2. The Primary Headaches
Migraine Headache
Tension-type Headache
Cluster Headache and Other Trigeminal Autonomic
Cephalgias
Other Primary Headaches
3. One year Prevalence of Common Headaches
0
5
10
15
20
25
30
35
40
45
Migraine Episodic Tension
Headache
Frequent
Headache
(>15/month)
18
41
56
40
3
Female
Male
4. Migraine Headache Definition
Any two:
Unilateral pain
Throbbing pain
Pain worsened by movement
Moderate or severe pain
+
Any one of associated symptoms:
Nausea
Vomiting
Photo or phonophobia
International Headache Society 2003
5. Migraines
Who has migraines in the US:
25% of women and 8% men lifelong
18% of women and 6% of men over past year
30 million have migraine
Up to 10 million have Chronic Daily Headache
8. Migraine patients have enhanced sensory and
neurophysiologic responses during as well as between
attacks
Visual (photosensitivity)
Auditory (phonophobia, tinnitus)
Balance (dizziness, motion sickness)
Allodynia
9. Common Migraine Comorbidities
Depression
Anxiety
Social Phobias
Bipolar Disease
Irritable Bowel Syndrome
Sleep Disorders
This means medications can be chosen to treat 2 issues
with one drug
10. Migraine Comorbidities
Anxiety (tend to precede onset of migraine in about
80% of patients)
Depression (tended to follow onset of migraine in 75%
of cases)
Merikangas, 1990
11. Migraine Treatment - Abortive
Triptans
DHE
Avoid in patients:
<18, >65
CAD
Uncontrolled HTN
12. Migraine Preventive/Prophylactic Treatment
If migraine headache more than 4-6/month
If significant work lost
If quality of life impaired or
If patient prefers this mode
14. Multimodal Approach
Education, education, education
Decrease OTC anelgesics to <2/week
Encourage Exercise
Biofeedback and behavioral therapies
Good sleep hygiene/OSA evaluation
Set up realistic expectations of therapy
15. Tension Headache
Prevalence: Episodic ~40%, Chronic ~2-5%
Peak 30-40 year olds
8% patients miss work days
However 43% have decreased work efficacy
Schwarts BS et al. JAMA 2009
16. Tension Headache
Definition
Episodic headache lasting minutes to days
Typically bilateral, pressing or tightening in quality
Mild to moderate intensity
Does not worsen with routine physical activity
No nausea
Phonophobia and photophobia may be present
International Headache Society 2003
17. Tension Headache vs. Migraine
Many Tension Headaches may actually be migraine
75% of migraine patients report neck
tightness/pain/stiffness
Stress, anxiety, sleep deprivation can trigger migraine
Migraines can present with bilateral pain
***Pharmacologically tension headache is equivalent to
migraine headache
18. Cluster Headache
Attacks of severe, strictly unilateral pain
Orbital, supraorbital, temporal
or in any combination of these sites
Lasts 15-180 minutes
Occurring every other day to 8 times per day
Often circadian pattern
International Headache Society 2003
19. Cluster Headache
One or more of ipsilateral:
-conjunctival injection,
-lacrimation,
-nasal congestion,
-rhinorrhea,
-facial sweating,
-miosis,
-ptosis,
-eyelid edema.
International Headache Society 2003
20. Therapy - Abortive
Smatriptan: injectable or nasal
100% O2 at 7-15L/min x 15mins
DHE: IM, SQ or IV
Ergotamine: Oral, suppository
Greater Occipital nerve block
22. Therapy -Transitional
Prednisone 10-12 day taper
Naratriptan: 2.5mg BID x7days
Ergotamine 2mg qhs – BID for seven days
DHE
Occipital nerve blockade
23. Evaluation
No study can establish headache subtype
Diagnostic testing should be considered to rule out
organic pathology.
If new onset HA in middle aged or elderly patient
Abrupt change in headache character, frequency
Precipitation by valsalva
Focal neurologic symptoms
Systemic symptoms
25. Bibliography
Bigal ME, Rapoport AM, Sheftell FD, et al. Transformed migraine and medication overuse in a tertiary headache
center –clinical charachteristics and treatment outcomes. Cephalalgia 2004;24:483-490.
Continuum: Headache. American Academy of Neurology. Volume 12, Number 6; December 2006.
International Headache Society 2003 Guidelines (ICHD-II). Part one -The Primary Headaches.
Silberstein SD, RB. Headache Epidemiology Emphasis on Migraine. Neurologic Clinics Vol 14, Issue 2 (May 1996).
Merikangas, Kathleen R. PhD; Jules Angst, MD; Hansruedi Isler, MD Migraine and Psychopathology Results of the
Zurich Cohort Study of Young Adults. Arch Gen Psychiatry. 1990;47(9):849-853.
Schwartz BS, et al. Epidemiology of Tension-Type Headache. JAMA, February 4, 1998 – Vol 279, No.5. 381-384.
Zwart JA, Gyb G, Hagen K, et al. Analgesic overuse among subjects with headache, neck and low-back pain.
Neurology 2004:62:1540-1544.
27. Visual symptoms come on in L temporal field and
spread to the right temporal field. No loss in vision.
Describes as “broken vision” with lights and flashes.
Headache lasts 4-5 hours, coming on slowly after the
initial visual symptoms. +Nausea.