This article includes discussion of headache attributed to disorder of homeostasis, headache associated with decompression illness, headache associated with dialysis, headache associated with hypercapnia, headache associated with hypoglycemia, headache associated with other systemic disorders, high altitude headache, and hypoxic headache. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.
Headaches in patients with complex medical problems may often be confusing and challenging. In this updated article on headaches due to disorders of homeostasis, the author provides definitive and full differential diagnosis in these complex patients. Recently it was reported that patients with diabetes may have fewer headaches with tighter control with the longer acting medications. COPD and sleep apnea were also recognized as causes of headaches that clinicians should screen for. Finally, many studies are trying to understand the CNS effects of autoimmune and connective tissue diseases and their clinical presentations. More CSF markers may be helpful in these often elusive conditions.
• Diets rich in linoleic and arachidonic acid cause neurologic irritation and headaches.
• Metabolic alterations associated with Bartter syndrome may be a cause of headache.
• Advanced neuroimaging helps diagnose altered metabolic states associated with various types of headaches.
• Functional MRIs suggest that understanding the pain neuromatrix and the central descending pain control symptoms will foster further understanding of headache pain.
Historical note and terminology
The current nomenclature of headache attributed to a disorder of homeostasis includes headache that resolves or significantly improves after treatment or spontaneous resolution of the homeostatic disorder. This new classification from the International Headache Society replaces the previously designated term “headache associated with metabolic disorder” (Headache Classification Committee of the International Headache Society 2004). This classification also includes headaches that occur during a metabolic disturbance and disappear within 7 days after normalization of the metabolic state. These changes in nomenclature were made to more accurately reflect the pathophysiologic process. The major disorders of homeostasis-related headache are hypoxia, hypercapnia, hemodialysis, arterial hypertension, hypothyroidism, fasting, and cardiac cephalalgia.
Headache caused by hypoxia or hypercapnia is defined as a headache that occurs when a patient has acute hypoxia with a PaO2 of 70 mm Hg or less or is chronically hypoxic, with PaO2 persistently at or below this level. Causes of this type of headache include high altitude, diving, and sleep apnea.
Headaches related to arterial hypertension consist of only secondary causes of hypertension, with the exception of hypertensive encephalopathy and hypertensive crisis. According to the International Headache Society, headaches attributable to the secondary causes of hypertension are pheochromocytoma, preeclampsia, eclampsia, and acute pressor response to an exogenous agent. Headaches associated with pulmonary hypertension and the physiologic sequelae are of rising significance.
The International Headache Society's new diagnostic criteria for hemodialysis-related headaches are as follows:
(1) The patient is on hemodialysis.
(2) The headache develops during at least half of the hemodialysis sessions.
(3) The headache resolves within 72 hours after each hemodialysis session or after renal transplantation.
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