Headaches

Anatomy or system affected: Brain, head, nervous system, psychic-emotional system

Definition: A general term referring to pain localized in the head and/or neck, which may signal mere tension or serious disorders

Causes and Symptoms

The International Headache Society developed a classification system for headaches. This system includes fourteen exhaustive categories of headache with the purpose of developing comparability in the treatment and study of headaches. Headaches most commonly seen by healthcare providers can be classified into four main types: migraine, tension-type, cluster, and other primary headaches.

Migraine headaches impact around one billion people globally and 15 percent of the US population each year, according to the International Association for the Study of Pain. Migraine headaches are more common in women, and they tend to run in families. They are usually first noticed in adolescence or young adulthood. For the diagnosis of migraine without aura (formerly called common migraine or hemicrania simplex), the person must experience at least five headache attacks, each lasting between four and seventy-two hours, with at least two of the following characteristics: The headache is unilateral (occurs on one side), has a pulsating quality, is moderate to severe in intensity, or is aggravated by routine physical activity. Additionally, one of the following symptoms must accompany the headache: nausea and/or vomiting or sensitivity to light or sounds. The person’s medical history, a physical examination, and (where appropriate) diagnostic tests must exclude other organic causes of the headache, such as brain tumor or infection, such as meningitis. Migraine with aura is far less common. Migraine with aura (formerly called classical migraine) refers to a migraine headache with visual disturbances such as the appearance of flickering lights, spots, or lines and/or the loss of vision; sensory disturbances such as numbness and/or tingling; and impairment of speech—symptoms that gradually develop over five to twenty minutes and that last for less than an hour. There are several subtypes of migraines with aura, including typical aura with migraine headache, typical aura with nonmigraine headache, typical aura without headache, familial hemiplegic migraine (migraine with aura including motor weakness in a patient with a first- or second-degree relative with hemiplegic migraine), sporadic hemiplegic migraine (migraine with aura including motor weakness in a patient with no first- or second-degree relatives with hemiplegic migraine), and basilar-type migraine (migraine with brain-stem aura).

Migraines may be triggered or aggravated by physical activity; menstruation; relaxation after emotional stress; the ingestion of tyramine in cheddar cheese or wine, chocolate, monosodium glutamate, sodium nitrate in processed meats, nitrites in red wine, and aspartame; prescription medications (including birth control pills and hypertension medications); and changes in the weather. Yet, the precise pathophysiology of migraines is unknown. Reduced blood volume in the brain is characteristic of migraine with aura, while the pathogenesis of migraine without aura is uncertain.

Tension-type headache is the most common type of headache; its mean lifetime prevalence is approximately 50 percent globally, according to the International Association for the Study of Pain. Tension-type headaches are not hereditary, occur slightly more frequently in women than in men, and have a mean age of onset of twenty-five to thirty years, although they can appear at any time of life. For the diagnosis of tension-type headaches, the person must experience at least ten headache attacks lasting from thirty minutes to seven days each, with at least two of the following characteristics: The headache has a pressing or tightening (nonpulsating) quality, is mild or moderate in intensity (may inhibit but does not prohibit activities), is bilateral in location, and is not aggravated by routine physical activity. Additionally, nausea, vomiting, and light or sound sensitivity are absent or mild. Tension-type headaches have been divided into episodic and chronic subtypes, and the episodic subtype has been further divided into frequent and infrequent subtypes. Tension-type headache sufferers describe these headaches as a band-like or cap-like tightness around the head and/or muscle tension in the back of the head, neck, or shoulders. The pain is described as slow in onset with a dull or steady aching.

Tension-type headaches are believed to be precipitated primarily by psychogenic factors but can also be stimulated by muscular and spinal disorders, jaw dysfunction, paranasal sinus disease, and traumatic head injuries. The pathophysiology of tension-type headaches is controversial. Tension-type headaches have been attributed to the fascia of the head, neck, and shoulder muscles causing myogenic-referred pain and to peripheral pain mechanisms, particularly in episodic tension-type headaches.

Cluster headaches are the least frequent of the headache types and are thought to be the most severe and painful. Cluster headaches are more common in men, affecting fewer than 1 in 1000 adults, according to the World Health Organization. Typically, these headaches first appear between ten and thirty years of age, although they can start later in life. Likely risk factors include a family history of cluster headaches, and possible risk factors include a history of tobacco smoking or head trauma. For the diagnosis of cluster headaches, the person must experience at least five severely painful headache attacks,ear, lending support with strictly unilateral pain lasting from fifteen minutes to three hours. One of the following symptoms must accompany the headache on the painful side of the face: a bloodshot eye, lacrimation, nasal congestion, nasal discharge, forehead and facial sweating, contraction of the pupil, or a drooping eyelid. Physical and neurological examination and imaging must exclude organic causes for the headaches, such as tumor or infection. Cluster headaches often occur once or twice daily, or every other day, but can be as frequent as eight attacks in one day, recurring on the same side of the head during the cluster period. The temporal “clusters” of these headaches give them their descriptive name.

A cluster headache is described as a severe, excruciating, piercing, sharp, and burning pain through the eye. The pain is occasionally throbbing but always unilateral. Radiation of the pain to the teeth has been reported. Cluster headache sufferers are often unable to sit or lie still and are in such pain that they have been known, in desperation, to hit their heads with their fists or to smash their heads against walls or floors.

Cluster headaches can be triggered in susceptible patients by alcohol, histamine, or nitroglycerine. Because these agents all cause the dilation of blood vessels, these attacks are believed to be associated with dilation of the temporal and ophthalmic arteries and other extracranial vessels. There is no evidence that intracranial blood flow is involved. Cluster headaches have been shown to occur more frequently during the weeks before and after the longest and shortest days of the year, lending support to the hypothesis of a link to seasonal changes. Additionally, cluster headaches often occur at about the same time of day in a given sufferer, suggesting a relationship to the circadian rhythms of the body. Vascular changes, hormonal changes, neurochemical excesses or deficits, histamine levels, and autonomic nervous system changes are all being studied for their possible role in the pathophysiology of cluster headaches.

Other primary headaches, using the International Headache Society’s classification scheme, constitute many of the headaches not mentioned above, including stabbing headache (occurs spontaneously in the absence of organic disease), cough headache (brought on by and occurring only in association with coughing or straining), exertional headache (brought on by and occurring only during or after physical exertion), headache associated with sexual activity (brought on by and occurring only as sexual excitement increases), hypnic headache (dull headaches that awaken the patient from sleep), and thunderclap headache (extremely painful headache with an abrupt onset).

Distinct from the primary headache types, which are often considered to be chronic in nature, secondary headaches signify an underlying disease or other medical condition. Secondary headaches can display pain distribution and quality similar to those seen in primary headaches. Secondary headaches of concern are usually the first or worst headache the patient has had or are headaches with recent onset that are persistent or recurrent. Secondary headaches typically occur for the first time in close temporal relation to another disorder that causes headaches. Other signs that cause a high index of suspicion include an unremitting headache that steadily increases without relief, accompanying weakness or numbness in the hands or feet, an atypical change in the quality or intensity of the headache, headache upon recent head trauma, or a family history of cardiovascular problems or cancer. Such headaches can point to hemorrhage, infections such as meningitis, stroke, tumor, brain abscess, drug withdrawal, and hematoma, which are serious and potentially life-threatening conditions. A thorough evaluation is necessary for all patients exhibiting the danger signs of secondary headache.

Treatment and Therapy

Because there are several hundred causes of headaches, the evaluation of headache complaints is crucial. Medical science offers myriad evaluation techniques for headaches. The initial evaluation includes a complete history and physical examination to determine the factors involved in the headache complaint, such as the general physical condition of the patient, neurological functioning, cardiovascular condition, metabolic status, and psychiatric condition. Based on this initial evaluation, the healthcare professional may elect to perform a number of diagnostic tests to confirm or reject a diagnosis. These tests might include blood studies, X-rays, computed tomography (CT) scans, psychological evaluation, electroencephalograms (EEGs), magnetic resonance imaging (MRI), or studies of spinal fluid.

Once a headache diagnosis is made, a treatment plan is developed. In the case of secondary headaches, treatment may take varying forms depending on the underlying cause, from surgery to the use of prescription medications. For migraine, tension-type, and cluster headaches, there are several common treatment options. Headache treatment can be categorized into two types: abortive (symptomatic) treatment or prophylactic (preventive) treatment. Treatment is tailored to the type of headache and the type of patient.

A headache is often a highly distressing occurrence for patients, sometimes causing a high level of anxiety, relief-seeking behavior, lost productivity, and reduced quality of life. The healthcare provider must consider not only biological elements of the illness but also possible resultant psychological and sociological elements as well. An open, communicative relationship with the patient is paramount, and treatment routinely begins with soliciting patient collaboration and providing patient education. Patient education takes the form of normalizing the headache experience for patients, thereby reducing their fears concerning the etiology of the headache or about being unable to cope with the pain. Supportiveness, understanding, and collaboration are all necessary components of any headache treatment.

There are a number of abortive pharmacological treatments for migraine headaches. Ergotamine tartrate (an alkaloid or salt) is effective in terminating migraine symptoms by either reducing the dilation of extracranial arteries or, in some way, stimulating certain parts of the brain. Isometheptene, another effective treatment for migraine, is a combination of chemicals that stimulates the sympathetic nervous system, provides analgesia, and is mildly tranquilizing. Another class of medications for migraines are nonsteroidal anti-inflammatory drugs (NSAIDs); these drugs, as the name implies, reduce inflammation. Both narcotic and nonnarcotic pain medications are often used for migraines, primarily for their analgesic properties, particularly acetaminophen. Antiemetic medications prevent or arrest vomiting and have been used in the treatment of migraines. Sumatriptan, a vasoactive agent that increases the amount of the neurochemical serotonin in the brain, shows promise in treating migraines that do not respond to other treatments.

There are several nonpharmacological treatment options for migraine headaches. These include stress management, relaxation training, biofeedback (a variant of relaxation training), psychotherapy (both individual and family), and the modification of headache-precipitating factors, such as avoiding certain dietary precipitants. Each of these treatments has been found to be effective for certain patients, particularly those with chronic migraine complaints. For some patients, they can be as effective as pharmacological treatments. The exact mechanism of action for their effect on migraines has not been established. Other self-management techniques include lying quietly in a dark room, applying pressure to the side of the head or face on which the pain is experienced, and applying cold compresses to the head.

The abortive treatment options for tension-type headaches include narcotic and nonnarcotic analgesics because of their pain-reducing properties. More often with tension-type headaches, the milder over-the-counter pain medications, such as aspirin or acetaminophen, are used. NSAIDs are a first-line treatment for tension-type headaches.

Prophylactic treatments for tension-type headaches include tricyclic antidepressants. Acupuncture and physical therapy may also be options to treat frequent tension-type headaches. Physical therapy options include massage, exercise, treatments to improve posture, and hot and cold packs. Electromyography (EMG) biofeedback has also been shown to have benefits in the treatment of tension-type headaches. The identification and avoidance of possible tension-type headache triggers, such as stress, irregular or inappropriate meals, high intake or withdrawal of caffeine, dehydration, inadequate sleep, or inappropriate sleep, may also be beneficial.

For cluster headaches, one of the most excruciating types of headache, the most common abortive treatment is administering pure oxygen to the patient for ten minutes. The exact mechanism of action is unknown, but it might be related to the constriction of dilated cerebral arteries. Other first-line treatments include a subcutaneous injection of sumatriptan and an intranasal spray containing zolmitriptan. Ergotamine tartrate or similar alkaloids can also abort the attack in some patients. Nasal drops of a local anesthetic (lidocaine hydrochloride) have been used to ease cluster headaches. The efficacy of these treatments is inconclusive.

Prophylactic treatment of this headache type is crucial. Verapamil is often given in addition to abortive treatments and then withdrawn at the end of a cluster episode. Lithium may be considered a second-line medication if verapamil is ineffective. Melatonin, corticosteroids, and dihydroergotamine may also be used for the prophylactic treatment of cluster headaches.

While no nonpharmacological treatment strategies are routinely offered to cluster headache patients, surgery is an option in severe cases in which the headaches are resistant to all other available treatments. Subcutaneous occipital nerve stimulation via an implant has been reported to improve chronic cluster headaches. Sphenopalatine ganglion stimulation via an implant may reduce the frequency and intensity of cluster headache attacks. Modest successes have been found with these extreme treatment options.

Perspective and Prospects

Headaches are among the most common complaints to physicians and quite likely have been a problem since the beginning of humankind. Accounts of headaches can be found in the clinical notes of Arateus of Cappadocia, a first-century physician. Descriptions of specific headache subtypes can be traced to the second century in the writings of the Greek physician Galen. Headaches are prevalent health problems that affect all ages and sexes and those from various cultural, social, and educational backgrounds.

The prevalence of headaches is greater in women, although the reason is unknown. Age seems to be a mediating factor as well, with significantly fewer people over the age of sixty-five years reporting headache problems. There are no socioeconomic differences in prevalence rates, with persons in high-income and low-income brackets having similar rates.

The total economic costs of headaches are staggering. The expenses associated with advances in assessment techniques and routine healthcare have risen rapidly. The cost in lost productivity adds to this economic picture. The scientific study of headaches is necessary to understand this prevalent illness. Efforts, such as those by the International Headache Society, to develop accepted definitions of headaches will greatly assist efforts to identify and treat headaches.

Bibliography

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