Types of Headache

Introduction

• Defined as pain or discomfort in the head.

• One of the most common symptoms reported to clinicians.

• A great majority of headaches arise due to benign conditions.

• It necessitates thorough investigation because, sometimes, it can represent an early manifestation of a possibly grave disorder.

Classification

Epidemiology

• Lifelong prevalence of headaches is 96%, with a female predominance.

• Global prevalence of Tension-type headache and Migraine is 40% and 10%, respectively.

• Migraine occurs between ages 25 to 55 years, 3 times more common in women.

• Cluster headache has a population prevalence of 0.1% and a male/female ratio of 3.5-7:1.

• Worldwide prevalence of chronic daily headaches has been consistent at 3%-5%, which mostly represents Chronic Migraine.

Pathophysiology

Migraine

• Caused presumably by genetically induced hypersensitivity of the brain.

• Arises from the activation and sensibilization of the trigeminovascular system.

• Results in the release of neuropeptides and other substances.

• Both cause local inflammation and distant amplification of neural circuitry in the brainstem, trigeminal nucleus caudalis, thalamus, and cortex, leads to central sensitization and symptom worsening.

• Reduced activity in central descending inhibitory systems and reduced ability to control or extinguish the headache attack.

• Hypothalamus, a higher brain center, is involved in initiation of migraine attack.

• Calcitonin-gene related peptide (CGRP) is involved in migraine.

Cluster headache

• Imbalance between the sympathetic and parasympathetic neural system causes cranial-autonomic symptoms.

• Calcitonin-gene related-peptide (CGRP) is also involved in cluster headaches.

Tension-type headaches

• Greater role played by environmental factors.

• Contributing factors; tenderness of pericranial muscles, co-existing mood disorders, and mechanical disorders of the spine and neck.

• Peripheral and central sensitization are relevant in chronification of migraine and tension-type headache.

Common Precipitating Factors

Migraine

• Skipping meals

• Too much or too little sleep

• Stressful events

• Smoking

• Depression or anxiety

• Drinking too much alcohol, particularly red wine

• Loud or sudden noises

• Processed meats that contain nitrates, aspartame, MSG, aged cheese, and chocolate

• Birth control pills or hormone replacement therapy

• Headache medicine used on a daily or near daily basis

• Menstruation

Cluster Headache

• More common in those who smoke

• Head trauma, such as an injury or surgery

Tension-type Headache

• Arthritis in the neck

• Changing hormone levels for females, due to the menstrual cycle, pregnancy and menopause, among other situations and conditions

• Fatigue from sleep deprivation or other causes

• Injury to the head or neck area

• Anxiety

• Depression

• Eye, neck or back strain caused by poor posture

• Stress

• Teeth grinding and jaw clenching

Diagnostic Criteria

ICHD-3 Criteria for Migraine Without Aura

• A. At least 5 headache attacks fulfilling the criteria B-D

• B. Attacks last 4-72 h

• C. With at least 2 of the following 4 characteristics:
• Unilateral location
• Pulsating quality
• Moderate or severe pain intensity
• Aggravation by or causing avoidance of routine physical activity

• D. At least 1 of the following during headache:
• Nausea and/or vomiting
• Photophobia and phonophobia

• E. Not better accounted for by another ICHD-3 diagnosis

ICHD-3 Criteria for Migraine with Aura

• A. At Least two attacks fulfilling criteria B and C

• B. One or more of the following fully reversible aura symptoms:
• Visual
• Sensory
• Speech and/or language
• Motor
• Brainstem
• Retinal

• C. At least two of the following characteristics:
• At least one aura symptom spreads gradually over ≥5 minutes, and/or two or more symptoms occur in succession
• Each individual aura symptom lasts 5-60 minutes
• At least one aura symptom is unilateral
• The aura is accompanied, or followed within 60 minutes, by headache

• D. Not better accounted for by another ICHD-3 diagnosis, and transient ischemic attack has been excluded

ICHD-3 Criteria for Cluster Headache

• A. At least five attacks fulfilling criteria B–D

• B. Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15–180 minutes (when untreated)

• C. Either or both of the following:
• At least one of the following symptoms or signs, ipsilateral to the headache:
• a) Conjunctival injection and/or lacrimation
• b) Nasal congestion and/or rhinorrhoea
• c) Eyelid edema
• d) Forehead and facial sweating
• e) Forehead and facial flushing
• f) Sensation of fullness in the ear
• g) Miosis and/or ptosis
• A sense of restlessness or agitation

• D. Attacks have a frequency between one every other day and eight per day for more than half of the time when the disorder is active

ICHD Criteria for Episodic Tension-type Headache

Evaluation

Detailed History

• Family history of migraine

• Childhood migraine proxy symptoms: car sickness, gastrointestinal complaints.

• Age of onset

• Frequency, severity, and tempo over time

• Triggering, aggravating, or alleviating features

• Autonomic features

• Aura features

• Current and prior treatments
• Drugs and toxins exposure
• Anticoagulants

• Lifestyle features; IV drug user (risk of infection)

• Comorbid conditions
• Immunosuppressive disorders
• Hypertension (risk of hemorrhage)
• Malignancy (risk of metastasis)
• Dementia
• Coagulopathy

• General physical examination to rule out secondary causes. Should include,
• Cardiovascular assessment
• Fundoscopy
• Palpation of head and face
• Tonometry to rule out Acute Angle Closure Glaucoma.

Neurologic examination

• Mental status

• Level of consciousness

• Cranial nerve testing particularly II, III, IV and VI

• Pupillary responses

• Motor strength testing

• Deep tendon reflexes

• Sensation

• Pathologic reflexes (e.g. Babinski's sign)

• Cerebellar function and gait testing

• Signs of meningeal irritation (Kernig's and Brudzinski's signs)

‘Red Flags’ indicating further need for imaging

• New headache in older patients

• Abnormal neurologic examination including papilledema and change in mental status

• New change in headache pattern or progressive headache

• New headache in the setting of HIV risk factors, cancer, or immunocompromised status

• Signs of a systemic illness (eg, fever, stiff neck, rash)

• Triggered by cough, exertion, Valsalva maneuver

• Headache in pregnancy/postpartum period

• First or worst headache

Neuroimaging

• CT-scan.

• MRI scan (more sensitive in identifying intracranial pathologies)

• Lumbar Puncture, if CT-scan is negative to rule out Subarachnoid Hemorrhage

Differential Diagnosis

• Tumors, particularly pituitary masses

• Abscess

• Hemorrhage (bleeding within the brain)

• Bacterial or viral meningitis (an infection or inflammation of the membrane that covers the brain and spinal cord)

• Pseudotumor cerebri (increased intracranial pressure)

• Hydrocephalus (abnormal build-up of fluid in the brain)

• Infection of the brain

• Encephalitis (inflammation of the brain)

• Blood clots

• Head trauma

• Sinus blockage or disease

• Malformation (such as Arnold-Chiari)

• Injuries

• Infections, such as Lyme disease

• Meningitis

• Aneurysm

• Temporal Arteritis

• West Nile Virus

• Carbon monoxide poisoning

Further Reading

Bibliography

1. The International Classification of Headache Disorders - ICHD-3. (2021). Retrieved 13 September 2021, from https://ichd-3.org/

2. Headache Rizzoli, Paul et al. The American Journal of Medicine, Volume 131, Issue 1, 17 - 24

3. PMC E. Europe PMC [Internet]. Europepmc.org. 2021 [cited 13 September 2021]. Available from: https://europepmc.org/abstract/MED/3248935

4. Spierings, E., Ranke, A., & Honkoop, P. (2021). Precipitating and Aggravating Factors of Migraine Versus Tension-type Headache.

5. Headaches: Types, Symptoms, Causes, Diagnosis & Treatment. Cleveland Clinic. (2021). From https://my.clevelandclinic.org/health/diseases/9639-headaches.

6. Headache Causes. Mayo Clinic. (2021). From https://www.mayoclinic.org/symptoms/headache/basics/causes/sym-20050800.

7. Risk Factors for Headache | Winchester Hospital. Winchesterhospital.org. (2021). From https://www.winchesterhospital.org/health-library/article?id=19555.

8. Headache. From https://www.healthgrades.com/right-care/migraine-and-headache/headache#risk-factors.

9. PRIME PubMed | Precipitating and relieving factors of migraine versus tension type headache. Neuro.unboundmedicine.com. (2021). From https://neuro.unboundmedicine.com/medline/citation/22920541/Precipitating_and_relieving_factors_of_migraine_versus_tension_type_headache_.

10. Clinch, C. (2021). Evaluation of Acute Headaches in Adults. Aafp.org. From https://www.aafp.org/afp/2001/0215/p685.html#afp20010215p685-t4.

11. Approach to the Patient With Headache - Neurologic Disorders - MSD Manual Professional Edition. MSD Manual Professional Edition. (2021). From https://www.msdmanuals.com/professional/neurologic-disorders/headache/approach-to-the-patient-with-headache.

12. Just In Time Medicine. Differential Diagnosis of Headache. Justintimemedicine.com. (2021). From https://www.justintimemedicine.com/CurriculumContent/p/6830.

13. Gilmore, B., & Michael, M. (2021). Treatment of Acute Migraine Headache. Aafp.org. From https://www.aafp.org/afp/2011/0201/p271.html.

14. Headache Management. Research.birmingham.ac.uk. (2021). From https://research.birmingham.ac.uk/portal/files/20437602/Sinclair_et_al_Headache_management_practneurol_2015_001167.full.pdf.

15. What Are the Symptoms of a Headache?. Verywell Health. (2021). From https://www.verywellhealth.com/headache-symptoms-1719563.

16. Tension headache: Background, pathophysiology, etiology. (2021, July 12). Diseases & Conditions - Medscape Reference. https://emedicine.medscape.com/article/792384-overview#a7