is defined as transitory ischemia of the vertebrobasilar circulation. Atherosclerosis is the most com- mon cause of this condition (Lima Neto et al., 2017). Headache is a common symptom of this condition, along with dizziness, vomit- ing, diplopia, ataxia, imbalance, and weakness on both sides of the body (Lima Neto et al., 2017). Arteriovenous malformation Arteriovenous malformations are abnormal shunts between ar- teries and veins that bypass the capillary bed (Schimmel et al., Ischemia Vertebrobasilar insufficiency
aches are one of the primary side effects of radiation (Side Ef - fects of Radiation Therapy/Radiation Effects on Body, n.d.). In addition, certain drugs and types of chemotherapy can have severe headaches as a side effect. In particular, hormonal ther - apies used for prostate and breast cancer treatment have been known to trigger headaches or migraines (Zizinia, 2021b). Self-Assessment Quiz Question #9 The risk of metastasis to the brain as a source of headache pain is rare. The type(s) of cancer that is/are the most likely cause of metastasis to the brain include(s): a. Lung cancer and pancreatic cancer. b. Breast cancer and kidney cancer. c. Lung cancer, breast cancer, and malignant melanoma. d. Malignant melanoma and pancreatic cancer. Cerebral venous thrombosis Cerebral venous thrombosis is characterized by obstruction of cerebral venous reflux, often accompanied by intracranial hy- pertension. It is a common cause of cerebrovascular disease in younger people, with the onset typically between 20 and 50 years of age (Lu et al., 2020). Headache is often the heralding symp- tom of cerebral venous thrombosis, preceding other manifesta- tion of the disease by days or weeks (Aliprandi et al., 2020). Ac- cording to Lu et al. (2020), severe headache is the most common symptom of cerebrovascular disease and is reported by 60% to 90% of patients (Lu et al., 2020). This headache can be unilateral and sudden (even thunderclap), or mild. It often mimics migraine symptoms (Lu et al., 2020). It worsens with activities that increase intracranial pressure and is often accompanied by focal neurologi- cal symptoms (Lu et al., 2020). Mitochondrial encephalomyopathy Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episode syndrome (MELAS) is another potential source of head- aches (Lu et al., 2020). It is associated with mitochondrial DNA gene mutations, with typical onset under 45 years. The headaches associated with this condition is migraine-like, short-lasting, and of mild or moderate severity. Stroke like seizures may be present (Lu et al., 2020). 2021). The anatomical location and stage of development of these malformations influence the potential complications they can cause, including stroke, brain abscess, hypoxemia, or local rupture (Schimmel et al., 2021). Headache is very commonly pres - ent with arteriovenous malformation (Lai et al., 2017). According to Lai et al. (2017), occipital brain arteriovenous malformations are more likely to present with migraine-like headaches, while fron- totemporal arteriovenous malformations are more likely to show tension-type headache. The mechanism of symptomatic head-
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