Primary Headache Disorders

Headaches are extremely common and have been recorded throughout history.  There are more than 45 million Americans with chronic or recurrent headaches at the present time.  Headaches are the fourth most common reason a person seeks emergency medical attention in the US.

There are two major types of headache treatment:  they are abortive headache treatment, aimed at stopping a current headache and prophylactic headache treatment, aimed at preventing the onset of symptoms.  Three or more attacks in one month usually means that the patient needs some kind of prophylactic treatment.

Tension Headaches

Tension headaches are not solely because of increased tension in the cranial and/or cervical muscles.  Patients with tension-type headaches (TTH) have been found to have changes in the serotonin levels, substance P levels, and neuropeptide levels in their system, indicating a possible brain involvement in the development of these types of headaches.  It is the most common type of headache and yet, its exact cause is unknown.  Patients can have both chronic and episodic types of tension headaches.  As many as 93 percent of people will report having at least one TTH within the last year.  The pain is usually bilateral and is described as a tightness around the head or a squeezing pressure in the head.  It can also be in the temporal, occipital, forehead or vertex regions of the head.  It is common to have shoulder and neck pain at the very same time.  There are usually no other symptoms, such as nausea or vomiting. 

TTH usually occur during times of stress or strong emotions.  Chronic headache sufferers usually have a great deal of anxiety and poor coping skills.  Common causes of chronic headaches include degeneration of the cervical spine, head or neck trauma, ankylosing  spondylitis, and TMJ dysfunction. 

Treatment of TTH can be with drugs or without drugs.  Things like cervical manipulation, exercise, massage, cold or warm compresses, stress avoidance, and relaxation techniques. If these do not work, patients can take NSAIDs or Tylenol (acetaminophen) for pain relief.  Sometimes the addition of caffeine to the headache medication will intensify the relief.  There are prescription pain relievers including acetaminophen combined with muscle relaxers like Soma or orphenadrine.  Addictive drugs, such as acetaminophen with butalbital, an opioid, or meprobamate may be required if the headaches are severe.  Drugs that reduce anxiety can help relieve a tension-type headache. 

Chronic TTH patients usually need some kind of prophylactic treatment to avoid opioid dependency.  The treatment of chronic headache prophylaxis involves the use of muscle relaxants or sedatives, taken on a regular basis.  NSAIDs and tricyclic antidepressants can also be helpful.  Nonpharmacological preventative measures include cervical manipulation, psychological treatment or tissue massage.

Migraine Headaches

Migraines occur in about 6 percent of men and up to 18 percent of women.  These manifest themselves in recurrent severe headaches with accompanying gastrointestinal, auditory, or visual disturbances.  Sufferers are usually between the age of 25 and 55 years.  Attacks generally last from 4 hours to three days.  Migraine headaches are usually on one side of the head and are associated with nausea, vomiting, phonophobia and photophobia.  Most people have 1-4 headaches per month.  Some people can have a wide variety of co-existing symptoms like constipation, blurry vision, cold extremities, double vision, diarrhea, chills, ataxia, and dysarthria.  Tiredness and lethargy can follow an attack for several days post-headache. 

Some people have prodromal auras as part of their pattern.  Auras tend to last less than an hour before the onset of headache symptoms.  People can complain of spots before their eyes, paresthesias, other visual symptoms, auditory or visual hallucinations or hemianopsia. 

There can be precipitating factors for a migraine headache.  These include appetite changes with fasting or even missing a meal.  Too much or too little sleep can precipitate a headache.  Oversleeping can contribute to “weekend migraines” so sufferers should try to get the same amount of sleep on the weekends as they do during the week.  Women have migraine attacks related to their menstrual cycle.  The worst attacks occur right before, during or right after their period.  There are many food triggers to migraine headaches.  Depression, fear and anger can cause migraine headaches.  Migraines can be brought on by flickering lights, bright lights, loud sounds, strong smells, and changes in barometric pressure.  Migraine sufferers have headaches during times of increased allergy symptoms.  Headaches occur during the first trimester of pregnancy but tend to go away after the first trimester.  Birth control pills contribute to migraines in women. 

The treatment of migraines involves pharmacological and nonpharmacological methods.  Medications can be abortive, prophylactic or symptomatic.  Prophylactic medications are for those who have more than four headaches per month.  Beta blockers are good for prevention as are SSRI medications.  Methysergide and divalproex sodium, along with beta blockers are approved for the prevention of migraines. 

Propranolol can’t be used in people with asthma or ischemic heart disease.  Patients on insulin or who take oral hypoglycemic drug or MAOI drugs should not take propranolol.  Clonidine is a useful preventative if a patient has food-induced migraines from tyramine in the food.  Divalproex sodium is appropriate for migraine sufferers who have bipolar disorder or epilepsy.  Topiramate is an anti-convulsive medication that works for some sufferers of migraines with few side effects.

Abortive therapy can be accomplished by using acetaminophen or aspirin with caffeine.  Ergotamine medications counteract the vasodilation seen in migraine attacks.  Nausea is a common side effect of taking these medications, however.  It can only be used every four days.  It can’t be used in the elderly or in pregnant populations.  NSAIDs can also abort migraine headaches as can sumatriptan, an SSRI medication given subcutaneously. 

Symptomatic treatment can be given when the above remedies fail; they act as rescue medications for migraine headaches.  Intranasal butorphanol is useful in episodic headaches with pain relief as soon as fifteen minutes after taking the medication.  Opioids can also act as rescue medications with the only problem being drug dependence on them. 

Intractable migraines do occur and are difficult to treat.  DHE has been successfully used in 90 percent of all intractable migraine headaches after two days of use.  Dexamethasone given by IV can also help these difficult migraines. 

Cluster Headaches

A cluster headache is a vascular headache that is particularly devastating.  The pain is unilateral, very severe, and is described as a burning, stabbing or boring pain in the area of the temple, eye or forehead.  Patients also have tearing of the eyes on the same side as the headache, nasal congestion, runny nose or facial droop on the side of the face where the headache is located.  Cluster headaches usually come on at the same time every day and commonly occur in the early morning.  It can occur for a period of days to weeks and then not be present for years after a cluster has happened.  It usually occurs in one’s 20’s to 30’s and usually occurs in men at a 5:1 ratio.  Many cluster headache patients are heavy smokers and heavy drinkers.  Alcohol can contribute to the onset of a headache but only during a cluster period. 

The best treatment for cluster headaches is prophylactic treatment.  Ergotamine, DHE, corticosteroids, lithium, calcium channel blockers and Methysergide are often used to prevent these types of headaches.  Abortive therapy is difficult because the headaches are of such short duration.  Inhaled oxygen seems to help some patients.  Ergotamine can be used in cluster headaches that are more long-lasting.  Opioids can reduce the anxiety of these attacks but they must be well supervised so as to avoid dependency and toxicity.

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