Headache Web Page

PATIENT INFORMATION

HEADACHES

Most individuals (adults and children alike) have experienced headaches and many have resorted to the over-the-counter pain medication for some relief. Some have sought medical attention for headache= s to combat inability to remain fully productive in our day-to-day activities. T= he majority of those individuals who sought professional care for headaches was not properly diagnosed and treated. How many you should ask? About 60 to 70= %, according to one study (Pharmacoeconomics, 6:215-221, 1994).

A visit to a physician who is trained in the diagnosis= and treatment of disorders of the nervous system may help ensure that you do not join that unfortunate “60-70%” category of headache sufferers.<= o:p>

Headaches are divided into two main groups – pri= mary and secondary.

Primary (or physiological) headaches (such as migraine, cluster headaches and tension-type headache) are those produced by abnormal= ities in the physiology of the nervous system.

Suggested mechanisms of pain included inflammation-like processes between neuronal connections (neurons are cells of the nervous sy= stem and billions of connections exist between neurons), abnormal head and neck = muscle contractions, abnormal narrowing (constriction) and widening (dilatation) of blood vessels surrounding nerve fibers (trigeminal nerve in particular), abnormal brain function and abnormal release of and abnormal response to serotonin= (a chemical that is present in the brain and other tissues).

Despite active research into the origins of headaches, their precise cause remains elusive. This is not surprising, unfortunately, when one considers the staggering complexity of the nervous system, of the = pain pathways (a path from the receptor of pain, through the peripheral nerves, = into the central nervous system, where that signal is “interpreted” = by brain structures as “pain”) and pain “interpretation̶= 1; by the brain.

Secondary (or organic) pain is a symptom of another organic disease. Over 300 causes of such secondary headaches have been identified, including brain tumors, infectious diseases (as relatively beni= gn as sinusitis and as serious as AIDS), metabolic and toxic disturbances, head trauma, hypertension and head trauma, to name just a few.=

In practical clinical terms this delineation between “primary” and “secondary” is not quite black-and-wh= ite, as many conditions may mimic or coexist with the primary headache. A thorou= gh neurological evaluation may help clarify the origin of headache and a lay a course to the correct diagnosis and a successful treatment plan. To fully appreciate this issue, consider this – the Internatio= nal Headache Society Classification of Headache (1999) includes 129 differe= nt subtypes of headache organized in 13 categories:

1. = Migraine

2. Tension-type headache

3. Cluster headache<= /span>

4. Miscellaneous headaches unassociated with structural lesion

5. Headache associated with head trauma

6. Headache associated with vas= cular disorders

7. Headache associated with nonvascular intracranial disorder

8. Headache associated with substances and their withdrawal

9. Headache associated with noncephalic infection

10. Headache associated with a metabolic disorder

11. Headache or facial pain asso= ciated with disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cranial structures

12. Cranial neuralgias, nerve tr= unk pain, and deafferentiation pain

13. Headache not classifiable

We will describe the most frequently occurring types of headaches – migraines, tension-type headaches and cluster headaches. =

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T= YPE 1 - MIGRAINE<= o:p>

What is it?

This type includes what has traditionally been called “ordinary” or “minor” headache. It seems to be three times more common in women than men and may be an inherited disorder. It is characterized by pain that m= ay last several hours, with short pain-free breaks, and then re-occur again. It may also progress into an almost constant, intensifying daily pain, with ve= ry few and short pain-free breaks.

Signs and symp= toms.

Migraines may occur on one or both sides, may range fr= om mild to severe in intensity and may last from several hours to several days, even weeks.

Migraines may occur with aura and without it. Aura refers to = one or several symptoms that will precede the upcoming migraine. If aura is presen= t, it develops over 5-20 minutes and usually will not last longer than an hour prior to the onset of the migraine. The most common features of aura are zig-zagging visual images, appearance of flashes of lights (photopsia), but= may include loss of consciousness, a feeling of “everything spinning around” you, slurred speech (dysarthria) and wobbly gait (ataxia), and abnormal skin sensations (either decreased or excessive sensitivity). The a= ura does have to end “abruptly” before the headache ends – the same symptoms that started as aura may continue and accompany the actual “painful” migraine.

In addition to the symptoms of aura, migraines may be accompanied by other symptoms – nausea, vomiting, diarrhea; depressio= n, mental dullness, irritability; abnormal blood pressure or heart rate.

Migraine is an illness in which genetic and environmen= tal factors tend to predispose to pain attacks. Some environmental factor are “notorious” for triggering migraines, but one has to remember t= hat their triggering ability is not the same for all persons – some may be very sensitive to, say, caffeine and quickly develop a migraine, but some m= ay not be sensitive to caffeine, yet develop debilitating headaches after consuming alcohol. Selected “triggers” are listed below:

1. = Stress/Anger

2. = Missed meals/Hunger

3. = Too little or too much sleep

4. = Some foods

<= span style=3D'font-size:10.0pt;font-family:Georgia;mso-fareast-font-family:Georg= ia; mso-bidi-font-family:Georgia'>a. = Caffeine

<= span style=3D'font-size:10.0pt;font-family:Georgia;mso-fareast-font-family:Georg= ia; mso-bidi-font-family:Georgia'>b. Alcohol

<= span style=3D'font-size:10.0pt;font-family:Georgia;mso-fareast-font-family:Georg= ia; mso-bidi-font-family:Georgia'>c. = Chocolate<= /p>

<= span style=3D'font-size:10.0pt;font-family:Georgia;mso-fareast-font-family:Georg= ia; mso-bidi-font-family:Georgia'>d. Sugar

<= span style=3D'font-size:10.0pt;font-family:Georgia;mso-fareast-font-family:Georg= ia; mso-bidi-font-family:Georgia'>e. = Meats with nitrites

<= span style=3D'font-size:10.0pt;font-family:Georgia;mso-fareast-font-family:Georg= ia; mso-bidi-font-family:Georgia'>f. = MSG (monosodium glutamate, a food additive)

<= span style=3D'font-size:10.0pt;font-family:Georgia;mso-fareast-font-family:Georg= ia; mso-bidi-font-family:Georgia'>g. = Sulfites (may be found in ma= ny wines)

<= span style=3D'font-size:10.0pt;font-family:Georgia;mso-fareast-font-family:Georg= ia; mso-bidi-font-family:Georgia'>h. Aged cheeses

5. = Hormonal changes (oral contraceptives, menses, pregnancy)

6. = Smoking

7. = Specific smells (paint, lacquer, paint remover, exhaust fumes)

8. = Flashing lights (strobe-like)

9. = Some metabolic and infectious diseases

T= YPE 2 – TENSION-TYPE HEADACHE

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What is it?

After considerable debate in academic and clinical for= ums (the questions was whether or not tension headaches were a clinical variety= of migraines, described above, or were they a separate entity), tension-type headaches received a separate heading in the 1999 Classification (see above). According to the Classification, tension-type headaches may exist without expressed tension of the head and neck muscles. Distinguishing this headache from a migraine remains a challenge.

Signs and symp= toms.

Tension-type headaches can be divided, based on their symptoms, into the following groups:

1. = Episodic tension-type headache

= &nb= sp; = &nb= sp; = i. &nb= sp; associated with disorder of pericranial (neck and lower head) muscle=

= &nb= sp; = &nb= sp; = ii. &n= bsp; unassociated with disorder of pericranial (neck and lower head) muscle=

2. = Chronic tension-type headache

= &nb= sp; = &nb= sp; = i. &nb= sp; associated with disorder of pericranial (neck and lower head) muscle=

= &nb= sp; = &nb= sp; = ii. &n= bsp; unassociated with disorder of pericranial (neck and lower head) muscle=

Episodic tension-type headaches are mostly mild in int= ensity and generally are not activity-limiting. They occur on both sides of the he= ad (bilateral), from 30 min and longer (up to several days), are of pressing a= nd tightening quality. Not associated with nausea or vomiting, is not likely t= o be exacerbated by loud sounds and bright lights (phonophobia and photophobia),= or by walking and routine activities.

Chronic tension-type headaches are not only longer las= ting and more frequently occurring than episodic ones. They may be more severe in intensi= ty, may inhibit routine activities, may be associated with either nausea, or photophobia or phonophobia.

T= YPE 3 - CLUSTER HEADACHE

What is it?

This disorder is characterized by frequent attacks of short-lasting (somewhere from 15 minutes to 2 hours), severe pain on one si= de of the head usually described by patients as boring, squeezing, stabbing, or burning. This pain may be so severe, as to awaken a sleeping person. Some patients report banging their heads against the wall during a cluster heada= che attack, some crawl on the floor screaming out of pain, some resort to taking hot showers in attempts to lessen the pain. Unlike migraines, this type of headache is more prevalent in men than in women.

Signs and symp= toms.

The majority of patients experience pain on the same s= ide of the head (in the area of the eye, temple, forehead or check), and few wi= ll report a shift of pain location from one side to the other. Up to 50% of the patients report feeling pain the back of their heads on the same side where headache is present. Rarely is this type of pain preceded by aura-like symptoms. These debilitating attacks occur in “clusters” (hence= the name), that may last several weeks, and repeat several times per year.=

Cluster headaches are commonly associated with specific symptoms. They include lacrimation (tears), conjunctival injection (a techn= ical term for “red eyes” due to increased blood flow to tiny blood vessels in the outer segment of the eye), nasal congestion and rhinorrhea (= “runny nose”), and other symptoms that also occur in migraines, such as photophobia (literally means “fear of light” and is referred to exacerbation of pain when looking at bright light), phonophobia (literally means “fear of sound” and is referred to exacerbation of pain w= hen hearing loud sounds). Nausea, vomiting and blurred vision may occur, but are very rare.

D= IAGNOSIS AND TREATMENT OF HEADACHES

If necessary, in addition to physical and neurological examinations, laboratory and instrumental testing may be indicated not only= to ensure correct diagnosis, but also effective and safe treatment. The most commonly used testing may include any of the following:

1. = Laboratory tests – chemical profile, complete blood count, endocrinological test= s, urinalysis, toxicology testing

2. = Lumbar puncture

3. = Instrumental studies

<= span style=3D'font-size:10.0pt;font-family:Georgia;mso-fareast-font-family:Georg= ia; mso-bidi-font-family:Georgia'>a. = Computerized Tomography (CT = scan)

<= span style=3D'font-size:10.0pt;font-family:Georgia;mso-fareast-font-family:Georg= ia; mso-bidi-font-family:Georgia'>b. Magnetic Resonance Imaging (= MRI)

<= span style=3D'font-size:10.0pt;font-family:Georgia;mso-fareast-font-family:Georg= ia; mso-bidi-font-family:Georgia'>c. = Magnetic Resonance Angiograp= hy (MRA)

<= span style=3D'font-size:10.0pt;font-family:Georgia;mso-fareast-font-family:Georg= ia; mso-bidi-font-family:Georgia'>d. Electroencephalography (EEG)=

<= span style=3D'font-size:10.0pt;font-family:Georgia;mso-fareast-font-family:Georg= ia; mso-bidi-font-family:Georgia'>e. = Electrocardiography (ECG)

<= span style=3D'font-size:10.0pt;font-family:Georgia;mso-fareast-font-family:Georg= ia; mso-bidi-font-family:Georgia'>f. = Routine X-rays

<= span style=3D'font-size:10.0pt;font-family:Georgia;mso-fareast-font-family:Georg= ia; mso-bidi-font-family:Georgia'>g. = Ultrasound testing

<= span style=3D'font-size:10.0pt;font-family:Georgia;mso-fareast-font-family:Georg= ia; mso-bidi-font-family:Georgia'>h. Evoked Potential Testing

Cluster headache is often under-diagnosed and under-treated. Consider this startling statistic: on average, a patient may suf= fer from cluster headaches for more than 6 years, see four doctors and have been diagnosed incorrectly four times until the correct diagnosis is given (Headache 2000, 40: 730-735).

Once correctly diagnosed, a cluster headache may be treated with the so-called abortive therapy (fast relief during a cluster headache attack), transitional therapy (therapy conducted during a headache= -free period, often in conjunction with preventive therapy) or preventive therapy (daily medication use aimed at lessening the severity of pain and shortening its duration during an attack). In some rare cases, surgical interventions = may be indicated.

IT IS CRITICAL THAT HEADACHES BE EVALUATED BY A NEUROLOGIST, AS IT VERY IMPORT= ANT TO COLLECT AN IN-DEPTH HEADACHE HISTORY, PERFORM A THOROUGH NEUROLOGICAL EXAMINATION, DIAGNOSE THE PROBLEM, CHOOSE THE APPROPRIATE PLAN OF ADDITIONAL TESTING (IF NECESSARY) AND DEVELOP A PROPER TREATMENT REGIMEN.