Introduction

Headache is a general term that describes pain anywhere in the head or neck. Headache is a unique medical phenomenon, in that there are no affirmative, positive tests to confirm a headache diagnosis. Rather, a primary diagnosis (stand-alone condition) of headache is considered after other possible underlying medical conditions that may cause head or neck pain have been ruled out.  For this reason, headache specialists divide headaches into two types: primary and secondary headaches.

Primary vs. Secondary Headaches

Primary headaches are the most common type of headaches. These headaches are not the consequence of an underlying condition, but can be caused by genetic or environmental factors. They are not associated with any permanent neurological abnormalities. Common examples of these headaches include migraines, tension-type headaches, and cluster headaches.

Secondary headaches are less common and are related to underlying conditions, such as brain tumors, aneurysms, inflammation, and systemic illnesses. Correctly identifying a secondary headache as a symptom of these potentially life-threatening conditions is critical. Detailed neurological exams, including examinations of the optic nerve, CT scans and MRIs of the brain or neck, blood tests, etc. are used to identify the causes. Active involvement with a healthcare practitioner is essential to help diagnose primary and secondary headaches.

Primary Headaches

Migraine

Migraine is a common disorder and ranks in the top 20 of the world’s most disabling medical illnesses. The factors that trigger migraines, and the experience of migraine headache pain varies widely between individuals. Generally, the pain of a migraine headache can be severe and may be associated with other symptoms such as nausea, vomiting, sensitivity to light, sensitivity to sound, and sensitivity to smells. Migraine attacks tend to last for several hours or more. Both preventative and acute treatments are available for migraines. Blood pressure medications, anti-seizure medications, antidepressants, and Botox injections can prevent migraines and have been shown to alleviate an attack in progress, by reducing the severity and intensity of the migraine. Additionally, lifestyle changes, such as regular exercise, diet modification, and a regular sleep schedule can help reduce the frequency and duration of migraines.

Tension-type Headache                                                                                       

Tension-type headache is the most common headache type but can be surprisingly difficult to treat. Often the pain is pressure-like and can feel like a band around the head. Unlike the severe intensity of a migraine headache, the pain of a tension-type headache is mild to moderate in intensity, usually without associated symptoms. Tension-type headaches exist in both episodic and chronic forms.  Treatment for chronic tension headaches (those occurring 15+ days in a month) involve a holistic approach, including medications, biofeedback, and stress reduction techniques. Biofeedback refers to a technique that gives a person control over his or her vitals, such as body temperature, muscle tension, and even brain waves.

Cluster Headache

Cluster headaches generally involve pain on one side of the head, and tend to be associated with unilateral tearing, redness of the eye, drooping of the eyelid, and drainage from one nostril. Cluster headache attacks can occur multiple times a day, and a “cycle” of attacks can last weeks to months before the patient spontaneously reverts to a pain-free state. These headaches can be episodic or chronic. Cycles are often treated with a course of steroids along with a medication to help prevent future attacks. Calcium channel blockers, antiepileptic medications, and lithium can be used as preventatives.

Secondary Headaches

Secondary headaches occur simultaneously with pre-existing conditions or can be linked with other conditions. Secondary headaches can be attributed to:

  • Trauma or injury to the head and/or neck
  • Cranial or cervical vascular disorder
  • Non-vascular intracranial disorder
  • Substance abuse or its withdrawal
  • Infection
  • Disorder of hemostasis
  • Disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, other facial or cranial structure
  • Psychiatric disorder

Healthcare practitioners need to carefully and precisely classify and determine treatment for these disorders.

Acute Treatments

Although there are specific treatments for different types of headache, there are certain common medications that can be taken to provide immediate relief for migraines, tension-type headaches, and cluster headaches. Pain relievers (Aspirin) and non-steroidal anti-inflammatory drugs (NSAIDs, such as ibuprofen) can be used in moderation. Triptans are used to treat migraine and cluster headaches. These medications provide temporary, symptomatic relief, but do not prevent future attacks. All medications can have side effects and must be chosen in accordance with other medical conditions and medications taken.

Cycle-Breakers

Occasionally, patients find that their headaches will not resolve using acute treatment and they may become stuck in a “cycle” of pain.  There are different methods of treating a headache cycle, depending on the primary headache type, medications taken, duration of the cycle, and the severity of symptoms. Treatment strategies may include various oral, nasal, or injected medications (such as nerve blocks). In rare, extreme cases, patients may seek hospitalization.

Preventive Treatments

Unfortunately, some patients with primary headache disorders are considered to suffer from chronic headaches- as they experience headache pain for at least 15 days out of the month. These individuals must be placed on a daily preventive medication regimen to help reduce the frequency and intensity of headache attacks. These medications include, but are not limited to, blood pressure medications, anti-seizure medications, antidepressant medications, and Botox injections.

References:

Broner SW, Yablon L. Migraine and its presentations. In: Martelletti P, Steiner TJ. Handbook of Headache, Practical Management. Springer. September 2011.

Broner SW, Cohen J. Epidemiology of Cluster Headache. Current Pain and Headache Reports. April 2009;13(2):141-146.

Lay CL, Broner SW. Migraine in Women. Migraine and Other Primary Headaches. Neurologic Clinics. May 2009;27(2):503-11.

Steiner TJ, Stovner LJ, Birbeck GL. Migraine: the seventh disabler. The Journal of Headache and Pain. January 2013;14(1):1. doi:10.1186/1129-2377-14-1.