Headache Classifications

Primary headache types

- migraine

- tension

- cluster

Migraine type of pain

- throbbing/stabbing

- moderate-severe

- wose w/ exertion

Tension headache type of pain

- dull and band-like tightness

- defuse pain, waxes and waines

Cluster headache-type pain

- abrupt onset

- deep, continuous

- excruciating, explosive

- stabbing quality usually near one eye

Migraine

- Location:

- Duration:

- Sx:

- Typical pt appearance:

- Location: 60-70% unilateral, often in frontotemporal region

- Duration: 4-72 h

- Sx: photo/phono-phobia, N/V, aura, sensitivity to movement

- Typical pt appearance: rest in quiet, dark room; younger female

Tension headache:

- Location:

- Duration:

- Sx:

- Typical pt appearance:

- Location: bilateral

- Duration: variable

- Sx: none, no N/V

- Typical pt appearance: can remain active or may prefer to rest (anyone)

Cluster headache:

- Location:

- Duration:

- Sx:

- Typical pt appearance:

- Location: unilateral facial pain, orbital, supraorbital or temporal pain

- Duration: 15 min-3 hr, once to multiple per day

- Sx: tearing, nasal congestion, miosis, ptosis, eyelid edema, rhinorrhea, pallor, facial sweating

- Typical pt appearance: male, smoker, restless, agitated, clutch head (ends when episode ends)

What are secondary causes of headaches?

• Head trauma

• Vascular disorders

• Infection

• Intracranial pressure (changes)

• Medications

• Metabolic disorders

• Toxic substances

• Substances of abuse

• Trauma

- Commonality for most of these causes is SERIOUS and may require medical attention to address

Secondary headache: RED FLAGS

- Acute onset of the"first" or "worst" headache ever

- Change in pattern of headaches or progressive worsening

- Onset of headache after age 50 years

- Headache associated with systemic illness (eg, fever, nausea, vomiting, stiff neck, and rash)

- Triggered by cough, exertion, Valsalva maneuver

- Abnormal neurologic exam with papilledema or change in mental status

- New-onset headache in a patient with cancer or human immunodeficiency virus (HIV) infection

Etiology of migraine

- Activation of trigeminal sensory nerves triggers the release of vasoactive neuropeptides, which interact with dural blood vessels to cause vasodilation and extravasation → inflammation

- nitric oxide, substance P, calcitonin gene-related peptide (CGRP)

- neurotransmitter release affects in other ways (serotonin in particular)

____________ mechanism provides a basis for drug targets

multi-factorial

Premonitory symptoms (Prodrome/Pre-Headache)

- anxiety, depression, euphoria, drowsiness/fatigue, hyperactivity, restlessness, irritability

- allodynia, photophobia, phonophobia, hyperosmia, difficulty concentrating

- stiff neck, thirsty, food cravings, anorexia, yawning

- polyuria, diarrhea, constipation

- about 77% of pts experience some of these warning signs hours-days before HA

Aura symptoms

- Positive features: scintillations, photopsia, teichopsia, fortification spectrum

- Negative features: scotoma, hemianopsia

- Motor/somatic: dysphagia, aphasia, weakness, hemiparesis, tingling sensation

Postdromal sx of migraine

- can occur for up to 48 hours after HA subsides

- Feel tired, exhausted, irritable, or listless. Conversely, some feel unusually refreshed or euphoric

- Impaired concentration may continue from HA

- Muscle weakness or myalgias; scalp tenderness

- Anorexia or food cravings

Risk factors for migraine

- family hx

- mood disorders

- vascular factors

- obesity

- any age, but less common w/ advancing age. first attack by age 40

- 3x more likely in women

- hormonal changes (OCPs, menstruation, preg)

- weather (changes in humidity, pressure)

- diet

Foods that may trigger migraine

- nuts

- caffeine

- chocolate

- dairy

- artificial sweeteners (aspartame, saccharin)

- nitrate-containing meats

- tyramine-containing foods (aged cheese), fermented age/pickled foods

- alcohol

- Usually trigger migraine within 1-12 hours, but patients may notice different patterns

Environmental triggers

• Glare or flickering lights

• High altitude

• Loud noises

• Strong smells and fumes

• Tobacco smoke

• Weather change

Behavioral-physiologic triggers

• Excess or insufficient sleep

• Fatigue

• Menstruation, menopause

• Sexual activity

• Skipped meals

• Strenuous physical activity (e.g., prolonged overexertion)

• Stress or post-stress

Episodic headaches

- <15 HA days/month

- Some may be migraines, some may be tension/other types

Chronic headaches

• >15 HA days/month, for at least 3 months, (tension type and/or migraine headache)

• HAs lasting 4-72 hours

• HAs have features of migraine without aura for ≥8 days/month

Menstrual-associated headache

• Hormone-related 2 days before or first 2 days of menses

• More severe, frequent and resistant to therapy

Medication overuse headaches

• Transition from episodic to chronic

• Analgesic or triptan overuse

• Unresponsive to prevention medications

What are medication overuse headaches caused by?

- frequent use of HA medication

- use >3 times/week

- escalating use of med increases quantity/severity of HA

- withdrawal sx occur upon d/c of offending drug

Causative agents of medication overuse HA

- Analgesics, especially combination products with caffeine

- Barbiturates

- Ergotamines

- Opioids

- Triptans

How can medication overuse headaches be prevented?

When HAs are well managed, limit use of acute abortive therapy to 2-3 times/week

T/F: Tensions are the most common type of headache

TRUE

Cluster headaches are more ______________, but also most ______________________

- severe

- uncommon

Cluster headaches usually happen in...

- concentrated time frame (days to months), separated by periods of remission (months-years)

- more common at night and in spring & fall

- onset is sudden w/ pain peaking quickly and lasting 15-180 mins (3 hours)

Pain in cluster headaches

- excruciating, penetrating

- intensity near the eye or temple (unilateral)

What are cluster headaches accompanied by?

- cranial autonomic sx

- resolve when HA resolves

- potentially restlessness or agitation

Timing of cluster headaches

has been observed to happen up to 8 times a day

At least one of the following must occur in a cluster headache

◦ Conjunctival injection

◦ Lacrimation

◦ Nasal congestion

◦ Rhinorrhea

◦ Facial sweating

◦ Miosis (constriction of pupil)

◦ Ptosis

◦ Eyelid edema

What is the difference between a tension headache and a migraine? Cluster?

Migraine: throbbing, unilateral, NV, photophobia, aura

Tension: bilateral, bandlike

Cluster: unilateral, focused in one eye, nasal sx, stabbing, excruciating

What constitutes a chronic headache/migraine?

≥15 HA days/month

What are three things that can potentially trigger migraines?

- food

- hormones

- environmental

- many more

Name 2 medications that can cause medication-overuse headaches

analgesics, sumatriptan, anything used to treat migraines

(Predict) How can patients best track their headaches/migraines?

journal, diaries