Headache Syndromes
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Migraine
General
- Migraine can occur with or without a preceding aura.
- An aura is a sensory phenomenon, typically a positive visual phenomenon, such as bright, shimmering, geometric shapes, often with jagged rims.
- Aura may be the first symptom of the migraine, followed shortly thereafter (within fifteen to thirty minutes) by the headache, itself.
- Note that aura can occur without headache and note that the aura can be a stroke-like symptom, such as speech disturbance or sensory loss on one side of the body.
- When stroke symptoms occur in the setting of migraine, we'll often call this a complex or complicated migraine.
- Migraines last at least 4 hours in duration and typically resolve within 72 hours but can certainly last longer.
- Migraine frequency varies widely – they can be so infrequent as to be quiescent for decades or occur so often as to be present daily.
- Migraines are classically unilateral, as we've shown them to be, but can be bilateral with wide ranging distributions.
- Other distinguishing features include their pulsating quality.
- Association with photophobia (sensitivity to light), phonophobia (sensitivity to sound), or osmophobia (sensitivity to smell).
- As well, nausea (and sometimes vomiting) can occur.
- And they are aggravated by activity.
- Patients with migraine typically want to lie down in a dark, quiet room to temper the headache, and sleep can often help resolve it.
Treatments
Abortive
- NSAIDs, Ergot alkaloids (eg, DHE – dihydroergotamine), Triptans, and, now, calcitonin gene-related peptide (CGRP) antagonists.
- Neuropathic pain medications such as antidepressants (eg amitriptyline, venlafaxine, duloxetine, etc…) and antiepileptic agents (eg, valproic acid, topiramate, zonisamide, levetiracetam, etc…); beta-blockers; botulinum toxin; and, again, now the CGRP antagonists. As well, we encourage avoidance of identifiable triggers.
Tension-Type Headache (TTH)
General
Duration
- Typical headache lasts anywhere from 30 minutes to a week.
- Varies widely: from only every-so-often to daily.
- Typically bilateral (as opposed to unilateral); they have a pressure quality (clamp-like or vise-grip-like, rather than throbbing); there is little photo/phonopbia, if any at all. And they are not associated with nausea or vomiting and activity doesn't make them worse.
Treatment
Abortive
- Over-the-counter (OTC) analgesics (importantly, less than 2-3 times per week to avoid analgesic overuse headache) and behavioral strategies, amongst other treatments.
- We use antidepressants and antiepileptic drugs, as we do with migraine treatment, and also behavioral strategies.
Cluster
General
Duration
- Typical duration is 15 – 180 minutes.
- Can be quiescent for several months and then, often at predictable times of the year, occur in a flurry anywhere from every-other-day to up to 8 times per day over a time period of several weeks to months.
- Attacks are severe, are associated with autonomic symptoms (eg, lacrimation and rhinorrhea) even Horner's syndrome (look for a small pupil), and a feeling of restlessness.
Treatments
Abortive
- Indicate that as abortive agents, we use high flow oxygen and triptans as mainstay treatments, and also intranasal lidocaine or even octreotide.
- As headache prophylaxis, we use a variety of treatments, namely verapamil, but also lithium, steroids, topiramate, and sometimes greater occipital nerve block.
Trigeminal Neuralgia
General
Duration
- Attacks last less than a second up to a couple of minutes in duration.
- Occur in discrete periods over weeks or longer but they're less predictable in when the attacks will flurry.
- Innocuous triggers, such as cold temperature, can instigate the pain, which is described as shooting/stabbing/electric shock-like twinges of pain.
Treatments
Abortive
- Triptans and also infusions (eg, lidocaine or phenytoin).
- Antiepileptic drugs (eg, carbamazepine).
- Now, star surgical treatment, as the most definitive method of curing the trigeminal neuralgia.
- Surgical treatments include microvascular decompression or denervation via various techniques: such as radiofrequency surgery and ablation.