...finding the balance
Which Type of Headache Do You Have?
Approximately 23-35 million people suffer from migraine.
Many of my patients come to my office with a long list of physicians, and 10-20 medications that they have tried and that have failed to stop their headaches. For many of my patients, their headaches are so disabling, that they cannot complete their jobs or fulfill their family obligations.
International Headache Society Criteria:
MIGRAINE Without AURA: (80-90% of migraines are without aura)
Two of the following:
- increases with exercise such as walking, going up stairs
AND one of the following :
- photophobia or phonophobia
- timing: 4-72 hours long and 1-3 Headaches per month
MIGRAINE With AURA: (10-20% of migraines)
Two attacks with 3/4 of the following:
- no single aura symptom for more than 60 minutes
- headache follows aura in less than 60 minutes
- aura symptoms must be reversible
- aura first develops gradually over 4 minutes
TENSION Headache - EPISODIC
Two of the following 4 pain characteristics:
- tightening, non-pulsating, steady, band-like constriction about the head/neck
- mild/medium: inhibits but does NOT prohibit activity
- usually bilateral, but can be unilateral
- does not increase by activity such as climbing stairs
- must have more than 10 headaches per year, less than 15 per month
- more than 30 minutes duration, and less than 7 days
- no nausea/vomiting, or infrequent nausea
- either photophobia or phonophobia, but not both
- increases in PM; - gradual onset
TENSION Headache - CHRONIC
- fulfills criteria for episodic as above BUT
- 15 days per month for 6 months
- mild nausea without vomiting
alternate names: Horton's headache/ Histamine headache/ Histamine cephalalgia
- pain is severe to excruciating and comes on suddenly without warning
- must be on the same side each time
- the pain must be behind or around the eye, or temporal pain
- must be at least 15 minutes - 180 minutes duration
- must have at least one of the following signs on the same side as the pain:
- eyelid swelling, drooping eyelid, redness in the eye, reduced pupil size, tearing, runny nostril
- on occasion nausea/vomiting, cheek edema, forehead and facial sweating
- frequency is 1 every other day-8 daily
- average duration 45-90 minutes
- comes in "clusters" with cluster periods of 4-12 weeks
- can be precipitated by alcohol, histamine or nitroglycerine
- male more often than female
- increases at night often after you fall asleep
- rocks back and forth in chair holding eye that hurts, or walks or paces around, bangs head on wall
Ergots, caffeine, Benzodiazepines, analgesics often transform episodic migraine to chronic daily headache. Once a patient has transformed migraine, acute or prophylactic treatment is usually less effective. Medication Overuse Headache / MOH, is defined in terms of treatment days per month, with intake of drug on at least 10 days per month for 3 months. The headache is present more than 15 days per month
Most chronic daily headaches are due to analgesic over-use such as (aspirin, acetaminophen more than 4-6 daily), ergots, butalbital, benzodiazepines, caffeine, opiates. Taking maximum dose of any OTC painkiller/analgesic more than 3 times per week. Other causes of sudden transformation from intermittent to daily are trauma, meningitis.
- subset of chronic daily headache
- on one side
- females much more than males
- transient stabs of pain forehead, temporal, on continuous pain background
- nocturnal awakening
- nausea/vomiting occasionally, with or without photophobia/phonophobia
- increase with menses
- the feeling of "something is in my eye" or a grain of sand in the eye
- can be secondary to medication overuse
CHRONIC PAROXYSMAL HEMICRANIA
- subtype of chronic cluster, but different from cluster in that more female than male and no response to Oxygen or Lithium
- one-sided autonomic signs, usually NO nausea/vomiting, painful episodes 6-30 each day, each attack 20 minutes to 1 hour usually can be precipitated with neck flexion
- pain is behind the eye
- patient does not pace as cluster patients do, instead goes into fetal position on bed
EPISODIC PAROXYSMAL HEMICRANIA
- resembles cluster, but very brief 5-20 minutes jabs of pain, occurring 10-20 times daily,
Although prior to puberty 4% of both boys and girls have migraines, after puberty, the gender difference becomes extremely severe, and there is a 3:1 ratio between women: men migraineurs.
- MENSTRUAL Migraine
- by definition, 90% of the headaches have to occur within 48 hours prior to menses
- 60% of female migraineurs have changes in their headache pattern associated temporally with menses
- only 14% of migrainers have exclusively menstrual migraines
- ORAL CONTRACEPTIVES + Migraine
Do contraceptives reduce or increase the headache?
- in order to lessen the fluctuations of estrogen, oral contraceptives are sometimes recommended
- PREGNANCY + Migraine
- during pregnancy there is an increase of estradiol levels by 100 times.
- women with pre-existing tension headache are not significantly changed by pregnancy
- most women without aura prior to pregnancy improve, but most women with migraine + aura worsen during pregnancy
- PERI and POST-MENOPAUSAL Migraine
- migraine usually improves with age, however, headaches worsen in 47% of post-menopausal females.
- headache may flare up in peri-menopause secondary to fluctuating levels of estrogen.
Symptoms: Headache ; psychiatric (depression), cognitive problems such as poor concentration, difficulty with memory, then dizziness, which is usually movement associated.
- headache is usually onset within 14 days of trauma.
- headache can be intermittent or continuous
- unilateral or bilateral
- often a mixed headache (migraine+tension)
- neck injuries are more common in older patients, due to baseline cervical arthritis