HEADACHE

HEADACHE
● Headache may be symptomatic of a distinct pathologic process or may occur without

an underlying cause.
● In 2004, the International Headache Society (IHS) updated its classification system
and diagnostic criteria for headache disorders, cranial neuralgias, and facial pain
1) MIGRAINE
a. Migraine without aura
b. Migraine with aura :
● Typical aura with migraine headache (aura lasting less than 1
hour)
● Typical aura with nonmigraine headache
● Typical aura without headache
● Familial hemiplegic migraine
● Sporadic hemiplegic migraine
● Basilar-type migraine
c. Childhood periodic syndromes that are commonly precursors of migraine
● Cyclical vomiting (self-limiting episodic condition)
● Abdominal migraine (episodic midline abdominal pain attacks
lasting 1 to 72 hours)
● Benign paroxysmal vertigo of childhood (brief episodic vertigo)
d. Retinal migraine (repeated attacks of monocular visual disturbance)
e. Complications of migraine
● Chronic migraine (occurring on 15 or more days per month for
more than 3 months)
● Status migrainosus (debilitating attack lasting for more than 72
hours)
● Persistent aura without infarction (symptoms persisting for more
than 1 week)
● Migrainous infarction (aura symptoms associated with an ischemic
brain lesion)
● Migraine-triggered seizure
f. Probable migraine
● Probable migraine without aura
● Probable migraine with aura
● Probable chronic migraine
2) Tension-type headache (Tension-type headache, the most common type of primary

headache, is more common in women than men. Pain is usually mild to moderate
and nonpulsatile.)
● Episodic tension-type headache
● Chronic tension-type headache
3) Cluster headache and other trigeminal autonomic cephalalgia

● Episodic cluster headache
● Chronic cluster headache
4) Other primary headaches
● Headache attributed to head and/or neck trauma
● Headache attributed to cranial or cervical vascular disorder
● Headache attributed to non-vascular intracranial disorder
● Headache attributed to a substance or its withdrawal
● Headache attributed to infection
● Headache attributed to disorder of homeostasis
● Headache or facial pain attributed to disorder of cranium, neck, eyes, ears,
nose, sinuses, teeth, mouth, or other facial or cranial structures
● Headache attributed to psychiatric disorder
● Cranial neuralgias and central causes of facial pain
CLUSTER HEADACHES
● Cluster headache, the most severe of the primary headache disorders, is

characterized by attacks of severe, unilateral head pain that occur in series lasting for
weeks or months (i.e., cluster periods) separated by remission periods usually lasting
months or years.
● Headaches are usually of short duration (15 to 180 minutes) and present as severe,
unrelenting, unilateral pain occurring behind the eye with radiation to the territory of
the ipsilateral trigeminal nerve (temple, cheek, or gum).
● Cluster headaches may be episodic or chronic.
● Men are four to seven times more likely than women to suffer from cluster headache.
● Onset can occur at any age but is most common in the late twenties
MIGRAINE HEADACHE
● Migraine is described as “paroxysmal attacks of moderate-to-severe, throbbing

headache with associated symptoms that may include nausea, vomiting, and
photophobia or phonophobia.
● Migraine headaches are subclassified according to the presence or absence of aura
symptoms.
● Most persons who suffer from migraine do not experience aura symptoms.
● In migraine with aura, focal neurologic symptoms precede or accompany the attack.
Triggers of migraine
Food triggers Environmental triggers Behavioral – psychologic triggers

● Alcohol ● Glare or flickering lights ● Excess or insufficient
● Caffeine/caffeine ● High altitude sleep
withdrawal ● Loud noises ● Fatigue
● Chocolate ● Strong smells and ● Menstruation, menopause
● fumes Tobacco smoke ● Sexual activity
● Fermented and pickled ● Weather changes ● Skipped meals
foods Monosodium ● Strenuous physical activity
glutamate (e.g., in (e.g., prolonged
Chinese food, seasoned overexertion)
salt, and instant foods) ● Stress or post stress
● Nitrate-containing foods
(e.g., processed meats)
● Saccharin/aspartame
(e.g., diet foods or diet
sodas)
● Tyramine-containing
foods
Pathogenesis
CLINICAL PRESENTATION AND DIAGNOSIS
1) GENERAL
● Migraine is a common, recurrent, severe headache that interferes with normal
functioning. It is a primary headache disorder divided into two major subtypes,
migraine without aura and migraine with aura.
2) SYMPTOMS
●Migraine is characterized by recurring episodes of throbbing head pain,
frequently unilateral, that when untreated can last from 4 to 72 hours.
Migraine headaches can be severe and associated with nausea, vomiting,
and sensitivity to light, sound, and/or movement
3) LABORATORY TESTS
● In selected circumstances and secondary headache presentation, serum
chemistries, urine toxicology profiles, thyroid function tests, lyme studies, and
other blood tests such as a complete blood count, antinuclear antibody titer,
erythrocyte sedimentation rate, and antiphospholipid antibody titer may be
considered.
4) DIAGNOSTIC TESTS
Check for abnormalities:
● vital signs (fever, hypertension), funduscopy (papilledema, hemorrhage, and
exudates),
● palpation and auscultation of the head and neck (sinus tenderness, hardened
or tender temporal arteries,
● trigger points,
● temporomandibular joint tenderness, bruits, nuchal rigidity, and cervical spine
tenderness), and
● neurologic examination (identify abnormalities or deficits in mental status,
cranial nerves, deep tendon reflexes, motor strength, coordination, gait, and
cerebellar function).
5) International headache society classification system

TREATMENT
A) Goals of therapy
● Goals of Long-Term Migraine Treatment
I. Reduce migraine frequency, severity, and disability
II. Reduce reliance on poorly tolerated, ineffective, or unwanted acute
pharmacotherapies
III. Improve quality of life
IV. Prevent headache
V. Avoid escalation of headache medication use
VI. Educate and enable patients to manage their disease
VII. Reduce headache-related distress and psychological symptoms
● Goals for Acute Migraine Treatment
I. Treat migraine attacks rapidly and consistently without recurrence
II. Restore the patient’s ability to function
III. Minimize the use of backup and rescue medications
IV. Optimize self-care for overall management
V. Be cost-effective in overall management
VI. Cause minimal or no adverse effects
B) Nonpharmacological therapy
● Apply ice to the head and recommend periods of rest or sleep, usually in a
dark, quiet environment.
● A headache diary that records the frequency, severity, and duration of
attacks can facilitate identification of migraine triggers.
● Identify and avoid triggers of migraine attacks
● Patients also can benefit from adherence to a wellness program that
includes regular sleep, exercise, and eating habits, smoking cessation,
and limited caffeine intake
● .Behavioral interventions (relaxation therapy, biofeedback, and cognitive
therapy) may help patients who prefer nondrug therapy or when drug
therapy is ineffective or not tolerated.
C) Pharmacological management (therapeutic interventions )
● ABORTIVE THERAPY : The general approach to treatment of acute

migraine headache attacks is one of pharmacotherapy aimed at relieving
migraine headache pain and associated symptoms. Such a treatment plan
may include
(a) 5-HT receptor agonists (e.g., triptans or ergot derivatives),
(b) analgesics,
(c) sedatives, and
(d) antiemetic drug therapy, depending on the exact nature of the patient’s
complaint.

HEADACHE

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HEADACHE

● Headache may be symptomatic of a distinct pathologic process or may occur without

2) Tension-type headache (Tension-type headache, the most common type of primary

3) Cluster headache and other trigeminal autonomic cephalalgia

● Cluster headache, the most severe of the primary headache disorders, is

● Migraine is described as “paroxysmal attacks of moderate-to-severe, throbbing

Food triggers Environmental triggers Behavioral – psychologic triggers

CLINICAL PRESENTATION AND DIAGNOSIS

5) International headache society classification system

C) Pharmacological management (therapeutic interventions )

● ABORTIVE THERAPY : The general approach to treatment of acute

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