Headache
Headache Symptoms | Causes
of Headache | Headache
Treatment
The primary headache syndromes are migraine, tension-type, and cluster
headaches. Migraine and cluster headaches are episodic and recurring
conditions. Tension-type headache is usually episodic but may be chronic,
occurring daily or almost daily for more than 15 days a month.
None of
these primary headaches is associated with demonstrable organic disease
or structural neurologic abnormality. Laboratory and imaging test results
are generally normal. Similarly, the physical and neurologic examinations
are also usually normal. During the headache attack however, cluster
and migraine patients might have some abnormal clinical findings, and
many patients with tension-type headache have demonstrable tightness
in the cervical muscles, with limitation of neck motion, scalp tenderness,
or both.
Secondary headaches are usually of recent onset and associated
with abnormalities found on clinical examination. Laboratory testing
or imaging studies confirm the diagnosis. Recognizing headaches related
to an underlying condition or disease is critical not only because treatment
of the underlying problem usually eliminates the headache but also because
the condition causing the headache may be life-threatening
Headache Symptoms
Migraine
Most migraine patients do not have an aura; migraine with aura occurs
in only 15% to 20% of sufferers. The aura is a well-defined visual
or neurologic deficit lasting less than 1 hour and is followed by the
headache within 1 hour. Most auras are visual, with photopsia (flashing
lights) being most common. The aura is initially small, then enlarges
or moves across the visual field. A typical migraine aura can occur
without a headache. This phenomenon tends to begin later in life. Occasionally,
a neurologic aura occurs, with a tingling or weakness that slowly spreads
up or down an extremity.
Many patients with migraine have prodromal symptoms for many hours or
even a day or so before the onset of an attack. These prodromal symptoms
are generally changes in mood or personality. Fatigue also is common,
and occasionally hyperactivity occurs.
The migraine attack lasts 6 to
72 hours. This pounding, throbbing pain of moderate to severe intensity
is generally unilateral, but some patients experience bilateral pain.
Pain caused by migraine worsens with physical activity. Photophobia and
phonophobia are very common, with sensitivity to odors being a little
less common. Migraine is a sick headache. Nausea occurs in many patients,
and vomiting can occur. Dehydration can occur, which increases the pain
and disability. Migraineurs want to be quiet, inactive, and in a darkened
area during the attack. Approximately 60% of women experience their worst
migraine attacks in conjunction with their menstrual period.
Tension-type
Headache
Tension-type headache is characterized by generalized pressure or a sensation
of tightness in the head. The discomfort level is usually mild to moderate
and does not worsen with activity. Although nausea and photophobia or
phonophobia can occur, they generally are not prominent features. Tension-type
headache can be episodic (less than 15 days a month) or chronic (more
than 15 days a month).
Cluster Headache
Cluster headache tends and occurs more commonly in the 5-7 decade. The
pain is very intense that is generally steady and boring behind one eye.
The pain can spread to the temple, face, and even into the upper neck.
It is so intense that most sufferers pace the floor or do vigorous exercises
during the attack. The attacks are short (usually less than 3 hours in
duration) and often last only 30 to 45 minutes. They occur from one to
several times a day for a period of several weeks or months, then remit,
leaving the patient pain free for several months or years, only to recur.
They frequently occur in the early morning hours between 2-6 am. They
can also be associated with tearing in the affected eye or a runny nose.
Chronic
Daily Headache
Daily headache can occur as a chronic tension-type headache, but it is
often a combination of tension-type and migraine (as often seen in headache
clinics). This type of combination headache is not listed in the official
classification, so one should diagnose both chronic tension-type headache
and migraine in these patients. Most often, this type of combination
or mixed headache develops in a person who initially had typical episodic
migraine but in whom, over several years, a chronic daily or almost-daily
headache develops. Many times, this daily headache seems to occur because
of the frequent use of analgesics, especially those combined with caffeine
or butalbital. A daily or near-daily migraine headache can occur from
the frequent use of ergotamine tartrate or any of the triptan drugs.
This headache pattern has been called headache or overuse headache. It
is important to make this diagnosis and limit the pain medications, as
taking more medications will only worsen the problem.
Migraine Headache Cause
The causes of migraine headaches are not clearly understood. In the
1940s, it was proposed that a migraine begins with a spasm, or partial
closing, of the arteries leading to the main part of the brain (called
the cerebrum). The first spasm decreases blood supply to part of the
brain, which causes the aura (lights, haze, zig-zag lines, or other symptoms)
that some people experience. These same arteries dilate to increase blood
flow which stretches the blood vessels causing the throbbing and the
pain.
About 30 years later, the chemicals dopamine and serotonin were
found to play a role in migraine headaches. (These chemicals are called
neurotransmitters.) Dopamine and serotonin are normally found in the
brain, but they can cause blood vessels to act in uncharacteristic ways
if they are present in abnormal amounts or if the blood vessels are unusually
sensitive to them.
Together, these 2 theories have come to be known as
the neurovascular theory of migraine, and it is presently believed that
both theories provide insight into the causes of headache.
Various triggers
are thought to initiate migraine headaches in people who are prone to
developing them. Different people may have different triggers.
- Smoking
has been identified as a trigger for many people.
- Certain foods such
as strong chesses, red wines, chocolate
- Missing a meal or changing sleep
patterns may bring on a headache.
- Stress and tension are also risk
factors. People often have migraines during times of increased emotional
or physical stress.
- Menstrual cycle
- Changes in weather
Headache Treatment
Most patients with primary headache require medication; however, other
management methods also may be useful. Secondary headache usually resolves
when the underlying neurologic or systemic problem is treated.
Migraine Treatment
Some migraine headaches can be relieved with the use of cold packs, pressure
on the temple, and sleep. However, most patients require abortive medication,
and many are candidates for daily preventive medication.
Educating the migraine patient to recognize and avoid headache triggers helps
to reduce the frequency of attacks. Common migraine triggers include weather
changes, the estrogen cycle, bright lights, strong odors, stress, foods, food
additives, and skipping meals. Migraineurs do better and have fewer headaches
by following regular eating and sleeping patterns.
Preventive Medications
Daily prophylactic medication should be considered whenever migraine
attacks occur several times a month or are very severe and do not respond
well to abortive medication. beta blockers, calcium channel blockers,
nonsteroidal anti-inflammatory drugs (NSAIDs), antidepressants, antiepileptic
drugs, and the serotonin agonist methysergide maleate .There are three
main classes of drugs used to prevent migraines: 1. beta blockers,
calcium channel blockers, 2. Nonseteroidial anti-inflammatory drugs
(NSAIDS) and 3. Antidepressants. The beta blockers propranolol and
timolol maleate and the anticonvulsants divalproex sodium and topiramate,
currently are the only drugs approved by the U.S. Food and Drug Administration
for migraine prevention. (Methysergide is no longer available in the
United States). Botulinum toxin type A injected into the scalp muscles
has also been found to decrease the frequency and severity of migraine
in about 50% of patients treated.
