ETIOLOGY, CAUSE, PATHOPHYSIOLOGY, MANAGEMENT AND COMPLICATIONS OF MIGRAINE AND TENSION TYPE OF HEADACHE

1. DR.UMARMUSHIR
M.B.B.S.,M.D.(PSYCHIATRY)
SENIORRESIDENT,CIMS&H,
LUCKNOW

2. MIGRAINE
 Migraine is a primary headache disorder
characterized by recurrent headaches that are
moderate to severe.
 Migraine is the second most common cause of
headaches.
 Migraine headache affects one half of the head,
are pulsating in nature and lasts for 2 to 72
hours.
 Associated symptoms may include nausea,
sensitivity to light, sound or movements ,
sensitivity to smell.

3. EPIDEMIOLOGYOF MIGRAINE
 Worldwide , migraines affect nearly 15%or
approximately one billion people.
 More common in women at 19% than ,men at
11% starts commonly between 15 and 24
years of age and occur most frequently in 30 to
45 years of age.
 The word “migraine” is from the Greek (
hemikrania ) ,”pain on one side of head”, from
(hemi -), “half” and (kranion),”skull”.

4. CAUSESOF MIGRAINE
 Migraine are believed to be due to a
mixture of environmental and genetic
factors.
 Number of psychological conditions are
associated including depression, anxiety,
and bipolar disorder.
 Familial hemiplegic migraine is inherited in
an autosomal dominant fashion.

5. Triggersof migraine
• Stress disorders and abuse
• Menarche, oral contraceptives, pregnancy,
perimenopause and menopause
PHYSIOLOGICAL
ASPECTS
• In 12 to 60% people foods such as junk
foods triggers migraine
• Smoking and taking alcoholic beverages
DIETARY
ASPECTS
• Outdoor environment
• Lightning
ENVIRONMENTAL
ASPECTS

6. PHYSILOGICALASPECTS
`

8. EMOTIONAL ASPECTS

9. PATHOPHYSIOLOGYOF MIGRAINE
Presymptomatic
hyperexcitability
increases brain stem
response to triggers
Release of Neurotransmitters
(5-
HT,NE,GABA,DA,GLUTAMATE
,NO,CGRP,SUBSTANCE P
,ESTROGEN)
Neurotransmitters
activate the
Trigeminal Nucleus
Dilatation of
meningeal blood
vessels
(Throbbing)
Activation of
Hypothalamus
(Hypersensitivity)
Activation of
cervical
trigeminal
system (Muscle
spasm)
Activation of
Cortex and
Thalamus (Head
pain)

11. SIGNSANDSYMPTOMS
 Migraine typically present
with self limited , recurrent
severe headache
associated with autonomic
symptoms.
 About 15 to 30 % people
with migraines experience
migraine with an aura.
 These are four possible
phases to a migraine –

12.  THE PRODROME , which occurs hours or
days before the headache.
 THE AURA , which immediately precedes
the headache.
 THE PAIN PHASE , also known as
headache phase.
 THE POSTDROME , the effects
experienced following the end of a migraine
attack.

13. Prodrome Phase
 Prodromal or premonitory symptoms occur in
about 60 % of those with migraines.
 Onset that can range from two hours to two
days before the start of pain or the aura.
 Symptoms may include altered mood,
irritability , depression or euphoria , fatigue
craving for certain foods, stiff muscle ,
constipation, diarrhea and sensitivity to
smells or noise.
 This may occur in those with either migraine
with aura or migraine without aura.

14. auraphase
 An aura is a transient focal neurological
phenomenon that occurs before or during the
headache.
 Symptoms can be visual, sensory or motor in
nature and many people experience more
than one.
 Visual effects occur most frequently in 99% of
cases and in more than 50% of cases are not
accompanied by sensory or motor effects.

15. AURAPHASEContd.
 Visual disturbances
often consist
scintillating scotoma (
an area of partial
alteration in the field of
vision which flickers and
may interfere with a
person’s ability to read
or drive)
 Sensory aura are the
second most common
type occur in 30 to 40%
of people with auras.

16. Painphase
 Headache is usually
unilateral , throbbing and
moderate to severe in
intensity.
 Headache usually comes
on gradually and is
aggravated by physical
activity.
 In more than 40% of
cases, pain may be
bilateral and neck pain is
commonly associated with
it.

17. PAINPHASECONTD.
Pain usually lasts for 4 to 72
hrs in adults and in children
less than 1 hour.
Pain is frequently
accompanied by nausea
,vomiting , sensitivity to light ,
sensitivity to sound , sensitivity
to smells , fatigue and
irritability.

18. POSTDROMEPHASE
 Migraine postdrome is defined as
constellation of symptoms occurring once that
acute headache has settled.
 The person may feel tired or “hung over” and
have head pain , cognitive difficulties ,
gastrointestinal symptoms , mood changes
, and weakness.
 “some people feel unusually refreshed or
euphoric after an attack ,whereas others note
depression and malaise.

20. CLASSIFICATIONOFMIGRAINE
 MAJOR FORMS-
Migraine without aura (common) 70%
Migraine with aura (classical ) 25%
Migraine variants and complicated migraine 5%
Hemiplegic migraine
Basilar type migraine
Ophthalmic migraine
Retinal migraine

21. MIGRAINEWITHAURA(CLASSICAL MIGRAINE)
 Headache is associated with premonitoring
sensory, motor or visual symptoms.
 Most common premonitory symptoms are visual;
Scotomas is central portion of visual field.
-Hallucinations
-Fortification spectrum ( paracentral scotoma
which expands into a “C” shape with luminous
angles at the enlarging outer border)

22. MIGRAINEWITHOUTAURA
 No focal neurological disturbances precedes
the episodes of headache.
 Headache is a pulsating quality, unilateral
location and aggravated by walking stairs or
similar routine activity.
 Concomitant nausea, vomiting,
photophobia and phonophobia.
 Each episode last for 4 to 72 hrs .

23. DIAGNOSIS
 Diagnosis of a migraine is based on signs and
symptoms .
 Diagnosis of migraine without aura , according
to the “International Headache Society” can
be made according to the following
criteria,”5,4,3,2,1 criteria
1. Five or more attacks –for migraine with aura,
two attacks are sufficient for diagnosis.
2. Four hours to three days in duration
3.Two or more of the following:

24. 3.Two or more of the following:
- Unilateral (affecting half of the head)
- Pulsating
-Moderate or severe pain intensity
-Worsened by or causing avoidance of routine
physical activity
4.One or more of the following :
- Nausea and/or vomiting
-Sensitivity to both light (photophobia) and sound
(phonophobia)
Functional neuroimaging has suggested that
brainstem regions in migraine by Positron
emission tomography

25. DIFFERENTIALDIAGNOSIS
 Temporal arteritis
 Cluster headaches
 Acute glaucoma
 Meningitis
 Subarchnoid haemorrhage

26. TREATMENTOF MIGRAINE
 Once a diagnosis of migraine has been
established it is important to assess the extent of a
patient’s disease and disability.
 The Migraine Disability Assessment
Score(MIDAS) is a well-validated,easy-to-use
tool.
 MIDAS Questionnaire
1. On how many days in last 3 months did you miss
work or school because of your headaches?
2. How many days in the last 3 months your
productivity at work or school reduced by half or
more because of your headaches?

27. treatmentof migraineContd.
 3.How many days in the last 3 months did you not
do the work because of your headaches?
 4.How many days in the last 3 months was your
productivity in household work reduced by half or
more because of your headaches?
 5. On how many days in the last 3 months did you
miss family , social , or leisure activities because of
your headaches?
 A. On how many days in the last 3 months did
you have a headache?
 B. On a scale of 0-10,on average how painful
were these headaches?
 (where 0-no pain at all and 10-Pain as bad it
can be)

28. MigraineDisabilityAssessment Score
Grade I-Minimal or infrequent Disability: 0-5
Grade II- Mild or infrequent Disability:6-10
Grade III- Moderate Disability:11-20
Grade IV-Severe Disability:>20

29. NONPHARMALOGICMANAGEMENT
 Most patients benefit by the
identification and avoidance
of specific headache
triggers.
 A regulated lifestyle is
helpful including a healthful
diet , regular exercise ,
regular sleep patterns ,
avoidance of excess
caffeine and alcohol and
avoidance of acute
changes in stress levels.

30. NONPHARMALOGICMANAGEMENT
 These measures that benefit a
given individual should be used
routinely since they provide a
simple , cost-effective approach
to migraine management.
 Since the stresses of everyday
living cannot be eliminated ,
lessening one’s response to
stress by various techniques is
helpful for many patients which
may include yoga ,
transcendental meditation ,
hypnosis and conditioning
techniques such as biofeedback.

31. ACUTE ATTACK THERAPIES FOR MIGRAINE
 The selection of the optimal regimen for a
given patient depends on a number of
factors , the most important of which is the
severity of the attack.
 Mild migraine can usually be managed by oral
agents , the average efficacy rate is 50-70%.
 Severe migraine attacks may require
parental therapy.

32. NONSTEROIDALANTI-INFLAMMMATORYDRUGS
 The combination of acetaminophen , aspirin and caffeine
with dosage 2 tablets 6 hourly(max 8 per day) has been
approved for use by the U.S Food and Drug Administration
for treatment of mild to moderate migraine.
 NSAIDS such as
Naproxen (250-500mg PO bid)
Ibuprofen (400mg PO 3-4 hourly)
Tolfenamic acid (200mg PO may repeat 1-2 hourly)
Paracetamol either alone or in combination with
metoclopramide / domperidone is another effective
treatment with a low risk of adverse effects.

34. 5-HT1 AGONISTS
ORAL
 Stimulation of 5-HT1BD/1D receptors can stop
an acute migraine attack. Ergotamine and
dihydroergotamine is non- selective receptor
agonists while triptans are selective receptor
agonists.
 Ergotamine (one 2 mg sublingual tablet at
onset and q ½ hourly),
 Naratriptan (2.5mg tablet at onset , may repeat
once after 4 hour),

35. 5-HT1 AGONISTS CONTD.
ORAL
Rizatriptan (5-10mg tablet at onset may repeat 2
hourly),
Frovatriptan (2.5mg tablet at onset ,may repeat
after 2hourly),
Sumatriptan (50-100mg tablet at onset , may
repeat after 2hour)
Almotriptan (12.5mg tablet at onset , may repeat
after 2hour) and
Zolmitriptan (2.5mg tablet at onset ,may repeat
after 2hour)

36. Contd.
 Nasal
 Dihydroergotamine
 Somatriptan
 Zolmitriptan
Parenteral
Dihydroergotamine and somatriptan

37. Dopamineantagonist
 Oral – metoclopramide (5 to 10 mg per
day ) ,
 prochlorperazine (1 to 25 mg per day )
 Parenteral – chlorpromazine (0.1 mg/kg
i.v at 2 mg per min. ,
 metoclopramide (10 mg i.v ) ,
 prochlorperazine (10 mg i.v )

38. TENSION TYPEHEADACHE
 It is the most common type
of primary headache
 It used to describe chronic
pain syndrome characterized
bilateral tight band like
comfort.
 The pain can radiate from
the lower back of the head ,
the neck, eyes or other
muscle groups in the body
typically affecting both sides
of the head.
 Tension type headache
account for nearly 90% of all
headaches.

39. Contd.
 Pain typically builds slowly
fluctuating in severity and
may persist more or less
continuously for many
days.
 Headache may be
episodic or chronic
(present > 15 days)

40. Epidemiology
 Tension headaches affect about 1.6 billion
people (20.8 % of the population)
 More common in women than men (23 % to 18
% respectively)
 Despite its benign character ,tension type
headache , especially in its chronic form , can
impart significant disability on patients as well
as burden on society.

41. PATHOPHYSIOLOGYOF TTH
 1.PAINMECHANISM
 If the muscles continue to
contract for a long time despite
a decreased blood supply
,pain substances such as
lactate , pyruvic acid ,etc. are
released .Pain occurs when
these substances stimulate the
nerves and sensation of pain
occurs at the sites of muscle
attachment and ligaments
where peripheral nerves are
densely distributed.

42.  2.Whydoes tensiontypeheadacheoccurs?
 bending down posture as a result, the
posterior neck muscles become vary tense.
 Use of high or hard pillows, which
consequently increase the tension in the
posterior neck muscles.

43. 3.problemswiththecervical
spine
 Cervical stability means
that the cervical spine
supports the head in a
stable way.
 The cervical vertebrae
usually form a slight curve
to support the head
securely.

44. 3.Problemswiththecervicalspine
If there is no cervical spine
,it would be impossible to
support the head only with
muscles .
Nonetheless , patients with
headache have problems
with this cervical stability .
On X-ray angulation and
neck instability were found
in 50% of patients with
TTH.

45. 4.stress
 Stress and depression do not
trigger headache immediately.
 When stress, such as a
mental arithmetic load is given
under the electromyogram ,
and vascular flow tests
,changes in muscle
contraction are not observed.

46. 4. Stress
If a strong stress is given when the
muscles of the head are continuously
contracted for some reason , muscle
contraction with oxygen deficiency
occurs immediately and pain
substances are released then
headache begins.

47. 5.Differences betweenvoluntary
bendingdownposture and
involuntarybending downposture
 Athletes never feel “stiffness”
during matches. On the other
hand, if the same posture must be
maintained ,”stiffness” must be
maintained.
 Upon examining the EMG activity
and the blood flow volume, it was
revealed that when involuntarily
passive muscle contraction
occurs , the blood flow in the
muscles decrease and the
decreased state continues as long
as it is contracted.

48. 5.Differences betweenvoluntarybendingdownposture
andinvoluntarybending downposture
On the other hand , even though muscle
contraction has the same intensity, when muscle
contraction is initiated voluntarily, the blood flow
recovers in about 20 to 30 seconds as a reflex
reaction.
In fact, headache is easily induced when the neck
and shoulders are relaxed and the head is
loosely bent downward.

49. 6.Problemswithpillow
 The higher the pillow,
the stronger the
tension in the
posterior neck
muscles.
 This fact can actually be
confirmed by surface
EMG.

51. SIGNSANDSYMPTOMSOFTTH
 Tension type headache pain is often described as
a constant pressure, as if head were being
squeezed and present on both sides of the head
at the same time.
 According to the third edition of the International
Classification of Headache Disorders, the
attacks must meet the following criteria:
 A duration of between 30 minutes to 7 days.
 At least two of the following four
characteristics
 1.bilateral location

52. Contd.
 2.pressing or tightening (non-pulsating)quality.
 3.mild or moderate intensity
 4.not aggravated by routine physical activity
such as walking or climbing stairs.
 Both of the following:
 No nausea or vomiting
 No more than one of photophobia or
phonophobia

53. CLASSIFICATIONOF TTH
1. Infrequent Episodic tension
type headache
 Diagnostic criteria for this TTH is at least 10
episodes of headache occurring on
<1day/month on average (<12days/year)
 Not associated with nausea , although
photophobia or phonophobia may be present .
 Can be associated with pericranial tenderness
or without pericranial tenderness upon
palpation of the cranial muscles.

54. 2.Frequent episodic
tension type
headache
 Diagnostic criteria for this TTH is at
least 10 episodes of headache
occurring on 1-14days/month on
average for >3 months(>12 days
and <180 days /year)
 Not associated with nausea ,
although photophobia or
phonophobia may be present.

55. Chronic tension
type headache
 Diagnostic criteria for this
TTH is headache occurring
on >15days/month on
average for >3months (
>180days/year).
 May be associated with
mild nausea , photophobia
or phonophobia.

56. DIFFERENTIAL DIAGNOSIS
 MIGRAINE
 OROMANDIBULAR DYSFUNCTION
 SINUS DISEASE
 EYE DISEASE
 CERVICAL SPINE
 INTRACRANIAL MASS
 IDIOPATHIC INTRACRANIAL HYPERTENSION
 MEDICATION OVERUSE HEADACHE
 SECONDARY HEADACHE
 GIANT CELL ARTERITIS

57. TREATMENTOF TTH
 Forepisodictensiontypeheadache
 Simple analgesics such as acetaminophen ,
aspirin or NSAIDS (ibuprofen ,naproxen ,
ketoprofen ) can be effective for a few times
in a week.
 Analgesic/sedative combinations are widely
used(e.g. analgesic/antihistamine
combinations like Syndol , Mersyndol and
Percogesic , analgesic/barbiturate
combinations such as Florinal ).
 Muscle relaxants are typically used for and are
helpful with acute post-traumatic TTH rather
than ETTH.

58. CONTD.
 Forchronictensiontypeheadache
 Medications involved in the treatment for CTTH
are tricyclic depressants ( amitriptyline )
,SSRIs , benzodiazepine ( clonazepam in
small evening dose) and muscle relaxants
(Tizanidine).

59. PREVENTIONOF TTH
 Drinking water and avoiding
dehydration helps in preventing
tension headache.
 Using stress management and
relaxing often makes
headaches less likely.
 Good posture might prevent
headaches if there is neck pain.

60. THANK YOU