Primary headaches include migraine headache, tension-type headache, cluster headache, chronic paroxysmal hemicrania, and hemicrania continua all unassociated with structural lesions. Only migraine, tension-type, and cluster headaches will be discussed. A complete description of all the subtypes of headaches and diagnostic criteria can be found in the IHS document.2
Migraine headache is a common, recurring, and disabling primary headache that includes two major clinical presentations of migraine, those with and without an aura. A migraine without aura is the most common. Migraines with and without aura are similar except for the obvious absence of the aura in migraine without aura. For migraine sufferers with aura, focal neurological symptoms either precede or sometimes accompany the headache. The pain is moderate to severe, and is often unilateral, throbbing, and accompanied by autonomic symptoms (e.g., nausea, sometimes vomiting, and sensitivity to light, sound, or odor). Migraines last 4 to 72 hours; those that last longer than 72 hours are called status migrainosus. There is a genetic component to migraines, and migraines are more common in women than in men. The onset is in childhood, adolescents, or early adulthood, and frequently diminishes after age 50.
are known to precipitate migraine headache, such as psychological stress, sleep deprivation or fatigue, alcohol intake, and environmental factors (bright lights, sunlight, fluorescent lights, and watching television or movies) (Chart 27-1
). For women who suffer from migraines, the menstrual cycle is a trigger in about 65% occurring immediately before, during, or immediately after menstruation. In 75% to 80% of women with migraines, there is often complete cessation of headaches during pregnancy. Patients must be educated to avoid triggers associated with headache.
A migraine attack can be viewed through four possible phases: prodrome
(premonitory symptoms); aura;
and the postdrome.
Patients may experience some or all of the phases in their migraine presentation. About 60% of patients experience a premonitory phase
that occurs hours or days before the onset of headache.2
The most common premonitory symptoms include hyperactivity, hypoactivity, depression, craving for particular foods, and repeated yawning. Only about 20% of migraine sufferers have an aura. An aura
is the constellation of focal neurological symptoms that precede or accompany an attack. Most auras develop over 5 to 20 minutes and usually last less than 1 hour. Visual disturbances (bright spots, dazzling zigzag lines) or somatosensory phenomena (unilateral or bilateral numbness or tingling of the lips, face, or hand; paresis of an arm or leg; mild aphasia; slight incoordination of gait; confusion; and drowsiness) are common.
The headache phase begins with the onset of a throbbing headache and a decline in serotonin levels. Often unilateral at onset, the
headache may be bilateral (40% of patients) either at onset or as the headache intensifies over the next several hours. Simple physical activity or even moving the head can intensify the pain. In addition to the pain, nausea occurs in up to 90% of patients, and vomiting occurs in about one third. Many patients experience heightened sensitivity to light, sound, and smell; they seek a dark, quiet room. Other symptoms that may occur include blurry vision, nasal stuffiness, anorexia, hunger, diarrhea, abdominal cramps, facial pallor, sensation of heat or cold, sweating, scalp tenderness, edema of the temporal artery, and stiffness or tenderness of the neck. Impaired concentration, depression, fatigue, anxiety, and irritability are common. The pain gradually subsides. In the postdromal period there is often scalp or neck tenderness, anorexia, feeling of exhaustion, irritability, listlessness, impaired concentration, and mood change.9
Tension-type headache (TTH), previously called tension headache, muscle contraction headache, stress headache, and ordinary headache, represents the most common type of primary headaches. The exact mechanism of TTH is not known. TTHs are subdivided into episodic and chronic TTHs; episodic TTH is further subdivided into frequent and infrequent TTHs (less than one per month).
An infrequent episodic TTH
is described as a headache that lasts from minutes to days. Pain is bilateral and of mild to moderate intensity with a feeling of tightness and pressure. Unlike migraines, it is not accompanied by nausea, nor does it intensify with routine physical activity. A TTH may be accompanied by sensitivity to light or sound and most often tenderness on palpation in the pericranial area. Frequent episodic TTHs
are similar to the infrequent TTH except there are at least 10 episodes occurring on a basis of 1 or more but less than 15 days per month for at least 3 months (≥12 and <180 days per year).2
Frequent TTHs often coexist with migraine headaches without aura. The major difference in the infrequent and frequent TTHs is the impact on the person. Infrequent TTHs have little effect on quality of life whereas frequent TTHs are disabling and have a major negative impact on quality of life. A chronic TTH
has the same characteristics as an episodic TTH and evolves from episodic TTH. The difference is the time element. A chronic TTH occurs for 15 or more days a month on average for more than 3 months (≥180 days per year).2
Episodic and chronic TTHs are further classified by whether the headache is accompanied by disorders of muscles around the cranium, such as in the temples and neck. Muscle contractions can be a part of the discomfort experienced in a headache and are further described in the IHS classification.
The third category of primary headaches is the cluster headache and other trigeminal autonomic cephalalgias. A cluster headache is a severe, ipsilateral pain located in the orbital, supraorbital, temporal, or any combination of these sites. The headache lasts from 15 to 180 minutes; comes in groups, or “clusters,” of one to eight daily, lasting up to several weeks or months; and is followed by a period of remission of months to years. Autonomic phenomena associated with the headache include any one or combination of the following symptoms: tearing, conjunctival congestion, nasal congestion, rhinorrhea, tearing, forehead and facial sweating, miosis, ptosis, and eyelid edema usually unilateral on the side of the headache. The headache often awakens the person during the night without prodromal signs or aura. Cluster headaches can be triggered by alcohol, histamine, or nitroglycerin. Cluster headaches are three to four times more prevalent in men, and the onset is usually between 20 and 40 years of age. They are uncommon headaches that occur in about 0.4% of the population.
Paroxysmal hemicrania, short-lasting unilateral neuralgiform headaches, and probable trigeminal autonomic cephalalgia headaches included in the classification are further described in the IHS classification.