Headache/Migraine Education & Treatment
The primary headache syndromes are migraines, tension-type, and cluster headaches. Migraines and cluster headaches are episodic and recurring conditions. Tension-type headaches are usually episodic but may be chronic, occurring daily or almost daily for more than 15 days a month.
None of these primary headaches are 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 headaches have demonstrable tightness in the cervical muscles, with the 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
Most migraine patients do not have an aura; migraine with aura occurs in only 15p percent to 20 percent of sufferers. The aura is a well-defined visual or neurologic deficit lasting less than one hour and is followed by the headache within one 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 migraines 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 six to 72 hours. This pounding, throbbing pain of moderate to severe intensity is generally unilateral, but some patients experience bilateral pain. Pain caused by migraines worsens with physical activity. Photophobia and phonophobia are very common, with sensitivity to odors being a little less common. Migraines are 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 percent of women experience their worst migraine attacks in conjunction with their menstrual period.
Tension-type headaches are 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 headaches can be episodic (less than 15 days a month) or chronic (more than 15 days a month).
A 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 three 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.
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 two theories have come to be known as the neurovascular theory of migraines, and it is presently believed that both theories provide insight into the causes of headaches.
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 cheeses, 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
Most patients with primary headaches require medication; however, other treatment methods also may be useful. Secondary headaches usually resolves when the underlying neurologic or systemic problem is treated.
Some migraine headaches can be treated 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.
Some patients may have benefited from occipital nerve blocks or Sphenopalatine ganglion nerve blocks
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. Nonsteroidal 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. Botulinum toxin type A injected into the scalp muscles has also been found to decrease the frequency and severity of migraines in about 50 percent of patients treated.
Contact a neurologist if you are experiencing frequent headaches.