HEADACHE PDF Print E-mail

Authored by MCN Neurologists

Headache, like chest pain or abdominal pain, is a symptom that can have many causes.  If the headache is not caused from another condition like an infection or brain tumor, we term it a primary headache disorder.  The common types of primary headache disorders are migraine, tension type headache and cluster headache.

EXAMINATION AND TESTS

The examination is very similar for all types of primary headache disorders.  Your doctor will first take a history of the length of time you have experienced headache, and will be interested to see what symptoms are associated with your headache.  You may be asked if you can identify triggers that bring on your headaches and if other family members have headaches.

A physical and neurological exam will be done to make sure there are no other causes for your headaches.  This will include looking in your eyes, checking sensation and reflexes in your body, as well as checking your strength.  Neck and jaw muscles will often be examined as well.

Often no additional laboratory or MRI testing is needed if your headaches are long-standing with no new neurological symptoms, but testing may be ordered, when appropriate, based on your history and examination.

MIGRAINE

A migraine headache is a recurrent, frequently unilateral (one-sided) headache often associated with nausea, vomiting and sensitivity to light and noise.  Migraines are most prevalent in persons between the ages of 25 and 55.  Women experience migraines three times as often as men.  The tendency to develop migraine headaches is often hereditary.  As many as 80% of migraine sufferers have a family history of some type of headache disorder.

CAUSES

Physicians now believe that migraine headaches are caused by an abnormal regulation of pain control in the brain.  The theory is that there is hypersensitivity in the neurons (brain cells) of migraine patients and this allows internal and external (environmental) irritants to trigger neurological activity in the brain, causing inflammation of blood vessels and migraine symptoms.  The hypersensitive neurons may be this way due to a patient’s genetic makeup.

Common triggers of migraine headaches are:

Hormonal fluctuations like menstruation and menopause

Sleep fluctuations - too much or too little sleep

Neck and jaw muscle spasm

Foods that excite the brain due to added artificial chemicals, like MSG, nitrates, wine or Nutrasweet, or foods with strong smells or tastes, like aged cheese and spicy food.

Weather/barometric pressure changes

Bright lights - sunlight or fluorescent lights

Medications - Nitroglycerin, for example

SYMPTOMS

Typically, the headache is a throbbing pain (like a heart beating) and is most commonly on one side of the head and behind the eye, but many individuals have more generalized pain. 
Migraine is typically associated with light and/or sound sensitivity, nausea and/or vomiting, inability to do normal daily functions and, in 25% of individuals, neurological symptoms of visual shimmering lights and/or numbness in the body prior to the onset of the headache pain.
Physical activity aggravates the pain.
Pain lasts 4-72 hours.
Occasionally a patient will have aura (visual light/neurological symptoms) without pain.  These episodes typically last 30-60 minutes and seem to be more common over the age of 50.

TREATMENT

Symptomatic (Acute) Treatments

Some medications are used at the first sign of migraine pain to try and stop the migraine from progressing. 
Triptans - Most specific abortive agents for stopping migraine as they bind to blood vessel and nerve receptors.  Maxalt, Relpax, Axert, Treximet, Amerge and Frova all come in pill form.  Imitrex and Zomig come in pill form and in a nasal spray, and Imitrex also comes in an injection form.
Ergotamines/Dihydroegotomines - Older class of migraine medication that, like the triptans, bind to blood vessel and nerve receptors, however they can have more side effects as binding is more diffuse in the body.  Cafergot is the tablet form, Migranol the nasal spray form and DHE-45 the injectable form in this group of medications.
Non-steroidal anti-inflammatories - Decrease a part of the blood vessel inflammation in migraine.  Motrin and Aleve are examples of medications in this category.
Pain medications - Used as a rescue if one of the primary treatments doesn’t work.  Don’t specifically stop the progression of a migraine, but promote sleep and relaxation.  Vicodin, Fiorinal and Tramadol are examples.

Preventative (Daily) Treatments

Physicians recommend these for three or more disabling attacks per month, or for less frequent attacks that are severe enough to curtail work or social activities.
Blood pressure medications - These decrease blood vessel swelling that occurs with migraine.  Typical medications used are beta-blockers, like Propranolol and Nadolol, and calcium channel blockers, like Verapamil.
Anti-depressant medications - These improve central pain control.  Typical examples are Amitriptyline, Nortriptyline and, used less often, SSRIs, like Citalopram, and SNRIs, like Cymbalta.
Anti-convulsant medications - These decrease nerve hypersensitivity.  Typical examples are Topamax, Depakote and Gabapentin.

Please note that not all medications mentioned have FDA approval for use in migraine prevention, but are mentioned as neurologists frequently use them.

Non-Medication (Alternative) Treatments

Physical therapy - Prescribed if neck and jaw spasm is felt to be a contributing factor.
Biofeedback - Involves relaxation-type exercises designed to teach you to control muscle contractions and breathing to help you relax.
Lifestyle changes – Such as eating regularly scheduled meals, establishing a regular sleep schedule, staying well hydrated and avoiding daily caffeine use can help avoid the triggering of migraines.
Acupuncture
Vitamins - Some small, uncontrolled trials have shown that riboflavin (vitamin B2), magnesium, Butterbur and Coenzyme Q10 may help decrease migraines.  You should speak with your doctor about doses and potential side effects.
Botox injections - Approved for use by FDA in November 2010 for chronic migraine (migraines that are 15 days/month or more).

TENSION HEADACHES

Tension headaches are chronic recurring headaches that occur in 70-80% of the population at some point in an individual’s life.  Most physicians believe tension headaches are on a continuum with migraine and related to abnormalities in central pain processing.  Unlike migraine, however, the blood vessels do not become inflamed with tension type headache, so patients do not have throbbing, incapacitating pain, nausea, vomiting or neurological symptoms (aura) that are seen in migraine.

CAUSES

Soreness in the neck and jaw muscles from poor posture or tension, or from injuries to the neck and neck muscles.
Depression and anxiety
Sleep disturbances, including difficulty falling asleep or frequent awakenings
Medication or caffeine rebound.  Use of oral caffeine or certain medications more that three days per week can cause withdrawal headaches, which have the characteristics of tension-type headaches. Common examples of medications that can cause rebound headaches are Excedrin, Tylenol and Butalbital compounds and narcotics.
Lifestyle - missing meals, dehydration, excessive stress and side effect of medications

SYMPTOMS

A tight, “band-like” sensation around the head
A “pressure”, or “squeezing sensation”, not throbbing like a heart beat
Pain is typically in the forehead, temples or back of the head and neck
Pain typically lasts 4-24 hours, but can last days
Pain is not worsened by physical activity

TREATMENT

Symptomatic (Acute) Treatments

These medications are used to treat individual attacks of headache.
Analgesics - Over-the-counter medications for pain, such as aspirin and acetaminophen.
Non-steroidal anti-inflammatories - Over-the-counter forms, such as Aleve and Advil, can help or, if needed, prescription forms, of which Motrin, Nambutone or Diclofenac are examples, among many others.
Mixed analgesics (combinations of medications) - An over-the-counter form is Excedrin, or in prescription form, Midrin or Fiorinal.  These should not be taken more than 2-3 days per week to avoid medication rebound headache.
Muscle relaxants - These are all prescription medications, of which Methocarbamol and Cyclobenzaprine are examples.

Preventative (Daily) Treatments

These medications are used daily to prevent attacks of headache usually in patients with 10-15 or more days of headache per month.
Anti-depressant medications - These improve central pain control.  Typical examples are Amitriptyline, Nortriptyline and, less often, SSRIs, like Citalopram, and SNRIs, like Cymbalta.
Anti-convulsant medication - These decrease nerve hypersensitivity.  Typical examples are Topamax, Depakote and Gabapentin.
Muscle relaxants - These help relax muscle irritability.  Tizanidine has been the main medication studied for daily use in tension headache.
   
Please note that not all medications mentioned have FDA approval for use in tension headache prevention, but are mentioned as neurologists frequently use them.

Non-Medication (Alternative) Treatments

Physical therapy - Prescribed if neck and jaw spasm is felt to be a contributing factor.
Trigger point injections - May be added to physical therapy to help with muscle relaxation.
Biofeedback - Involves relaxation-type exercises designed to teach you to control muscle contractions and breathing to help you relax.
Lifestyle changes - Such as eating regularly scheduled meals, establishing a regular sleep schedule, staying well hydrated and avoiding daily caffeine use can help avoid tension headache.
Acupuncture
Vitamins
- Some small, uncontrolled trials have shown that riboflavin (vitamin B2), magnesium, Butterbur and Coenzyme Q10 may help decrease migraines, and they may help tension headache as well.  You should speak with your doctor about doses and potential side effects.

CLUSTER HEADACHES

Cluster headaches are relatively brief headaches lasting 60-90 minutes and occurring repetitively one to several times a day for several weeks (in “clusters”).  The typical length of a cluster is 6-12 weeks.  The patient will then have a period of months to years with no cluster headaches; the average being 12 months between “clusters.”  Cluster headaches affect less than 1% of the population and it is four times more common in men than women.

CAUSES

The precise causes of cluster headaches are complex, but there appears to be an activation of the nerve that supplies sensation to the face.  The blood vessels around this nerve become inflamed as well, giving rise to some of the distinct symptoms of cluster headache.  The centers of the brain that sense photoperiods and circadian rhythm are likely activated in patients with cluster headaches, as the headaches often come at the same time of the day and year in individual patients.  Spring and fall are the most common seasons for cluster headaches to occur.  Most patients with cluster headache are cigarette smokers, but the mechanism of the cause is unknown.  Alcohol consumption is a common trigger of an acute attack.

SYMPTOMS

Pain is severe, burning or piercing in quality.  It is almost always one-sided and typically behind one eye and at the back of the skull on this same side.  Patients often describe it as “a hot poker in the eye.”
The headache is shorter in duration than migraine, lasting 20-180 minutes.
The cluster headache attacks come 1-3 times per day (though can be up to 8) and classically wake patients from sleep.  They often come at the same time every day.
Associated symptoms are drooping of the eyelid, tearing, constriction of the pupil and nasal congestion on the affected side.
Patients typically pace, bang their heads against a wall and drive their fists into the painful eye rather than lying in a dark room, as a patient with migraine likes to do.

TREATMENT

Symptomatic (Acute) Treatments

100% oxygen by mask can stop the headache in 70% of patients in less than 15 minutes.
Sumatriptan injection has a high response rate in treating cluster headaches within 10 minutes.  The nasal spray also works, but is not quite as effective.
Intranasal lidocaine drops help some patients.
Oral triptans, like Zomig and Sumatriptan, typically take too long to work, but do help some patients.
Narcotic medications are used as a back up, especially Stadol nasal spray.

Preventative (Daily) Treatments

Corticosteroids - Medrol/Prednisone for a 1-2 week course will often stop a cluster episode completely or for a period of time.
Calcium channel blockers, such as Verapamil.
Lithium Carbonate
Methysergide
Anti-convulsants - There is less experience and data with these, but Depakote and Topamax have shown some results in patients.

Alternative Treatments

Surgical procedures - Performed in refractory patients with chronic cluster headache, not episodic. Patients can be left with permanent facial numbness.  Examples include use of Gamma Knife or glycerol injection to the trigeminal ganglion, sphenopalantine ganglionectomy.
Occipital nerve stimulator implantation – Again, this is just for chronic patients not responding to medications. This treatment is just starting to be studied for this condition.

For further information about Headache, click on the following links:

The Headache Clinic at the Minneapolis Clinic of Neurology
www.americanheadachesociety.org (American Headache Society)
www.headaches.org (National Headache Foundation)
www.migraines.org (Migraine Awareness Group: A National Understanding for Migraineurs)
www.ouch-us.org (Organization for Understanding Cluster Headaches)

January 1, 2010

© 2013 Minneapolis Clinic of Neurology, Ltd.®  All rights reserved.  A single copy of these materials may be reprinted for noncommercial personal use only.

 
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