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Headache

Summarized By:   Shahdad Azmoon, MD

Date of  Publication: May 1st, 2005

Migraine headaches

15% Americans; second most common headache (1^st tension HA)

well-defined attacks w/ periods of symptom free; frequently morning

begins and ends gradually over 4 to 72 hours;  70% unilateral

typically dull, deep, and steady when mild to moderate

throbbing or pulsatile when severe

worsened by rapid head motion, light, sneezing, straining or physical exertion

relief by lying down in a darkened, quiet room

Auras 20% visual or neuro sx prior to onset

aura may include flashing, bright spots, zig-zag lines, loss of part of the field of vision, numbness or tingling in the hand, tongue, or side of the face, or weakness in one of the extremities.

Auras last 15 to 60 min

HA w/ aura = classic migrane

HA w/out aura = common migrane

often accompanied by n/v, acute light & sound sensitivity.

20% nasal congestion, rhinorrhea, lacrimation, tearing, skin tone or temp changes

when neuro sx last for more than HA = complicated migraines

There are three major types of complicated migraine:

   Ophthalmoplegic often seen in children and young adults; typically causes problems with eye muscle movement (i.e. double vision) in addition to headache.

   Hemiplegic migraine w/ loss of movement and sensation on one half of body; usually there is complete recovery which may take weeks and permanent weakness may result after multiple attacks.

   Basilar artery migraine usually affects young children and women and may have associated sx of vertigo (a sensation of movement or spinning), diplopia (double vision), tinnitus (ringing in the ears), and ataxia (balance instability)

Tension headache

most common HA

feeling of pressure or tightness all around the head (like a tight band)

pain tends to fluctuate during the course of the headache (not steady like migrane)

and the severity of pain and its effects on daily activities vary from person to person. In contrast to migraine headaches,

most often not assoc w/ sx like migrane

Cluster headache

repetitive headaches (in clusters) that occur for weeks to months at a time, followed by periods of remission.

More common in men (migrane more common in women)

Peak age of onset is 25 to 50 years.

80% nocturnal headaches (between 9 pm and 9 am) which awaken you from sleep (unlike migrane which are typically morning HA)

The pain of cluster headache begins quickly without any warning and reaches a peak within a few minutes (unlike migrane which starts gradually and intensifies over hours)

usually deep, excruciating, continuous, and explosive in quality, occasionally pulsatile

Pain typically around eye or temple and less commonly around face, neck, ear, or side of the head; Pain is unilateral.

Most people with cluster headache prefer to stay active when an attack is in progress (patients w/ migrane HA prefer dark quiet place)

Assoc sx may include tearing and redness of the eye on the side of the pain, stuffy and runny nose, sweating, a pale appearance, and possibly drooping of the eyelid.

50% w/ sensitivity to alcohol during a cluster bout which ceases when the cluster ends.

A typical cluster headache lasts from 30 minutes to 3 hours.

Attacks of pain tend to recur at the same hour each day for the duration of a single cluster

There are two types of Cluster Headaches:

   Episodic cluster headaches which are the most common of cluster HA (90% of cluster HA). Usually characterized by 1 to 3 attacks of pain around the eye per day over a four to eight week period, followed by an average pain free interval of six months to one year; The remission period may last for years.

   Chronic cluster headaches are characterized by the absence of sustained periods of remission.

Other types of headaches

   Temporomandibular joint dysfunction (TMJ) typically causes pain of the jaw muscles with chewing, but also can cause headaches (sometimes in the absence of jaw pain). The headache associated with TMJ is usually characterized by one-sided ear pain or pain in front of the ear that radiates to the jaw, temple, or neck. The pain is deep, dull, continuous, and usually worse in the morning, and is usually associated with a limitation of jaw motion.

   Giant cell (temporal) arteritis is an inflammation of blood vessels that typically occurs in people ages 55 and older which can cause mild or severe headaches, often in association with fatigue, generalized aches and pain, and night sweats.

   Chronic nasal stuffiness, allergies, or allergic rhinitis may cause HA

   Rebound headaches occur with overuse of headache medication.

DANGER SIGNS of Headaches

   A sudden, severe, persistent headache that reaches maximal intensity within a few seconds or minutes after the onset of pain, or pain that you would describe as "the worst headache of your life," may represent a serious problem.  ( although cluster HA often come on suddenly they usually last less than one to two hours and are associated with other symptoms).  You should never hesitate to consult a physician for further diagnosis and prompt medical management.

   A severe headache associated with a fever or stiff neck requires an immediate evaluation by a physician.

   Headache associated with a seizure, confusion, or loss of consciousness requires an urgent evaluation.

   Headaches that occur within one to two days after head trauma are relatively common. Most people report a generalized dull, aching, constant discomfort with intermittent exacerbations. Other common accompanying symptoms include vertigo (sensation of spinning), lightheadedness, inability to concentrate, problems with memory, easy fatiguability, and irritability. Posttraumatic headaches may continue for up to a few months, although headaches that are not beginning to improve within a week or two after a traumatic event should probably be evaluated. People who experience the rapid onset of headache with exercise after a minor traumatic event also should be seen by a physician.

   Headaches associated with neurologic symptoms (eg, weakness, numbness, impaired vision) should be evaluated by a physician. Often these represent migraine headaches, but your physician should make that diagnosis not you.

   Headaches that are new after the age of 50 yrs should be discussed with your physician for proper medical workup.

    HA occur with 50% of people who have brain tumors.  Such HA may become chronic and may worsen with bending over and/or nausea and vomiting.

    If you have a headaches that interferes with your normal daily activity or a change in a previous headache pattern you should be seen by a physician.

 References:  "UpToDate"

Remember:

1)  Please follow up with your physician on a routine basis as needed.

2)  Please follow directions when taking medications.

3)  Please do not hesitate to see a physician when concerns arise regarding your health.

4)  Your health should be your most important investment, take good care of it!

Sincerely,

Dr. Azmoon

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